4605_FM_i-xxvi 02/11/17 10:49 AM Page i

Functional Performance
in Older Adults
FOURTH EDITION

Bette Bonder, PhD, OTR/L, FAOTA

Professor Emerita, School of Health Sciences
Cleveland State University
Cleveland, OH

Vanina Dal Bello-Haas, PhD, Med, BSc(PT)

Associate Professor
School of Rehabilitation Science
Assistant Dean, Physiotherapy
McMaster University
Hamilton University, Ontario, Canada
4605_FM_i-xxvi 02/11/17 10:49 AM Page ii

F. A. Davis Company
1915 Arch Street
Philadelphia, PA 19103
www.fadavis.com

Copyright © 2018 by F. A. Davis Company

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authors, editors, and publisher are not responsible for errors or omissions or for consequences from application of the book, and make no warranty, expressed
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Library of Congress Cataloging-in-Publication Data

Names: Bonder, Bette, editor. | Dal Bello-Haas, Vanina, editor.

Title: Functional performance in older adults / [edited by] Bette R. Bonder,
Vanina Dal Bello-Haas.
Description: Fourth edition. | Philadelphia : F. A. Davis Company, [2018]
Identifiers: LCCN 2017043990 | ISBN 9780803646056 (hardcover)
Subjects: | MESH: Aging—physiology | Health Services for the Aged | Mental
Disorders | Health Promotion | Aged
Classification: LCC RC953.5 | NLM WT 104 | DDC 612.6/7—dc23
LC record available at https://lccn.loc.gov/2017043990

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4605_FM_i-xxvi 02/11/17 10:49 AM Page iii

For our parents, older family, friends, and clients, who are wonderful role models for
aging gracefully.
—BRB and VDBH
4605_FM_i-xxvi 02/11/17 10:49 AM Page iv
PREFACE
It is hard to believe that more than 20 years have passed since
the first edition of this volume was published in 1994. It has
been a fascinating process analyzing the situation in 2017
and comparing it to years past. And it’s been heartening to
see the many ways in which older adults around the world
have seen improvements in their circumstances. At the same
time, the ongoing challenges are sobering for those of us in
health care.
Updating and expanding the text has taken on personal
immediacy over the years. We, the editors, and many of our
longtime and excellent contributors are, ourselves, reaching
old age. We have taken care of—and in some instances lost—
older loved ones. We have adjusted to changes in our physical
capacities, activities, social networks, and living situations.
As is true for all older adults, these changes have tested our
adaptive capacities and required flexibility and, often,
courage. Thus, the material in this book has increasing
salience in our own lives. This has encouraged us to be ever
more mindful of reflecting not only the facts associated with
aging but also the emotional realities of the experience.
Those of you who have read previous editions will note
that the content has been dramatically expanded. We have
tried to ensure a comprehensive picture of aging. We are well
aware that this is not really possible in a single volume. Even
if we could do so, it would be a snapshot in time. Writing
iv
and publishing a text of this scope takes time, and science
and reality march on in the meantime. We hope readers will
check the literature regularly to see what has happened since
this book was written.
As one way to promote such exploration, we’ve added an
online site to provide elaboration, additional resources, items
of interest, and materials you might find useful in working
with clients. We hope you’ll find it helpful, and that you’ll
visit it often.
We made a concerted effort to address interprofessional
care, particularly focused on physical and occupational ther-
apy. It is inevitable that there will be those who disagree with
our delineation of the two disciplines and will wonder why
we didn’t more fully incorporate others. Those disagreements
and questions serve to highlight some of the very real chal-
lenges of instituting truly interprofessional care. We believe
such care is in the best interests of clients, but we also know
that professional boundary disputes and the realities of
health-care systems and reimbursement make interprofes-
sional care difficult in the real world. It is worth striving to-
ward but not easy to enact.
We hope you will find the new content and features of
this book helpful and engaging, and that the updated material
is worthy of your time and helpful in your professional and
personal lives.
4605_FM_i-xxvi 02/11/17 10:49 AM Page v
ACKNOWLEDGMENTS
This edition is a significantly expanded version of Functional
Performance. It has been a labor of love for many people
who’ve been instrumental in making it the best book it could
possibly be.
We thank our many excellent authors for their thoughtful
contributions and patience during a lengthy revision process.
We also thank our reviewers, who offered helpful observa-
tions that have greatly improved the final product. We thank
Melissa Spor, who provided technical writing assistance, and
Rebecca and Jordan Bray who were instrumental in develop-
ing the online materials.
We thank F. A. Davis for its continuing support and con-
fidence in this project. In particular, Christa Fratantoro, Rose
Foltz, George Lang, Amelia Bevins, Nicole Liccio, Megan
Chandler, Carolyn O’Brien, and Bob Butler. Our sincere
apologies if we left anyone off this list; many F. A. Davis staff
work hard and effectively behind the scenes.
We appreciate the input from our students over the years,
and we are deeply grateful to the many clients who have
enabled us to learn from their experiences. We also appreciate
the students who helped us refine the content of the book,
responding to material, checking references, and otherwise
helping us enhance the product. We are grateful to the many
people who have read the book, and especially those who
contacted us with suggestions or posted reviews that helped
us continue to improve it.
And, as always, we thank our families. The process of
bringing this book to completion has been a very long term,
and at times intensive, effort, and they’ve not only provided
helpful input, but have also cooked meals, handled household
chores, and been cheerleaders during the process. Patrick Bray,
Lisa Gomersall and Aaron Bray, Rebecca and Jordan Bray,
and Tom Haas have our profound gratitude.
v
4605_FM_i-xxvi 02/11/17 10:49 AM Page vi
CONTRIBUTORS
Georgia J. Anetzberger, PhD, ACSW, LISW
Adjunct Assistant Professor
Department of Medicine
Case Western Reserve University
Cleveland, OH
Julie D. Bass, PhD, OTR/L, FAOTA
Professor
Occupational Therapy
St. Catherine University
St. Paul, MN
Susana Villasana Benítez, PhD
Maestría en Antropología Social
Instituto de Estudios Indígenas
Universidad Autónoma de Chiapas
San Cristobal de las Casas, Chiapas, Mexico
Patricia Bowyer, EdD, OTR, FAOTA
Associate Director and Professor
School of Occupational Therapy
Texas Women’s University
Houston, TX
Brent Braveman, PhD, OTR/L, FAOTA
Director
Rehabilitation Services
M. D. Anderson Cancer Center
Houston, TX
Patrick Bray, MD, MPH
Medical Consultant
Shaker Heights, OH
Jenny Brodsky
Director
Center for Research on Aging
Jerusalem, Israel
Anita C. Bundy, ScD, OT, FAOTA
Professor and Department Head
Department of Occupational Therapy
Colorado State University
Fort Collins, CO
Faculty of Health Sciences
University of Sydney
Sydney, Australia
vi
Lindy M. Clemson, PhD, MAppSc, OT, DipOT
Professor
Occupational Therapy
University of Sydney
Sydney, Australia
Nicole T. Dawson, PT, PhD, MA, GSC
Assistant Professor
Department of Physical Therapy
University of Central Florida
Orlando, FL
Elizabeth Dean, PhD, PT
Professor
Department of Physical Therapy
Faculty of Medicine
University of British Columbia
Vancouver, British Columbia, Canada
Sanetta H. J. Du Toit, PhD, MSc (OT), BOccTh
Lecturer, University of Sydney
Affiliated Lecturer, University of the Free State
Sydney, Australia
Beth A. Ekelman, PhD, JD, OTR/L
Professor and Director
Program in Occupational Therapy
Cleveland State University
Cleveland, OH
R. Elaine Fogerty, OTR/L
Occupational Therapist
Clovis, NM
Laureano Reyes Gómez, PhD
Vocal Titular de Investigación
Instituto de Estudios Indígenas
Universidad Autónoma de Chiapas
San Cristobal de las Casas, Chiapas, Mexico
Joshua Greene, OTD, OTR/L
Adjunct Faculty
Occupational Therapy
Quinnipiac College
Hamden, CT
4605_FM_i-xxvi 02/11/17 10:49 AM Page vii

CONTRIBUTORS vii

Kristine Haertl, PhD, OTR/L, FAOTA Norma J. MacIntyre, PhD, PT

Professor Associate Professor
Department of Occupational Science and Therapy Physical Therapy
Saint Catherine University McMaster University
St. Paul, MN Hamilton, Ontario, Canada

Cynthia Hovland-Scafe, PhD, MSSW Mary Ann McColl, PhD, MTS

Assistant Professor Associate Director
School of Social Work Centre for Health Services & Policy Research
Cleveland State University
Professor
Cleveland, OH
Rehab Therapy/Community Health
Queen’s University, Abramsky Hall
Linda A. Hunt, PhD, OTR/L, FAOTA
Kingston, Ontario, Canada
Professor, School of Occupational Therapy
Director, Graduate Program in Gerontology
Bobby Nijjar, BSc, MSc, EdD, RD
Pacific University
Assistant Professor
Hillsboro, OR
Simon Fraser University
Vancouver, British Columbia, Canada
Katherine S. Judge, PhD
Associate Professor
Megan E. O’Connell, BA Hon, MA, PhD, RD Psych
Department of Psychology
Associate Professor
Cleveland State University
Psychology
Cleveland, OH
University of Saskatchewan
Saskatchewan, Canada
Maayan Katz, PhD, OT
Deputy Director of Occupational Therapy
Evguenia S. Popova, MS, OTR/L
National Service
Graduate Research Assistant
Director of Geriatric Occupational Therapy
University of Illinois at Chicago
Ministry of Health
Chicago, IL
Jerusalem, Israel
Iris Rasoolu, MD, MPM
Karen la Cour, PhD, MSc, OT
Head, Community Services Department
Associate Professor
Geriatric Division
Head of the Research Initiative of Activity Studies and
Israel Ministry of Health
Occupational Therapy Institute of Public Health
Jerusalem, Israel
University of Southern Denmark
Odense, Denmark
Julie Richardson, PT, PhD
Associate Dean
Lori Letts, PhD, OT Reg (Ont)
School of Rehabilitation Science
Assistant Dean, Occupational Therapy Program
McMaster University
Professor
Hamilton, Ontario, Canada
School of Rehabilitation Science
McMaster University
Nancy Richman, OTR/L, FAOTA
Hamilton, Ontario, Canada
Occupational Therapist
Rehabilitation Associates
Kim Lewitte, BOT
Chicago, IL
Occupational Therapist, Private Practice
Johannesburg, South Africa
Sergio Romero, PhD
Research Assistant Professor
Line Lindahl-Jacobsen, PhD, MPH, OT
Department of Occupational Therapy
Associate Professor
University of Florida
Department of Public Health, General Practice
University of Southern Denmark Research Health Scientist
Odense, Denmark Center of Innovation on Disability and Rehabilitation
Research
North Florida/South Georgia Veterans Health System
Gainesville, FL
4605_FM_i-xxvi 02/11/17 10:49 AM Page viii

viii CONTRIBUTORS

Sirirat Seng-Iad, PhD(C) Joyce Tryssenaar, PhD, OT Reg (Ont)

Doctoral Candidate Associate Professor
School of Rehabilitation Science McMaster University
McMaster University Hamilton, Ontario, Canada
Hamilton, Ontario, Canada
Sarah Wojkowski, PhD, PT
Anupa Singh, BOT Assistant Professor
Occupational Therapist, Private Practice School of Rehabilitation Science
Johannesburg, South Africa McMaster University
Hamilton, Ontario, Canada
Wendy Stav, PhD, OTR/L, SCDCM, FAOTA
Chair and Professor Missi Zahoransky, MS, OTR/L
Occupational Therapy Department Adjunct Faculty
Nova Southeastern University School of Health Sciences
Ft. Lauderdale, FL Cleveland State University
Cleveland, OH
Amanda Stead, PhD, CCC, SLP Integrity Home Care
Assistant Professor Cleveland, OH
College of Education, School of Communication Sciences
and Disorders Yael Zilberslag
Pacific University Occupational Therapist
Forest Grove, OR Jerusalem, Israel

Renée R. Taylor, PhD

Professor
Department of Occupational Therapy
University of Illinois at Chicago
Chicago, IL
4605_FM_i-xxvi 02/11/17 10:49 AM Page ix

REVIEWERS

Ron Carson, OTD, MHS, OT David Greene, PhD, OTR

Assistant Professor Associate Professor Occupational Therapy
Occupational Therapy Occupational Therapy
Adventist University of Health Sciences Colorado State University
Orlando, FL Fort Collins, CO

Susan M. Cleghorn, MS, OTRL, TRS, CAPS Ashley Halle, OTD, OTR/L
Assistant Professor Assistant Professor
Occupational Science & Therapy Chan Division of Occupational Science & Occupational
Grand Valley State University Therapy
Allendale, MI University of Southern California
Los Angeles, CA
Erica DeFrancesco, MS, OTR/L
Clinical Assistant Professor Margaret D. Hart, PhD, OTR/L
Occupational Therapy Professor Emeritus
Quinnipiac University Occupational Therapy
North Haven, CT Worcester State University
Worcester, MA
Susan P. Denham, EdD, OTR/L, CHT
Occupational Therapy Nathan B. Herz, OTD, MBA, OTR/L CEAS
Alabama State University Founding Director
Montgomery, AL Occupational Therapy
Murphy Deming College of Health Sciences
Mary Lou Donovan, PhD, OTR/L Fishersville, VA
Assistant Professor
Occupational Therapy Sandra Hobson, BSc(OT), MAEd, LLD, FCAOT
College of St. Scholastica Professor Emerita
Duluth, MN School of Occupational Therapy
The University of Western Ontario
Ruth Ford, EdD, MSBS, OTR/L London, Ontario, Canada
OTD Program Director
Occupational Therapy, Doctorate Brenda Kennell, OTR/L
Huntington University Program Chair
Fort Wayne, IN Occupational Therapy Assistant
Central Piedmont Community College
Susan Friguglietti, DHA, MA, OTR/L Charlotte, NC
Associate Professor of Occupational Therapy
College of Health Sciences Cindy Koehn, OTR/L
Lenoir-Rhyne University Academic Fieldwork Coordinator
Hickory, NC Occupational Therapy Assistant Program
Hawkeye Community College
Lynn Gitlow, OTR/L, PhD, ATP Waterloo, IA
Associate Professor
Occupational Therapy Susan Kristoff, LMT, PTA
Ithaca College President/Owner of a private practice: Homecare PT
Ithaca, NY Massage Therapy, Physical Therapy
Nuebody Therapy
Willow Grove, PA
ix
4605_FM_i-xxvi 02/11/17 10:49 AM Page x

x REVIEWERS

Danielle N. Naumann, BA(H), MSc(OT), PhD(c), OT Stacey L. Schepens Niemiec, PhD OTR/L
Reg(Ont) Research Assistant Professor
Occupational Therapist; PhD Candidate Rehabilitation Chan Division of Occupational Science and Occupational
Science Therapy
School of Rehabilitation, Faculty of Health Sciences University of Southern California
Queen’s University Los Angeles, CA
Kingston, Ontario, Canada
Nancy Schneider Smith, PT, DPT, GCS
Terry Peralta-Catipon, PhD, OTR/L Clinical Associate Professor
Department Chair Physical Therapy
Occupational Therapy Winston Salem State University
California State University Dominguez Hills Winston Salem, NC
Carson, CA
Steven Wheeler, PhD, OTR/L
Ann Marie Potter, MA, OTR/L Associate Professor
Lecturer Occupational Therapy
Occupational Therapy West Virginia University School of Medicine
Elizabethtown College Morgantown, WV
Elizabethtown, PA
Caryn Young, BA, BSc, PgDIP, MBAOT, MCOTSS-NP,
Samia H. Rafeedie, OTD, OTR/L, CBIS HCPC Registered OT
Assistant Professor Lecturer in Occupational Therapy
Division of Occupational Science & Occupational Therapy School of Health Sciences
at the Herman Ostrow School of Dentistry Ulster University
University of Southern California Newtownabbey, Northern Ireland
Los Angeles, CA

Patricia Louise Schaber, PhD, OTR/L, FAOTA

Associate Professor
Program in Occupational Therapy
University of Minnesota
Minneapolis, MN
4605_FM_i-xxvi 02/11/17 10:50 AM Page xi

CONTENTS

PREFACE iv
ACKNOWLEDGMENTS v
CONTRIBUTORS vi
REVIEWERS ix
INTRODUCTION TO THE FOURTH EDITION xxv

PART I Global Health and Aging: Implications for Health and Participation 1
1 Growing Old in Today’s World 3
Bette Bonder
History of Aging 4
Life Expectancy 4
Impact of Economic Circumstances and Gender Throughout History 4
Attitudes About Aging From a Historical Perspective 5
Historical Roles of Older Adults 6
Cohort Effects 6
Aging Today: Factors Affecting the Experience of Aging 7
Physical Environment 7
Sociocultural Factors 8
Individual Characteristics 10
The Impact of Gender in Modern Times 11
Socioeconomic Factors 11
Positive Aging 12
2 Theories of Aging: A Multidisciplinary Review for Occupational and Physical
Therapists 19
Bette Bonder, Renée R. Taylor, and Evguenia S. Popova
Challenges of Societal Aging 19
What Do Gerontologists Want to Explain? 19
Sociodemographic Changes 20
The Current State of Theory in Gerontology 20
Theories of Aging 20
Biological Theories of Aging 20
Neuropsychological Theories of Aging 21
Psychological Theories of Aging 22
Sociological Theories of Aging 24
Client-Centered Approaches With Older Adults 26
The Systems Theory of Motor Control 26
The Model of Human Occupation 27
The International Classification of Functioning, Disability, and Health and the Occupational Therapy Practice
Framework, Third Edition 28
The ICF 28
The Occupational Therapy Practice Framework, Third Edition 29

xi
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xii CONTENTS

3 Public Policy and Advocacy in North America 33

Nancy Richman
Public Policy and Aging 33
Federal Policy 34
State Policy 38
Local Policy 38
Public Policy in International Context 38
Models of Advocacy 39
How Policy Is Made 39
Advocating for Policies 40
Advocating for Individuals 40
The Role of OT and PT in Advocacy 41
Advocacy at Work: The Olmstead Act 42

4 Aging Around the World 45

Services for Older Adults in Israel 45
Yael Zilberslag, Maayan Katz, Jenny Brodsky, and Iris Rasoolu
The Demography of Aging in Israel 46
Health and Welfare Services 46
Long-Term Care for Disabled Elders 47
The Social Formal System of Care 47
The Health System of Care 48
Issues and Challenges 49
Health Care for the Elderly in Mexico 49
Laureano Reyes Gómez and Susana Villasana Benítez
Sociodemographic Context 49
Health-Care Systems 50
Conclusion 52
Aging in South Africa 53
Kim Lewitte and Anupa Singh
The Effect of Apartheid on South African Aged 53
The Rainbow Nation: Current Status of Older Adults 54
Health Care in South Africa 54
The Role of the Aged in the South African Community 56
Challenges for the Aged in South Africa 57
Conclusion 58

5 Meaningful Occupation in Later Life 61

Bette Bonder
The Search for Meaning 61
Occupation and Meaning 62
Themes of Meaning 63
Supporting Meaning in Occupational and Physical Therapy Interventions 66

6 Culture, Ethics, and Elder Abuse 75

Bette Bonder and Georgia J. Anetzberger
Culture and Aging 75
Aging in International Context 76
Culture and Aging in the United States 77
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CONTENTS xiii

Aging, Culture, and Function 77

Occupations 77
Performance Skills 79
Performance Patterns 79
Context 80
Activity Demands 80
Client Factors: Body Functions and Body Structures 81
Culture and the Intervention Process 81
Cultural Competency 81
Analysis of Occupational Performance 81
Intervention 82
Ethical Issues in Later Life 82
Elder Abuse 83
Definition and Forms 83
Prevalence and Incidence 83
Reporting 84
Examples, Signs, and Risk Factors 84
Addressing Elder Abuse 85

PART II Aging: Body Structures and Body Functions 91

SECTION 1 Normal Age-Related Changes 93
7 Cognitive Function 93
Katherine S. Judge and Nicole T. Dawson
Bases of Cognitive Aging 94
Key Tenets of Cognitive Aging Across the Life Span 94
Methodological Considerations 94
Foundations of Cognition Aging: Basic and Higher Order Cognitive Processes 95
Basic Cognitive Processes 95
Higher Order Cognitive Processes 99
Additional Cognitive Processes 101
Theories Of Cognitive Aging 102
Speed of Processing Theory 102
Working Memory 102
Inhibition 103
Common Cause Hypothesis (Sensory Functioning) 103
Optimizing Cognitive Aging and Health 103

8 Cardiopulmonary and Cardiovascular Function 109

Elizabeth Dean
Interrelationships Among Structure and Function, Activity, and Social Participation: Cardiovascular and Pulmonary
Function 110
Age-Related Changes in the Cardiopulmonary System and Its Function 110
Airways 110
Lung Parenchyma 110
Alveolar Capillary Membrane 110
Chest Wall 110
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xiv CONTENTS

Respiratory Muscles 111

Net Effect of Age-Related Cardiopulmonary Changes 111
Age-Related Changes in the Cardiovascular System and Its Function 111
Heart 111
Blood Vessels 112
Net Effects of Age-Related Cardiovascular Changes 112
Functional Consequences of Age-Related Cardiopulmonary and Cardiovascular Changes 112
The Functional Performance Threshold 112
Functional Capacity 116
Functional Consequences of Fitness in Older People 118
Deconditioning 118
Conditioning 118
Implications for the Management of the Care of Older People 119
Safety 124
Customizing the Environment to Maximize Function 124

9 Sensory Function and Function Related to the Skin 129

Linda A. Hunt, Amanda Stead, and Bobby Nijjar
Vision System and Functional Performance 130
Normal Age-Related Vision System and Vision Changes 130
Auditory System and Functional Performance 132
Normal Age-Related Auditory System and Hearing Changes 132
Effects of Normal Age-Related Auditory System and Hearing Changes 134
Taste and Smell: Physical Changes and Functional Performance 136
Somesthesis: Physical Changes and Functional Performance 138
Skin Changes With Aging 138
Touch and Pressure 138
Pain 138
Temperature 139

10 Neuromuscular and Movement Function: Muscle, Bone, and Joints 145

Vanina Dal Bello-Haas, Norma J. MacIntyre, and Sirirat Seng-Iad
Neuromusculoskeletal and Movement Function in Older Adults 146
Age-Related Changes in Muscle Strength and Power 148
Age-Related Muscle Changes and Function 150
Age-Related Changes in the Skeletal System 151
Age-Related Changes in the Nervous System 153
Assessing the Neuromusculoskeletal System in Older Adults 154
Range of Motion and Flexibility Assessment 154
Muscle Strength and Power Assessment 154
Management of Neuromusculoskeletal Impairments in the Older Adult 155
Strength and Resistance Exercises 156
Flexibility (Stretching) Exercises 158

11 Neuromuscular and Movement Function: Coordination, Balance, and Gait 163

Vanina Dal Bello-Haas, Norma J. MacIntyre, and Sirirat Seng-Iad
Age-Related Changes in Postural Alignment 163
Age-Related Changes in Coordination 165
Age-Related Changes in Balance and Gait 166
Changes in Proprioception 167
Changes in Gait 167
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CONTENTS xv

Assessing Posture, Coordination, Balance, and Gait in Older Adults 167

Static Posture Assessment 167
Coordination Assessment 168
Balance Assessment 169
Gait Assessment 172
Management of Posture, Coordination, Balance, and Gait Problems in the Older Adult 174
Postural Problems and Skeletal Deformities 174
Coordination 174
Balance and Gait 174

SECTION 2 Age-Related Health Conditions, Impairments, and Limitations 181

12 Cognitive and Emotional Function: Health Conditions 181
Katherine S. Judge and Nicole T. Dawson
Key Tenets for Understanding and Maximizing Success With Atypical Cognitive Changes 182
Neurodegenerative Illnesses: Dementia and Associated Disorders 184
Prevalence of Dementia and Associated Disorders 184
Etiology and Types of Dementia 184
Symptoms of Dementia 185
Diagnosing Dementia 186
Pharmacological and Nonpharmacological Interventions for Dementia 187
Stroke 188
Prevalence 188
Etiology and Types of Stroke 188
Symptoms of Stroke 188
Diagnosing Stroke 189
Pharmacological and Nonpharmacological Interventions for Stroke 189
Mental Health Conditions 189
Depression 190
Anxiety Disorders 191
Schizophrenia 192
Bipolar Disorder 192
Substance Use Disorders 193
Understanding the Illness Experience of Individuals With Cognitive Conditions 194
Translating Research Findings Into Rehabilitation Treatment Plans for Cognitive and Emotional Disorders 194

13 Cardiopulmonary and Cardiovascular Function: Health Conditions 201

Elizabeth Dean
Factors Affecting Cardiopulmonary and Cardiovascular Health in Older People 202
Pathophysiology, Etiology, and Epidemiology 203
Gravitational Stress and Exercise Stress 208
Extrinsic Factors 209
Intrinsic Factors 209
Exercise Testing and Training Older People With Cardiopulmonary and Cardiovascular Health Conditions 210
Assessment Findings and Implications for Exercise Testing 210
Exercise Test Findings and Implications for Exercise Training 211

14 Sensory Function, Function Related to the Skin and Pain: Health Conditions 217
Linda A. Hunt, Bobby Nijjar, and Amanda Stead
Pathological Changes in the Visual System 217
Cataracts 218
Age-Related Macular Degeneration 219
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xvi CONTENTS

Glaucoma 219
Diabetic Retinopathy 220
Functional and Behavioral Adaptations 221
Other Diseases That May Affect Vision, Visual Processing, and Functional Performance 222
Pathology of the Auditory System 224
Skin 224
Pain 225
Assessment 225
Interventions 226

15 Neuromuscular and Movement Function: Health Conditions 231

Norma J. MacIntyre, Vanina Dal Bello-Haas, and Sirirat Seng-Iad
Osteoarthritis 231
Risk Factors and Signs and Symptoms 232
Management of Osteoarthritis 232
Osteoporosis 233
Clinical Diagnosis 233
Fractures 233
Management of Osteoporosis 234
Amputation in Older Adults 236
Physical and Psychosocial Challenges of Limb Amputation 236
Management of Limb Amputation in Older Adults 236
Complications of Limb Amputation 237
Parkinson’s Disease 238
Management of Parkinson’s Disease 238
Stroke 241

16 Neuromuscular and Movement Function: Falls 249

Vanina Dal Bello-Haas and Norma J. MacIntyre
Definition of Fall and Near-Fall 249
Fall Facts 249
Where and When Do Older Adults Fall? 250
Consequences and Sequelae of Falls 250
Risk Factors for Falls 251
Risk Factors—Age-Related and Biological 251
Risk Factors—Behavioral and Cognitive 252
Risk Factors—Environmental and Community 253
Fall Risk and Fall Prevention Assessment 253
Fall Risk and Fall Prevention Intervention 255
Exercise 256
Prescription of Assistive and Adaptive Devices and Activities of Daily Living, Mobility, and Gait Training 257
Fear of Falling Interventions 257
Environment/Community: Prevention and Intervention 257
Other Interventions 257

17 Considerations for Medical Care of Older Adults 263

Patrick Bray and Bette Bonder
Differential Impact of Disease and Disorder in Later Life 264
Physiological and Psychosocial Factors and Disease 264
Severity of Specific Conditions 264
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CONTENTS xvii

Presenting Symptoms 264

Preexisting Conditions 264
Acute Conditions 265
The Impact of Hospitalization 265
Common Medical Conditions in Later Life 265
Cancer 265
Diabetes and Obesity 266
Urinary Tract Infection 268
Infectious Diseases 268
Nutritional Deficiency and Oral Health 269
Frailty Syndrome and Posthospital Syndrome 269
Medication 270
General Principles for Effective Medication Use in Later Life 270
Pain Management 271
Substance Abuse 271
Implications for Occupational Therapy and Physical Therapy 272

PART III Active Aging: Supporting Client Activities and Participation 277
18 Self-Care 279
Kristine Haertl
Defining Self-Care 280
Models to Explain Everyday Functional Abilities 280
Competence, Value, and Meaning in Self-Care 280
Significance of Self-Care 281
Prevalence and Type of Limitations of Activities of Daily Living Among Older Adults 282
Effects of Medical Conditions on Self-Care 282
Stroke 282
Cardiovascular Disease 283
Dementia and Cognitive Decline 283
Joint Inflammation and Disease 283
Sensory Problems 283
Measuring Self-Care Performance 284
Assessing Factors Contributing to Self-Care Deficits 284
Assessing Instrumental Activities of Daily Living 285
Assessing Environmental Factors 285
Safety 286
Activities of Daily Living Intervention 286
Skill Training 286
Environmental Modifications 287
Assistive Devices for Self-Care 288
Task Modifications 289

19 Leisure 295
Anita C. Bundy, Sanetta H. J. Du Toit, and Lindy M. Clemson
Leisure and Aging 296
Leisure as a Statement of Identity 297
Leisure as a Fully Engaging Experience 298
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xviii CONTENTS

Elements of Leisure 299

Control 299
Motivation 302
Freedom From Unnecessary Constraints of Reality 304
A Model of Leisure Engagement 304
Promotion of Leisure: Application of the Model 304
Role of Physical Therapy in Promoting Leisure 306

20 Work and Retirement 313

Brent Braveman, Patricia Bowyer, and R. Elaine Fogerty
Models of Retirement and Transition to Retirement 314
The Retirement Process and Models 315
Who Are the Older Workers of Today and Tomorrow? 316
Barriers to Successful Continued Employment Faced by Older Workers 317
Generational and Cultural Perspectives on Work and Retirement 317
Therapy Perspectives on Work and Retirement 318
Occupational Therapy and Older Workers 318
Physical Therapy and Older Workers 319
Ergonomic and Assistive Technologies 319
Volunteerism and Leisure 320
Legislative and Policy Issues Around the World 321
Other Health-Care Providers Involved in Work and Retirement 321
21 Environment, Products, and Technology 327
Sergio Romero
Aging and Functional Performance 327
The Built Environment and Functional Performance 328
Change the Individual 328
Change the Environment 328
Provide Individuals With Tools 330
Aging in Place 330
Assessing the Need for Assistive Technology 331
Determining Assistive Technology Needs Using the ICF and Practice Framework 331
Assistive Technology for Older Adults 333
Devices for Persons With Mobility or Motor Impairments 333
Devices for Persons With Vision Impairments 334
Devices for Persons With Hearing Impairments 335
Devices for Persons With Memory Loss 336
Issues Relating to Use of Assistive Technology With Older Adults 336

22 Driving 341
Wendy Stav and Beth A. Ekelman
Overview of National Statistics on Violations, Crashes, and Fatalities 341
Driving as an Occupation 342
Client Factors 343
Performance Skills 343
Performance Patterns 343
Contexts 343
Age-Related Physiological and Disease-Related Changes Affecting Driving Performance 345
Sensory Functions 345
Changes in Other Functions 346
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CONTENTS xix

Clinical Assessment and Intervention 348

Medical and Driving History and Performance Patterns 349
Clinical Assessment of Movement 350
Clinical Assessment of Visual Functions 350
Clinical Assessment of Other Client Factors and Performance Skills 351
Evidence-Based Practice 352
Suggestions for Clinicians in Geriatric Practice 353
23 Community Mobility 359
Wendy Stav
Losing the Ability to Drive: A Psychosocial Perspective 359
Source of Decision to Stop Driving 360
Implications of Driving Cessation 360
Family Involvement 361
Suggestions for Clinicians in Geriatric Practice 361
Community Mobility: Some Alternative Solutions 362
Facilitating Change in Transportation Services 364
Evidence-Based Practice 364

24 Interactions, Relationships, and Sexuality 367

Bette Bonder and Cynthia Hovland-Scafe
Social Relationships in Later Life 368
Culture and Family 369
Family Constellations 369
Family Occupations 370
Grandparenting 371
Special Circumstances 371
Spousal Relationships and Widowhood 371
Implications for Intervention 372
Sexuality and Aging 372
Defining Sexuality 372
Life-Stage Effects 373
Gays and Lesbians in Older Adulthood 373
Sexual Attitudes and Behaviors of Older Adults 373
Age-Related Physical Changes and Sexual Functioning 373
Effects of Disease and Other Factors on Sexuality 374
Implications for Health-Care Providers 375
When Caregiving Becomes Necessary 375
The Intentional Relationship Model 376
Techniques for Practice 377
Addressing Family Issues in the Current Health-Care Environment 378

25 Learning in Later Life 383

Vanina Dal Bello-Haas and Megan E. O’Connell
Gerogogy 384
Impact of Sensory System Changes on Older Adult Learning 384
Impact of Psychological and Physical Changes on Older Adult Learning 385
Impact of Cognitive Changes on Older Adult Learning 385
Impact of Social-Cultural Elements on Older Adult Learning 385
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xx CONTENTS

Learning and Memory: Not Just One Way to Learn 385

Episodic and Semantic Memory 386
Free Recall and Supported Recall 387
Prospective Memory 387
Procedural Memory and Motor Learning: Skill Learning 387
Formal, Nonformal, and Informal Learning in Later Life 388
Why Do Older Adults Engage in Learning? 391
Learning and Older Adult Health 391
Cognitive Reserve 391
Health Literacy 392
E-Learning in Later Life 392

26 Spirituality 397
Mary Ann McColl
Defining Spirituality 397
Differentiating Religion from Spirituality 398
Spirituality as a Vital Dimension of Rehabilitative Practice 398
As Human Beings 398
As Health Professionals 398
As Occupational Therapists in Particular 398
As Witnesses and Advocates for People With Chronic Illnesses and Disabilities 399
As Specialists in Elder Care 399
Approaches to Spirituality in Occupational and Physical Therapy 400
Acknowledge the Issue 400
Refer to a Spiritual-Care Professional 400
Intervene Directly Using Spiritual Interventions 401
Intervene Indirectly Using Familiar Therapeutic Interventions 401
Narrative 401
Ritual 401
Appreciation of Nature 402
Creativity 402
Work 402
Movement 402

PART IV Service Delivery for the Aging Client 405

27 Evaluation of Functional Performance 407
Lori Letts and Julie Richardson
Functional Performance 407
Evaluating Functional Performance 408
Conceptual Frameworks for Evaluation of Functional Performance 409
International Classification of Functioning, Disability, and Health 410
Glass Model 410
Person-Environment-Occupation Model 411
What to Assess When Focusing on Function in Older Adults 411
Priority Areas of Functional Performance With Older Adults 412
Specific Issues Related to Evaluation of Functional Performance 415
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CONTENTS xxi

28 Health and Wellness 421

Julie D. Bass
Concepts Related to Health and Wellness 421
Factors Associated With Health and Wellness in Older Adults 422
Rowe and Kahn Model of Successful Aging 422
Other Factors Associated With Health and Wellness for Older Adults 423
Therapy for Health and Wellness 425
Occupational Therapy 425
Physical Therapy 426
Occupational Therapy and Physical Therapy Interventions and Programs 426
Professional Development for Practice 430
Addressing Health and Wellness in the Current Health-Care Environment 430
29 Community-Based Services 437
Georgia J. Anetzberger
Service Imperative 438
Service Classifications 438
Continuum of Care 438
Location 439
Function 439
Service Utilization 439
Service Barriers 440
Linkage 441
Something to Do 441
Working 442
Learning 442
Giving 442
Experiencing 443
Someone to Care 444
Adult Protective Services 445
Someplace to Live 445
Implications for Physical and Occupational Therapy 446
30 Primary Care 453
Julie Richardson and Sarah Wojkowski
Primary Care and Primary Health Care 453
Models of Integrating Rehabilitation Professionals and Services in Primary Care 454
Theoretical Frameworks Used to Understand Access to Health Services 455
A Conceptual Framework for Access to Health Care 455
Theoretical Framework for Health Service Utilization 456
The Expanded Chronic Care Model 456
Interpreting the ECCM 456
The ECCM and the Health-Care Professional 456
Roles for Occupational Therapists in Primary Care 458
Roles for Physical Therapists in Primary Care 459
Patient-Centeredness in Primary Care 459
Multimorbidity 460
Physical Function as a Primary Health Outcome 460
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xxii CONTENTS

Self-Management and Behavior Change 461

Lifestyle Conditions and Interventions 462
Health Coaching and Motivational Interviewing 463
Motivational Interviewing 463
Cognitive Behavioral Therapy 464
Patient Satisfaction 464
The Integration of Technology to Maximize Service Delivery 465
Integration of Occupational Therapy and Physical Therapy Within the Primary Care Team 465

31 Home Health Care 471

Missi Zahoransky
History of Home Health Care in the United States 472
Cultural Competence and Patient-Centered Care 472
Overview of Important Legislation 473
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) 473
The Balanced Budget Act of 1997 (BBA) 473
The Affordable Care Act (ACA) 473
The Improving Medicare Post-Acute Care Transformation Act (IMPACT) 473
Home Health-Care Agencies and Medicare 474
Criteria for Medicare Reimbursement to Home Health Agencies 474
Criteria for Coverage of Home Health Services for Medicare Beneficiaries 474
Impact of Regulations on Therapy Provision 477
The Role of OT, PT, and SLP in the Survey Process 477
Patients’ Rights and Confidentiality 477
The Role of the Therapist in Communication and Plan of Care 477
Therapy Services and Therapy Assistants 478
The Initial Visit and Comprehensive Assessment 478
Documentation 480
Initial Evaluation 481
Reassessment 481
Payment Systems and Reimbursement 481
Therapy Thresholds 482
Part B Outpatient Therapy Services 482
Other Sources of Payment 483
What Intervention Looks Like 483
Therapy and Data Collection 483
Intervention 483
Measuring Quality and Best Practice 484

32 Rehabilitation 489
Vanina Dal Bello-Haas and Joyce Tryssenaar
Disability in Older Adulthood 490
Psychological Consequences of Disabling Events 491
Aging With a Preexisting Disability 491
Issues for Persons With Intellectual Disability 492
Issues for Persons With Serious Mental Illness 492
Issues for Persons With Physical Disabilities 492
What Makes Older Adult Rehabilitation Unique? 492
Chronological Versus Physiological Aging 492
Progressive Versus Catastrophic Disability 493
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CONTENTS xxiii

Biological and Other Factors 493

Management 493
The Rehabilitation Team 493
Coordinating the Rehabilitation Team 495
Case Management 495
The Occupational Therapy-Physical Therapy Partnership 496
Delivery Systems 496
Acute Care 497
Transitional Care Facilities and Units 497
Rehabilitation Units 497
Day Hospital Care and Adult Day Care Facilities 497
Home Health and Domiciliary Care 498
Outpatient and Ambulatory Care 498
Evaluation 498
Assessment Instruments 499
Personal and Environmental Factors to Consider 499
Personal Factors That May Influence Rehabilitation 499
Environmental Factors That May Influence Rehabilitation 500
Rehabilitation for Older Adults—The Evidence 501

33 Long-Term Care 507

Joshua Greene
Evolution of the Nursing Home 508
Legislation and Regulation 508
Medicare and Medicaid 508
State Regulations 510
Models of Care 510
Profile of Nursing Home Residents 511
Therapy in Nursing Home Settings 511
Occupational Therapy 512
Occupation in Long-Term Care 512
Physical Therapy 513
Interdisciplinary Teams in Long-Term Care 514
Therapies and the Total Environment 516
Evidence-Based Approaches to Care for Patients With Dementia 516
34 End of Life 521
Karen la Cour and Line Lindahl-Jacobsen
End of Life, Palliative Care, and Hospice Philosophy 522
Living in Old Age With a Life-Threatening Illness 524
A Good Death and Different Cultures 525
The Influence of End of Life on Close Family and Relatives 526
Needs for Palliative Occupational Therapy and Physiotherapy 527
Health Policy and Related Factors Affecting End-of-Life and Palliative Care 528
End-of-Life Palliative Occupational Therapy and Physiotherapy Interventions 528
Referral 529
Assessment 530
Goal Setting 530
Intervention 530
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xxiv CONTENTS

Bereavement for Older Persons in End of Life and for Family Members 531
Family Involvement and Support 531
Palliative Care: A Team-Based Approach 532
Appropriate Outcomes for Palliative Occupational Therapy and Physiotherapy and Implications for Practice 533

35 The Future of Aging 539

Bette Bonder and Vanina Dal Bello-Haas
Demographic and Societal Trends 539
Cohort Effects 540
Culture and Aging 541
Meaning in Life 541
Participating in Life and Community 541
Work and Retirement 542
Aging and Environment 542
Financial Considerations 542
Living Arrangements 543
Trends in Health Care 544
Systems of Care—Facilitating Transitions 544
Evidence-Based Practice 544
Technology 545
Biomedical Research 545
Paying for Care 546
Implications for Physical and Occupational Therapy 546

GLOSSARY 550
INDEX 557
4605_FM_i-xxvi 02/11/17 10:50 AM Page xxv
INTRODUCTION TO THE FOURTH EDITION
In the 2 decades since the first edition of this book was pub-
lished, the aging of the global population has continued
apace. Although some realities about aging remain constant,
the experience has changed in important ways. Many of these
changes are very positive: good health until later in life, con-
tinuing engagement with important occupations, improved
societal perceptions about aging and older adults. However,
these positive changes do not represent universal realities.
In some places, older adults continue to be marginalized and
devalued. Good health is not a certainty, particularly in the
developing world and among lower socioeconomic groups.
Ensuring adequate financial and instrumental resources can
be a struggle for many.
Yet all of us are, if we’re lucky, headed toward old age.
Many of us have loved ones who are already there—or perhaps
we’re there ourselves. Much can be done to promote positive
aging for everyone, and much is already being done; physical
and occupational therapists are actively engaged in these
efforts and have tremendous contributions to make in ensur-
ing the best possible experience of later life for everyone.
This volume is greatly expanded from previous versions:
an acknowledgment of the complexity of the aging experi-
ence, the science that contributes to positive aging, and the
specific considerations that therapists must bring to their
efforts to support older adults.
The major organizing principle for this edition is the In-
ternational Classification of Function (ICF; World Health
Organization, 2001/2008). This structure reflects a frame-
work often used by physical therapists and is closely aligned
with the related Occupational Therapy Practice Framework
(3rd ed.; American Occupational Therapy Association,
2014). The choice to use the ICF to organize the material
reflects our wish to promote professional collaboration,
acknowledging the close relationship between occupational
therapy (OT) and physical therapy (PT) and the increasing
emphasis in health care on interprofessional practice.
Incorporating the perspectives of two health professions
in a single book has been surprisingly challenging. We, and
our reviewers, had lively discussions about professional roles,
boundaries, and interactions. You may disagree with some of
our assertions about the roles of the two disciplines. These
disagreements may depend not only on your field, but also
on where you practice. Some countries (Canada, for example)
are more likely to be comfortable with some crossing of
professional boundaries. In some settings in the United States
(especially rural and inner city), boundary crossing may be
essential because there may be limited access to any care at
all. We have also incorporated consideration of how PT and
OT interact with other disciplines. The “Interprofessional
Practice” boxes throughout the book provide insights about
the health-care team as a whole. Effective practice in working
with older adults requires that team: something to keep in
mind as you make use of the material presented here.
Using This Book
Each chapter begins and ends with a clinical case, some briefly
presented, others more fully developed. These are designed
to help readers apply the facts on a given topic. Most cases
focus on individuals, but some emphasize population-based
interventions. PT and OT both work increasingly in these
more global kinds of care, helping to adapt environments, for
example, or addressing public policy. In a few instances, cases
appear more than once, with a different focus related to new
material in a given chapter, or they appear at the start and end
of a chapter to encourage more in-depth consideration of a
situation.
Each chapter also includes a number of feature boxes in
addition to “Interprofessional Practice.” “Around the Globe”
boxes are designed to promote understanding of what is
universal and what is culturally and societally mediated about
aging. They also provide interesting ideas that may be trans-
ferrable from one location to another. The “Promoting Best
Practice” boxes highlight research that can inform practice.
Keep in mind that most of the material in the book is based
on evidence. Evidence-based practice is not simply about
reading the occasional study; it requires exploring what is
known about any condition, situation, or intervention that is
part of your work and applying that knowledge to treatment
planning and delivery.
Although we tried to avoid excessive overlap, some is
unavoidable. Both the normal changes associated with aging
and the many possible illnesses and disabilities that can
develop reflect complicated factors, with many interacting
dynamics. To ensure adequate coverage, some linked material
appears in several chapters. For example, cardiovascular
accident (CVA/stroke) is a vascular event, so it fits the
discussion of cardiopulmonary conditions of later life, but it
also has significant cognitive, musculoskeletal, and sensory
consequences, so some material fit those chapters. In the end,
we included relevant content in several places where it made
sense to do so.
Likewise, material focused on evaluation and intervention
had relevance for many topics. So the chapters on how sys-
tems age have a primary focus on the probable and potential
changes that occur, but where it seemed logical, discussion
of evaluating cardiovascular function, vision, pulmonary
xxv
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xxvi INTRODUCTION TO THE FOURTH EDITION
capacity, and so on has been included. Relevant information
about exercise, one of the most vital interventions for both
well and impaired older adults, is included in several chapters,
each with a somewhat different emphasis. You will want to
refer back and forth to build a comprehensive perspective,
recognizing that it is simply not feasible to provide every piece
of information simultaneously.
This edition also has a robust online supplement where a
wealth of information can be found: websites, video links,
lists of assessments, news articles, case studies, video lectures,
and more. We hope you will use these liberally and that the
online materials will serve as a good resource for practice.
Understanding later life and focusing on enhancing posi-
tive aging can benefit not just older adults but their families,
friends, communities, and society at large. We hope that as
you read and as you move from learning to application, you
will consider the ways in which this material can help you
make a difference in your communities, your work, and in
your own lives.
References
American Occupational Therapy Association. (2014). Occupational therapy
practice framework: Domain & process (3rd ed.). American Journal of
Occupational Therapy, 68(Suppl. 1), S1-S48. http://dx.doi.org/10-5014/
ajot.2014.682006
World Health Organization. (2001). International classification of function.
Geneva: Author. Retrieved from www3.who.int/icf
World Health Organization (2008). ICF: International classification of func-
tioning, disability, and health. Geneva: Author.
4605_Ch01_001-018 31/10/17 12:01 PM Page 1
PA RT I
Global Health and Aging:
Implications for Health
and Participation
L ife expectancy has increased dramatically worldwide in
the late 20th and early 21st centuries (Centers for
Disease Control and Prevention, 2013). This increase is the
result of reductions in deaths from infectious diseases such
as polio and measles, as well as improved health-related
habits including smoking cessation and the use of seat belts.
At the same time, modern innovations like fast food and sub-
urban living have led to poor eating and limited exercise, with
associated increases in chronic diseases such as diabetes. The
positive changes in health care provide reason for optimism
about late life, but at the same time, the more negative be-
haviors are worrying. Beyond the obvious increase in longevity,
it is somewhat difficult to project whether later life will be
characterized primarily by good health and function or by in-
creased disease and disability (Crimmins, 2015; Crimmins &
Beltrán-Sánchez, 2010); indeed, each of these descriptions
may fit a segment of the older population.
The vast majority of older adults, even those with physical
or cognitive limitations, live in the community and adapt well
to the changes that are an inevitable part aging. Many con-
tinue to participate in meaningful occupations that contribute
to quality of life. Individuals find ways to manage the typical
decrements in physical and cognitive skills that often occur
in later life. These differences are not all negative. Individuals
may have to adjust to reduced vision or hearing, but they also
have life experience and knowledge that can help them cope.
For example, as can be seen in this text, although older adults
may learn differently than younger people do, they are still
quite capable of acquiring new skills and abilities, and may
offer valuable insights and observations to younger people as
well. It is essential to understand both the universal aspects
of aging and the individual experience, because “although
there are universal age-related changes, the process of aging
for each individual is unique” (Martin & Gillin, 2013, p. 53).
Part I of this book provides an overview of the aging ex-
perience and an introduction to biological and psychosocial
theories of aging, the meanings of occupation in later life,
and the social, cultural, and political environment in which
aging occurs. These chapters offer a framework in which the
experience of growing old can be understood. To ensure the
best care, providers must understand the individual, including
his or her history, needs, and wishes. It is also essential to
think of the individual in context, not as separate from life
experiences and community. In understanding contexts, it is
important to recognize that these include those in the older
adult’s immediate surroundings: the built environment, social
networks, neighborhood characteristics, and local policies.
But they also include the more global contexts: societal atti-
tudes toward aging, cultural values in the society, public pol-
icy affecting later life, and many other factors. This section of
the book is designed to provide an understanding of the con-
text in which aging occurs, and the experiences of individuals
and populations as they age.
Centers for Disease Control and Prevention. (2013). The state of aging &
health in America, 2013. Retrieved from http://www.cdc.gov/aging/help/
DPH-Aging/state-aging-health.html
Crimmons, E. M. (2015). Lifespan and healthspan; Past, present, and
promise. Gerontologist, 55, 901–911. doi: 10.1093/geront/gnv130
Crimmons, E. M., & Beltrán-Sánchez, H. (2010). Mortality and morbidity
trends: Is there a compression of morbidity? Journal of Gerontology: Psy-
chological Sciences and Social Sciences, 66, 75–86. doi: 10.1093/geronb/
gbq088
Martin, D. J., & Gillin, L. L. (2013). Revisiting gerontology’s scrapbook:
From Metchnikoff to the spectrum model of aging. Gerontologist, 54,
51–58. doi: 10.1093/geront/gnt073
1
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4605_Ch01_001-018 31/10/17 12:01 PM Page 3
Growing Old in Today’s World
“Be on the alert to recognize your prime at whatever time of your life—Muriel
LEARNING OUTCOMES
By the end of this chapter, readers will be able to:
1. Discuss the challenges in defining old age and provide
historical and current definitions.
2. Describe historical perspectives on aging and old age.
3. Identify reasons for increased longevity in modern
times.
4. Identify demographic characteristics, including age,
education, gender, and ethnicity, of older adults in the
United States and globally.
5. Discuss how these demographic characteristics affect the
experience of aging.
6. Analyze the effect of place of residence on the experience
of aging.
7. Identify the impact of cohort effects and individual
differences on the experience of aging.
8. Describe the interaction of public policy with the
experience of aging.
9. Describe models of positive aging.
10. Discuss the importance of these factors to the health-care
provider working with older adults.
Clinical Vignette
An inner-city community in a large city in the United States
has experienced a change in demographics over the past
3 decades. Formerly home primarily to upper-class couples,
the population of older adults has increased as younger cou-
ples have moved to the suburbs to raise their families. At the
same time, the average income in the community has gone
down, and the number of disadvantaged minority elders has
increased. At present, more than 20 percent of the population
is over age 60, and more than 50 percent of the population
has incomes below the poverty level.
1. How do you think the change in average age in the
community has changed the nature of life there?
2. What do you think might be some specific considera-
tions in terms of the services the community might
need to provide?
CHAPTER 1
Bette Bonder
it may occur.
Spark
”
3. Would you like to live in such a community? Why or
why not?
4. What might be some implications of these factors for
provision of health care in that community?
T he world is growing older. In the United States, the
population of people over age 65 is projected to in-
crease from 40.2 million in 2010 to 88.5 million in 2050
(Werner, 2011). Between 1990 and 2011, the adult mortality
rate around the globe decreased from 204 per 1,000 to
160 per 1,000 (World Health Organization [WHO], 2013).
As the WHO (2012) notes, “Population ageing is a global
phenomenon that is now occurring fastest in low- and
middle-income countries” (p. 5).
This demographic trend is, in part, the result of im-
proved wellness practices and improved health care. How-
ever, in the United States, more than a third of individuals
over age 65 have at least one disability (Administration on
Aging [AOA], 2012). By age 80, three-quarters reported
at least one disability, and 50 percent reported a serious
disability.
AROUND THE GLOBE: Demographics of Aging
The number of older adults globally will be larger than the number
of children by 2050. In 2009, there was one older adult for every
nine persons; by 2050, one older adult for every five persons is
expected worldwide (United Nations, 2009).
The social consequences of an aging population are uncer-
tain; the costs—for example, in terms of retirement funding,
availability of skilled workers, and health-care costs late in
life—have received considerable attention. However, there is
no consensus about how these issues will develop over time
(Crimmins & Beltrán-Sánchez, 2010; Vincent & Velkoff,
2010). Pessimistic projections suggest that the large popula-
tion of elders will place an undue financial and social burden
3
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4 PART I ■ Global Health and Aging: Implications for Health and Participation
on younger individuals. More optimistic projections suggest
that elders will be a source of significant support for younger
individuals and that they will continue to contribute to society
in meaningful ways. The one certainty is that around the
world, there will be more older individuals in the next several
decades, both in absolute numbers and as a percentage of the
population (WHO, 2013).
Changing definitions of aging and differing perceptions
of the aging process contribute to confusion about expected
roles, activities, and functional ability of older adults. The
concept of successful aging (Rowe & Kahn, 1998, 2015) has
received a great deal of attention; it is believed that support-
ing older adults in remaining functional and active can help
ameliorate pressure on social and health-care agencies as the
number of older adults continues to increase. The idea of suc-
cessful aging has been elaborated and refined to focus on op-
timal aging, positive aging, and other related constructs
(Fernández-Ballesteros, 2011), all of which attempt to de-
scribe ways in which older adults can experience later life in
the most positive way. These concepts will be discussed more
fully later in this chapter and in Chapter 5.
A historical and cultural context for understanding the
aging process is important because, as Achenbaum and Sterns
(1978) noted, “We cannot discuss old age without some sense
of trend, of where we are coming from and where we are
heading” (p. 307).
There has been growing attention to understanding the so-
cial determinants of health (Dean, Williams, & Fenton, 2013),
which can be directly linked to the experience of aging
(Marmot & Wilkerson, 2003). Individual factors such as gen-
der and personality, environmental factors such as physical sur-
roundings and place of residence, and sociocultural factors that
include economic circumstances, values and beliefs, and soci-
etal perceptions all affect an individual’s later life. They also
affect the health-care provider’s beliefs and actions in working
with elders. Figure 1-1 shows how these factors interact.
This chapter provides an overview of some of the many
influences on individuals’ experiences of later life. The first
section explores historical perspectives on aging. A current
definition of aging is provided, followed by a discussion of
current attitudes toward aging as well as the social determi-
nants of aging: individual factors, the physical environment,
and the sociocultural environment. The interrelationships
among these elements and the experience of aging are
Physical Sociocultural
environment environment
Place of residence Cultural factors
Neighborhood Public policy
characteristics
Individual characteristics
and experiences
FIGURE 11 Factors affecting the experience of aging.
examined, as are concepts of positive, usual, and patholog-
ical aging. Finally, the implications of these interrelated
elements for care provider are discussed.
History of Aging
Life Expectancy
In very early civilizations, the average life expectancy was
roughly 30 years (Carvallo, 2010). This is somewhat mislead-
ing because mortality was extremely high in the first year of
life so those who survived infancy might live well beyond 30.
As time went on, life expectancy increased to 40, a figure that
remained stable until about 6000 B.C.E. In ancient Greece,
Rome, and Egypt, men who reached the age of 25 could ex-
pect to live to 48 or so. In the Middle Ages, life expectancy
was roughly 33 to 35 years, although those in the upper
classes might survive to 50. By the end of the Renaissance, it
was increasingly common to find individuals living to 70.
Throughout that time, as is true in modern days, efforts
to prolong life were evident (Gruman, 1966/2003). These
efforts were recorded not only in the Old Testament but in
Greek, Indian, and Celtic myths. Long life was something
to be sought, although the search for the Fountain of Youth
suggests that although long life was valued, old age was not.
Life expectancy soared in the 20th century, primarily be-
cause of advances in public health, such as reductions in infant
mortality and improved treatment of communicable diseases
(Crimmins & Beltrán-Sánchez, 2010). At the beginning of
the 20th century, average life expectancy was between 45
and 49 years (National Center for Health Statistics, 2015),
although some individuals far outlived this age. For those born
in the United States in 2010, life expectancy is 81 years for
white women, 78 for African American women, 76 for white
men, and 62 for African American men. White men and
women who were 65 years of age in 2010 can expect to live
on average another 19 years; African Americans aged 65 in
2010 can expect another 18 years of life on average. According
to the WHO (2013), there is increased longevity worldwide.
Longevity alone does not define old age, although clearly
when life expectancy was shorter, individuals were considered
old at an earlier age than is the case now. So, for example,
during Shakespearean times, old age was said to begin at 40
(Sherman, 1997). By comparison, when the Social Security
Act was enacted in 1935 in the United States, the age of
eligibility—thus, the definition of old—was set at 65. There
are now conversations about whether old age begins
later given the fact that more than half of individuals in the
United States will live into their late 70s or 80s.
Impact of Economic Circumstances
and Gender Throughout History
Historically, the wealthy have always lived the longest. The
elements that contributed to this reality are similar to those
that persist to this day: access to adequate diet, health care,
4605_Ch01_001-018 31/10/17 12:01 PM Page 5
and information. Wealth also affected general perceptions
about older adults. Men of wealth were more likely than poor
men to be thought of as wise. In medieval Italy, older clergy
and men of means took on positions of increased authority
later in life (Cossar, 2012). Those who were impoverished,
however, worked until they could no longer do so and were
then perceived as burdensome (Haber, 1997).
Gender has also influenced the experience of aging
throughout history. Women generally were thought to
reach old age well before men (Achenbaum & Sterns,
1978), but they also lived longer, thus spending a much
greater proportion of their lives being old than men
(Moody, 1986). Their specific circumstances depended in
part on their wealth. In societies where widows could not
keep their late husbands’ resources, older women lived in
poverty, but even in societies in which they were able to re-
tain resources, they were generally treated with suspicion
(Haber, 1997). When pensions were introduced as a ben-
efit of employment in the middle of the 20th century, these
often stopped at the husband’s death (probably earlier). To
this day, older women are far more likely than older men
to live in poverty (Vlachantoni, 2012), although this may
change as more women who have held paying jobs reach
old age. Over the past century, living arrangements have
changed substantially but differently for men and women
(Gratton & Guttman, 2010). The dominant living
arrangement for women became solitary, but for men, it
was with a spouse.
There are also ways in which women have aged more sat-
isfactorily than men (Perrig-Chiello & Hutchison, 2010),
primarily because of their historical responsibility for house-
holds and for grandparenting activities. These defined roles
continued women’s earlier activities, minimizing challenges
in the transition to old age. In addition, roles such as teach-
ing (Fig. 1-2), typically considered a feminine occupation
in the United States, offered options that did not rely on
family relationships. It may also have been more comfort-
able, or at least more socially acceptable, for women to
accept dependency.
FIGURE 12 Teaching can be a way to maintain social ties. Jose Luis
Pelaez Inc/Thinkstock
CHAPTER 1 ■ Growing Old in Today’s World 5
Another largely economic issue is that of retirement. Until
relatively recently, the gerontology literature suggested that
retirement was an innovation of the mid-20th century when
many countries implemented various pension strategies.
However, more recent authors indicate that, in fact, retire-
ment has existed as an option for centuries, at least for some
individuals (Cossar, 2012). Shahar (1997) notes that during
medieval times, landlords might well have provided support
for those peasants they wished to remove from farming
activities. Vinovskis (2005) describes the pension system that
emerged following the American Civil War, when soldiers
were provided with pensions, as were their surviving spouses.
Hayward (2005) indicates that similar trends can be seen in
the histories of European countries.
It is worth noting that there are examples of modern forms
of care and support for older adults dating back many cen-
turies. As early as 1489, there were assisted living facilities
with services much like those found today (Warren, 2012).
These facilities were primarily for men, as women were per-
ceived as inferior and unworthy of attention.
Attitudes About Aging From a Historical
Perspective
Ambiguity has characterized attitudes about aging through-
out history (Ryan, O’Rourke, Ward, & Aherne, 2011).
“Perceptions of the aged’s worth, as well as their demographic
and socioeconomic status, have varied enormously according
to historical time and societal context” (Achenbaum &
Sterns, 1978, p. 307).
Older men are described in some sources as foolish and
burdensome while in others as respected, wise, and revered
(Sherman, 1997). Older women have sometimes been por-
trayed as wise although more commonly as irrational and
childish (Covey, 1989). The Old Testament suggests that
older adults should be revered for their wisdom. The Greeks,
in contrast, believed that aging was unpleasant as did the
Romans. During colonial times in the United States, there
was a Calvinist ideal of veneration for older adults who at
that time represented 4 percent to 7 percent of the popula-
tion. Throughout history, aging has been associated with wis-
dom (Edmonson, 2005), a perception that was not always
realized in action as older adults were often shunted aside
(Covey, 1989). This appears somewhat less true in non-
European cultures. In Native American groups, elders were
perceived as wise and were respected and valued (Eden &
Eden, 2010). They also had meaningful roles in the commu-
nity as caregivers for children, wise elders, hunters, story-
tellers, and healers.
Attitudes have shifted over time as well. Note, for exam-
ple, that the word “hag” derives from a Greek word meaning
“holy one” (Sokolovsky, 1997). It retained that positive
meaning until the 13th century, when the Catholic Church
felt threatened by independent older women and it became
pejorative. There are many more such negative terms for
women than for men.
4605_Ch01_001-018 31/10/17 12:01 PM Page 6
6 PART I ■ Global Health and Aging: Implications for Health and Participation
Historical Roles of Older Adults
Expectations about appropriate or expected functions for
older people have varied over time (Campbell, 2010; Cossar,
2012). In ancient and medieval society, contemplation was
considered the central purpose of old age (Covey, 1989).
Other activities, including work, sex, and military activities,
were not thought to be appropriate.
For years, conventional wisdom suggested that older
adults did well in agrarian societies, where their supportive
efforts were a vital part of the culture (Achenbaum &
Sterns, 1978). Certainly in Native American groups, older
adults were central to the well-being of the community
(Eden & Eden, 2010). Even in agrarian cultures, individ-
uals who did not live on farms or with extended families
were denied clear roles (Hagestad, 1986), and older adults
in industrial settings were denigrated because they could
not contribute to their families’ economic well-being
(Achenbaum & Sterns, 1978). However, in some specific
areas, including politics, religion, and academe, elderly
people—that is, elderly men—were valued for their expe-
rience and wisdom (Cossar, 2012).
Cohort Effects
Individuals age in particular clusters or cohorts that experi-
ence a set of historical events that influence personal behav-
ior and the experience of aging (Hudson & Gonyea, 2012).
For example, today’s cohort of the very old in the United
States—those born before 1935—lived through both the
Great Depression that began in 1929 and World War II in
the 1940s. These experiences led to a strong value placed on
frugality as well as great patriotism that may have con-
tributed to their tendency to vote in large numbers today.
That same cohort includes long-term survivors of polio who
TABLE 11 ■ Characteristics of Cohorts in the United States
GENERATION BORN
Traditionalists 1922–1945
Baby Boomers 1946–1964
Generation X 1965–1980
Generation Y/ Millennials 1981–2000
Based on Tolbize (2008).
are experiencing renewed disability attributed to “post-polio
syndrome” (National Institute of Neurological Disorders and
Stroke, 2006). In contrast, members of the Baby Boom gen-
eration (born 1946–1964) were the recipients of the first
polio vaccine, which has now all but eliminated polio around
the world. The World War II generation has reason to be
much more attuned to the benefits of availability of preven-
tive vaccines because of their experiences with polio and
other potentially deadly diseases.
Cohort experiences influence attitudes toward such
issues as Social Security benefits and other policy consid-
erations (Pruchno, 2012). It remains to be seen how cohort
experiences of the Baby Boom generation, including such
events as the Vietnam War, the women’s liberation move-
ment, and Watergate, will affect the group of older adults
now entering late life (Hudson & Gonyea, 2012). Early
research suggests that significant differences between
cohorts—rates of unmarried older adults (Lin & Brown,
2012), health status (L.G. Martin, Freedman, Schoeni,
& Andreski, 2009), and expectations about lifestyle (Roth
et al., 2012), for example—will influence these individuals’
plans about retirement, their financial circumstances, and
their interactions with other generations. For example,
Baby Boomers, who as a group had fewer children than
their predecessors, may have greater difficulty securing
informal care as they age (Ryan, Smith, Antonucci, &
Jackson, 2012).
At the same time, within a given cohort, experiences and
environment can lead to considerable variability among older
adults (Hsu & Jones, 2012). Table 1-1 shows the character-
istics attributed to some of the generations currently alive in
the United States. Groups in other countries will have differ-
ent experiences that affect cohort values and behaviors. But
individuals within a given cohort may vary significantly from
these stereotypes.
CORE LIFE VALUES WORKRELATED ETHIC AND VALUES
Respect for authority Sacrifice
Conformity Hard work
Discipline Duty before pleasure
Optimism Driven
Involvement Personal fulfillment
Personal Question authority
gratification/growth
Fun Risk takers
Balance Skeptical
Informality Self-reliance
Confidence Multitasking
Realism Collectivistic
Social Entrepreneurial
4605_Ch01_001-018 31/10/17 12:01 PM Page 7

CHAPTER 1 ■ Growing Old in Today’s World 7

Aging Today: Factors Affecting (Rosenberg, Huang, Simonovich, & Belza, 2012; Wahl,
Iwarsson, & Oswald, 2012). “The ecology of aging perspective
the Experience of Aging
posits old age as a critical phase in the life course that is pro-
foundly influenced by the physical environment” (Wahl et al.,
Current understanding of old age is influenced by both pub-
2012, p. 307). Considerations include the nature of the
lic policy and the rapid increase in life expectancy. “Two
immediate physical environment—for example, whether
factors—longer life spans and aging Baby Boomers—will
there is access to safe outdoor space for physical activity; the
combine to double the population of Americans aged
location—urban, suburban, or rural; and the familiarity of the
65 years or older during the next 25 years to about 72 million.
individual to the location—whether aging in place or migration.
By 2030, older adults will account for roughly 20% of the
In rural environments, older adults are likely to be an in-
U.S. population” (Centers for Disease Control and Preven-
tegral part of the community and are involved in volunteer
tion [CDC], 2013, p. ii). The most rapid growth is among
activities and social networks (Fast & de Jong Gierveld,
those over age 85.
2008). The grocery store, post office, and bank are important
Simply defining what is meant by the term “old” can be
sources of socialization and support, and informal networks
complicated. Neugarten (1976, 1978), while acknowledging
are effective for both maintaining health and providing care
these were imperfect reflections of personal attributes, iden-
for those who are ill. These supports are essential to positive
tified two groups of older adults: the “young-old,” those aged
quality of life, whether they are provided by family or by
55 to 75 years, and the “old-old,” those aged 76 and older.
others (Keating, Swindle, & Fletcher, 2011).
The “young-old” may have more in common with individuals
Although there is good social support in small towns,
in their middle years than with the very old, or those over
older adults who live a distance from town may have limited
85 years (Velkoff, He, Sengupta, & DeBarros, 2006). Some
social opportunities and more difficulty obtaining needed as-
categorizations go further to describe a group of oldest-old
sistance in part because of distance and transportation diffi-
who are 85 years or older and add a group of middle-old in-
culties (Baernholdt, Yan, Hinton, Rose, & Mattos, 2012).
dividuals aged 76 to 84. However, chronological definitions
This can result in poor access to care and increased health-
are of limited value because extreme individual variability
care costs (McAuley, Spector, & Van Nostrand, 2009). Older
characterizes later life (Schafer & Shippee, 2010).
adults in rural communities may also have limited access to
Definitions of old age must differentiate the old person
environments that support physical activity and may find
(an individual) from old people (a group) (Settersten, 2005).
their social networks disrupted by outmigration of younger
It is important to distinguish old age (a period of life) from
individuals (Dye, Willoughby, & Battisto, 2011).
aging (which occurs throughout life). The experiences of a
For suburban elders, transportation is frequently a prob-
single older person may vary substantially from that of old
lem (Pekmezraris et al., 2013). They tend to have the greatest
people in general.
financial resources but fewer community resources, and for
For purposes of this book, old age is considered in the
those who are frail, the lack of resources and transportation
context of function rather than absolute chronological age.
can make occupational engagement difficult. More affluent
However, in terms of public policy in the United States, old
suburban elders deal with the dilemmas of suburban life by
age most often refers to individuals age 65 years or older. This
moving to communities designed specifically for them
definition is based largely on eligibility for Medicare and
(McHugh & Larson-Keagy, 2005). This may address some
Social Security in the United States and public pensions in
instrumental problems but can be isolating.
other developed countries. Even in policy, though, the defini-
Urban elders may have greatest access to transportation
tion of old age is a moving target. For example, to reduce Social
and services, resulting in greater social interaction than may
Security outlays as the Baby Boom generation reaches later life,
be available in suburban or rural settings (Baernholdt et al.,
eligibility is being gradually increased to age 67 by 2030.
2012). However, they may not have the economic capacity
Recall the factors outlined in Figure 1-1, which showed
to take advantage of those services. The built environment,
the interaction among individual characteristics, the physical
the constructed aspects of the community, can be perilous in
environment, and the social/cultural environment. The ways
urban settings. Buffel, Phillipson, and Scharf (2012) note that
in which these interrelated considerations come together
“urban hazards and risks may affect older people in a number
influence the extent to which a given individual can ensure
of ways. Traffic congestion and limited provision of public
positive aging.
toilets and places to rest, have variously been identified as fac-
tors that may reduce the quality of daily life” (p. 602).
Physical Environment The impact of rural versus urban residence is an issue
in many parts of the world (Mollenkopf et al., 2004).
Place of Residence Mollenkopf and colleagues studied five European countries
The geographic location in which an older adult resides and and found that rural elders were more likely to own their
the quality of housing in that location are among the charac- homes but had less access to services and amenities. Life sat-
teristics of the physical environment that influence late life. isfaction was similar in rural and urban settings assuming that
There are strong links between housing, health, and function there was adequate access to leisure activities.
4605_Ch01_001-018 31/10/17 12:01 PM Page 8
8 PART I ■ Global Health and Aging: Implications for Health and Participation
Aging in Place
Regardless of place of residence, most elders express a wish
to age in place—that is, to remain in their own homes
(Löfqvist et al., 2013). Remaining at home enables older
adults to remain independent and to retain social support
from friends and families (Wiles, Leibing, Guberman, Reeve,
& Allen, 2011). They see aging-in-place as “an advantage in
terms of a sense of attachment or connection, practical ben-
efits of security and familiarity, and as being related to peo-
ple’s sense of identity through independence and autonomy”
(Wiles et al., 2011, p. 364). A wide array of programs is being
implemented at the community level to support older adults’
wishes to remain in their own homes (Greenfield, Scharlach,
Lehning, Davitt, & Graham, 2013; Rantz et al., 2011).
Although aging in place is typically considered to be positive,
for some elders it is not optional because, particularly in the
certain economic environments, they may not be able to sell
their homes (Perry, Andersen, & Kaplan, 2013).
Type of housing and related environmental factors corre-
late with relative well-being of elders (cf. S. C. Brown et al.,
2009). Those living in more affluent neighborhoods, regard-
less of location, tend to age more successfully than those
in poor neighborhoods (Cagney, Browning, & Wen, 2005).
Resources such as local colleges can enhance activity and
socialization (Harrison & Tsao, 2006) as can structural fac-
tors such as front porches.
✺ PROMOTING BEST PRACTICE
Naturally Occurring Retirement Communities
A program in two suburban Maryland neighborhoods offered
health care, social work, activities, and transportation services to
six apartment buildings that had become Naturally Occurring
Retirement Centers (NORCs) housing primarily older adults. Of
individuals using the services, three-quarters were satisfied with
them. Although physical health of the service users showed no
difference from other residents, their level of depression was
significantly lower after participation (Cohen-Mansfield,
Dakheel-Ali, & Frank, 2010).
When elders choose not to age in place or cannot for
reasons of health, economics, or other factors, careful con-
sideration must be given to supporting successful transitions
(E. Walker & McNamara, 2013). Such transitions can be
disruptive and unsettling. The decision to move seems to be
most positive when it is made by the individual when he or
she is still capable of the cognitive, physical, and emotional
adjustment to a new environment.
Migration and Institutional Residence
Migration has consequences for elders (Bradley & Van
Willigen, 2010). Some individuals develop a pattern labeled
“snowbirding” in which they maintain two households, one
in their community of long-standing residence and one in
a warmer climate where they live during the winter (Bjelde
& Sanders, 2012). Some elders who have moved to a
warmer location ultimately decide on “reverse migration” to
be closer to family as they become more frail (Stoller &
Longino, 2001). Elderly immigrants moving from their
countries of origin to the United States also have unique
characteristics (Becker, 2002), a situation probably found
in many countries with large immigrant populations.
Decisions about where to live can cause anxiety and discom-
fort for elders (Löfqvist et al., 2013).
AROUND THE GLOBE: Immigration and Health Status
Aging immigrants from Eastern European countries who moved
to Western European countries had greater depression and worse
health than older adults who lived and remained in Western
Europe. This may have been the result of poor health before
immigration, the stresses that led to the decision to immigrate,
or factors associated with experiences after immigration. Care
providers must consider immigration status and circumstances
in providing care (Lanari & Bussini, 2012).
An additional often overlooked issue is that of homeless-
ness (Culhane, Metraux, Byrne, Stino, & Bainbridge, 2013).
The number and proportion of older homeless individuals has
increased due in part to deinstitutionalization of individuals
who are chronically mentally ill, reductions in social safety
net programs, and lack of family support. Survival is, of
necessity, a primary focus of activity, leaving little time for
concern about “successful” aging.
Few older adults are institutionalized. In 2012, roughly
1.5 million elders or 3.6 percent of the population over age
65 resided in nursing homes (AOA, 2012). The oldest-old,
women, and individuals without family support are dispro-
portionately represented in this group, with roughly 11 per-
cent of the over age 85 population residing in long-term care.
A wide array of alternative supported living arrangements are
described in Chapters 27, 28, 30, 31, and 32. It is possible
that alternative supportive housing arrangements will play a
role in further reducing institutionalization.
Sociocultural Factors
Current Attitudes
Attitudes have the potential to affect the experience of grow-
ing old in several ways. “A large body of evidence points to
the powerful effects that subjective evaluations and attitudes
can have on a wide range of future behaviors and health out-
comes” (Bryant et al., 2012, p. 1674). Positive attitudes toward
aging can enhance the experience, increasing the potential for
good quality of life in later life (Gilbert, Hagerty, & Taggert,
2012; Lu, Kao, & Hsieh, 2010), both for healthy elders and
those with significant health issues such as dementia (Trigg,
Watts, Jones, Tod, & Elliman, 2012). In addition, positive
attitudes among health-care providers (Samra, Griffiths, Cox,
4605_Ch01_001-018 31/10/17 12:01 PM Page 9
Conroy, & Knight, 2013) and family caregivers (Hilton,
Kopera-Frye, & Krave, 2009) can improve the experience of
aging for elders and caregivers alike.
In contrast, negative perspectives on later life are common
and damaging (Jönson, 2012). All too often “older people are
regarded and treated as people with other lesser needs”
(p. 198). This negative view, typically labeled ageism, is
somewhat ironic given that all of us will eventually be old;
thus, as Jönson notes, we are discriminating against our future
selves. Negative stereotypes of later life contribute to discrim-
ination and negatively affect older adults’ function and health
(Palmore, 2015).
Stereotypes of aging compete with the various realities,
leading to considerable confusion of views (Roth et al., 2012).
At one end of the spectrum are extremely negative perspec-
tives, leading Butler (1975) to ask, “Why survive?” There has
been some improvement in media portrayals of elders
(Kessler, Schwender, & Bowen, 2009), although too often
older adult characters are presented as foolish or inept
(Grandpa Simpson on The Simpsons, the Woody Grant char-
acter in the movie Nebraska, for example). At the same time,
social media platforms such as Facebook have provided new
outlets for ageist expression (Levy, Chung, Bedford, &
Navrazhina, 2013).
Stereotypes of aging contribute to relatively pervasive if
increasingly subtle ageism (Kotter-Grühn & Hess, 2012).
This extends to the views care providers hold about older
adults’ abilities to benefit from care (cf. C. A. Brown, Kother,
& Wielandt, 2011). In addition, negative perceptions con-
tribute to inadequate care for elders, care that they themselves
would not accept (Jönson, 2012). These findings suggest that
providers must ensure that personal biases do not negatively
affect intervention.
Fortunately, over the past several decades, there has been
an increase in the number of studies of aging as a positive
phenomenon (Jeste & Palmer, 2013; Rowe & Kahn, 1998).
A substantial body of research suggests that the majority of
older adults make significant contributions to society and enjoy
life as well (Fernández-Ballesteros et al., 2013) and this aware-
ness has, to some extent, modified negative attitudes toward
later life. There is some danger that the idea of positive aging
will lead to a different type of ageism, one that marginalizes
elders who are disabled or “simply old and not well preserved”
(Minkler & Holstein, 2005, p. 308). It appears that the most
effective strategy for portraying later life to ensure positive
perspectives is to reflect images that are realistic but upbeat
rather than completely optimistic (Fung et al., 2015). This
reduces the potential to leave older adults feeling inadequate
if they experience normal age-related change or significant
illness or disability.
It may be that some of the range of perspectives is the
result of experience with elders of different ages. There is no
question that the picture is somewhat less positive (although
by no means automatically bleak) for the oldest-old, those
older than age 85 (CDC, 2013), who are likely to have some
degree of dependence and infirmity. As discussed throughout
CHAPTER 1 ■ Growing Old in Today’s World 9
this volume, these individuals can, and many do, still enjoy
meaningful lives. And there are more and more examples
such as the Benjamin Rose Institute on Aging Mythbusters
(2014), stereotype-defying elders who remain engaged in life
and activities as they manage the changes associated with
later life.
Attitudes toward older adults can be changed through sys-
tematic efforts at education (Fernández-Ballesteros et al.,
2013), for example, through courses and workshops that
emphasize positive aspects of aging and public awareness
campaigns like the Mythbusters. Individual experiences with
older adults whose behavior and appearance contrast with
stereotypes can also encourage reexamination of negative
beliefs. Elders need to find strategies for resisting negative
stereotypes, for example, by focusing on the uplifting aspects
of their own lives and those of their friends, to avoid having
negative perspectives become self-fulfilling prophecies
(Wurm, Warner, Ziegelmann, Wolff, & Shcuz, 2013). Like-
wise, policy makers and care providers need to acknowledge
that older adults are not somehow less important or less de-
serving of attention than younger individuals (Jönson, 2012).
Across the globe, there are some common elements re-
garding attitudes toward older adults. At the same time, there
are cultural variations as well. Understanding and acknowl-
edging these differences can support older adults’ sense of
meaning (Fung, 2013).
Cultural Factors
Historical and demographic trends are important to under-
stand, but they are not the same for all cultures. To under-
stand the experience of aging, cultural factors must also be
examined. “Age is a social construction and the experience of
growing old is culturally mitigated” (Fry, 1996, p. 123).
Demographic trends are a good indicator of some impor-
tant cultural and societal differences. In the developed world
(Canada, the United States, Europe, Australia, and Russia),
13 percent or more of the population was aged 65 years
or over in 2000 (He, Muenchrath, Kowal, & U.S. Census
Bureau, 2012). The percentage of elders in the Chinese pop-
ulation mirrors that of developed countries—over 13 percent
(WHO, 2012). However, the country has experienced social
dislocation for older adults, with significant impact on their
quality of life (Li & Wu, 2013).
In the developing world, the current percentage of the
population over age 65 years is less than 8 percent (and less
than 3 percent in central Africa, where AIDS has taken a toll;
WHO, 2012). But an increase in the proportion of the pop-
ulation that is older is growing worldwide. Fifty-nine percent
of the world’s elderly population now lives in Africa, Asia,
Latin America, the Caribbean, and Oceania. By 2050, two
important population trends, already evident, will be far more
pronounced:
1. The absolute number and percentage of elders worldwide
2. The change in demographic structure from a pyramid
to a more rectangular shape (WHO, 2012).
4605_Ch01_001-018 31/10/17 12:01 PM Page 10
10 PART I ■ Global Health and Aging: Implications for Health and Participation
Culture may affect individuals’ expectations about what
old age will be like, their plans and goals for this period of
their lives, their values and attitudes about being older and
about health care, and their motivations for engaging in or
withdrawing from activity. In the United States, one reason
for increasing interest in cultural factors is the growing recog-
nition of significant health disparities (Ferraro & Shippee,
2009; Villa, Wallace, Bagdasaryan, & Aranda, 2012). Racial
and ethnic differences are associated with rates of disease,
views on health care, access to care, and outcomes of care.
For elders, an accumulation of disadvantage throughout the
life course may intensify these disparities (Villa et al., 2012).
The reasons for the differences are not clearly understood,
with hypotheses ranging from genetic differences to socioe-
conomic and environmental factors to systematic discrimi-
nation. Culture as it affects aging is discussed in greater detail
✺ PROMOTING BEST PRACTICE
in Chapter 6.
Public Policy and Aging
Public policies emerge from cultural values and beliefs in par-
ticular societies and have a substantial impact on individuals’
lives. For example, retirement income and health-care cov-
erage are among the issues closely tied to legislation. Policies
about pensions, investments, and health care can greatly
influence the extent to which elders are sufficiently secure
financially in later life (Bergstrom & Holmes, 2004). Policy
can also support or impede positive aging as it supports or
impedes individual function (Hinrichsen et al., 2010). Let us
consider one example: financial support for older adults.
Until relatively recently, in most societies elders undertook
various instrumental tasks such as farming, gathering, and
child care until they were too infirm to continue. At that
point, they were tended to by families or they managed as
best they could on their own until they died, usually soon
thereafter. The industrial revolution led to the gradual imple-
mentation of pensions over several decades beginning in the
late 1800s in Germany (Hawthorne, 2013).
In the United States, Social Security was instituted in the
1930s as a response to the Great Depression (Hawthorne,
2013). The system encouraged elders to retire to open jobs
for younger individuals. Other forms of pension became more
common after World War II at a time when wages were fed-
erally controlled to minimize the threat of massive inflation.
Now, however, pensions are rapidly disappearing in the
United States (Westerman & Sundali, 2005). Many devel-
oped countries, including Great Britain and Germany, also
face changes in pension structure because of the rapid
growth in the proportion of older adults in their popula-
tions (Büchel, Frick, & Zaidi, 2005). Social Security,
meanwhile, has reduced poverty among older adults
(Kingston & Herd, 2005). Recent concern about Social
Security focuses on the fact that the population of the
United States has an increasing proportion of elders relative
to the population of working age individuals (typically de-
fined as 22 to 65 years of age). Policy analysts suggest this
dependency ratio—the ratio of those in the workforce to
children and elders depending on workers to provide their
financial support—is projected to increase from 22 to 35
between 2010 and 2030 (Vincent & Velkoff, 2010). This
may be an inaccurate calculation because many older adults
have opted to remain in the workforce because of the major
recession that began in 2008.
One result of these various factors coming together at this
point in time is substantial economic uncertainty for older
adults. This is particularly problematic because they do not
have the luxury of a long time frame to recoup investment
losses or to earn additional income.
Public Policy and Active Aging
A review of policies in Europe suggested the need for a new
“integrated” model of policies for aging that emphasizes family,
leisure, and community; work; and education and training as
simultaneous, integrated activities (A. Walker & Maltby, 2012).
Policy also influences access to health care. There is a com-
plex maze of legislative initiatives intended to address the
needs of elders while at the same time attempting to constrain
costs. Care providers working with older adults also must
negotiate a confusing and ever-changing set of rules and reg-
ulations that determine where care will be provided—in the
community, a hospital, a nursing home—and what kinds of
care will be reimbursed. A more in-depth discussion of public
policy and of the role for therapists in influencing policy to
benefit their clients can be found in Chapter 3.
Individual Characteristics
The experience of aging is unique to each individual, even in
the context of the broader society. Individual genetic traits,
personality characteristics, and personal experience through-
out the life span are central to a person’s later life circum-
stances, behaviors, and attitudes. Morack, Infurna, Ram, and
Gerstorf (2013) cite Spiro (2007), noting “there are substan-
tial between-person differences in how physical and mental
health change with age. Some people maintain good health
until late in life, and others experience precipitous declines
early on” (pp. 475–476).
Genetic factors vary among individuals and have a signifi-
cant impact on aging (Blagosklonny, Campisi, & Sinclair,
2009). As human genetic structure is better understood, it is
clear that differences in DNA among individuals (and among
species) are small, but those differences can have profound
implications for development of each person (Sutphin &
Kaeberlein, 2011). Genetic explanations have been proposed
for a variety of disorders commonly seen in later life, includ-
ing Alzheimer’s disease, osteoporosis, diabetes, and heart dis-
ease (Bostock, Soiza, & Whalley, 2009). However, there is
also compelling evidence that a variety of environmental and
social factors can mediate the expression of genes (Vaupel,
4605_Ch01_001-018 31/10/17 12:01 PM Page 11
2010). As W. Johnson and Krueger (2005) indicate, “genetic
expression may be buffered in some environmental circum-
stances but manifested in others” (p. 50).
Personal experience includes the cumulative advantage
or disadvantage that results from differences in socioeco-
nomic status and education that can influence health status
and outlook in later life (T. H. Brown, O’Rand, & Adkins,
2012). Stress has a significant influence on well-being in
later life (M. Martin, Grünendahl, & Martin, 2001) as does
self-identity (Franks, Herzog, Holmberg, & Markus, 2003).
Early life events such as parental loss among African
Americans are associated with poor integration into family
life and friendships and fewer social resources very late in
life (C. L. Johnson & Barer, 2002).
A factor proposed as serving to buffer genetic characteris-
tics is individual personality (Morack, Infurna, Ram, &
Gerstorf, 2013) as can personal skills and abilities. Adapt-
ability and emotional regulation contribute to well-being in
later life (Holahan & Velasquez, 2011) as does the ability to
establish a social network (Steverink, Westerhof, Bode, &
Dittmann-Kohli, 2001). Some research has found that it is
the act of helping others that is important as opposed to sim-
ply receiving help from a social network (Kahana, Bhatta,
Lovegreen, Kahana, & Midlarsky, 2013).
Positive outlook is consistently associated with well-being
in later life (Bryant et al., 2012). Positive self-esteem (Bailis
& Chipperfield, 2002) and optimistic expectations may influ-
ence decisions to seek help when difficulties arise (Sarkisian,
Steers, Hays, & Mangione, 2005).
Some older adults seem to age with grace and to identify
old age as a time of fulfillment. Others seem pessimistic and
dour. Identifying and drawing on individual strengths is an
important strategy in providing interventions that are helpful
in enhancing later life for elders. These factors are discussed
in greater detail in later chapters.
The Impact of Gender in Modern Times
The experiences of older women and older men diverge in
significant ways. Because of differences in life expectancy,
women may experience greater isolation and loneliness and
lower life satisfaction in later life (Schaan, 2013). The current
cohort of oldest-old women has limited work histories, re-
sulting in financial difficulties in late life; the median income
of older men in 2011 was $27,707, whereas for women it was
$15,362 (AOA, 2012). These financial effects are also found
in other countries, including those where social welfare poli-
cies have been enacted to avoid such problems (Gornick,
Sierminska, & Smeeding, 2009). The situation may improve
somewhat because the Baby Boomer generation includes a
much larger percentage of women who have had independent
careers and, hence, greater financial security (Seaman, 2012).
Women’s higher rates of late-life disability present signifi-
cant challenges (Gill, Gahbauer, Lin, Han, & Allore, 2013).
Women are more likely to develop Alzheimer’s disease, ex-
perience bone fractures, and have other compromising health
CHAPTER 1 ■ Growing Old in Today’s World 11
conditions. This means that they are more likely to require
assistance but, because they are also more likely to be
widowed, have less access to informal care (Lahaie, Earle, &
Heymann, 2013).
Men also face unique challenges. Although older men
have fewer financial difficulties, men who are alone experi-
ence greater social isolation and loneliness (Greenfield &
Russell, 2011). On the other hand, older men have less phys-
ical disability, perhaps because they are less likely to survive
into very old age (Gill et al., 2013).
Socioeconomic Factors
As can be seen from the discussion to this point, socioeco-
nomic status (SES) factors play a significant role in aging.
Education, occupation, and income level influence the expe-
rience of aging as well as morbidity and mortality (Taylor,
2010). Public policies that encourage or discourage social and
economic mobility (sociocultural environment) and the avail-
ability of effective schools (physical environment) also play a
role in SES.
The consequences of long-standing socioeconomic disad-
vantage have received particular attention (Hatch, 2005);
these persist into very late life (Enroth, Raitanen, Hervonen,
& Jylhä, 2013). This is true to a lesser extent in countries that
have more robust social supports for older adults such as
Canada and Denmark (Granados, 2013). At its most basic,
the influence of SES can be summarized to suggest that “high
SES, especially high levels of education, provides the access
needed to make use of health information, medical proce-
dures, and disease prevention strategies earlier than these
resources become available to lower SES individuals” (Dupree
& George, 2011, p. 117).
SES is linked to both physical and mental health, with
disadvantage associated with higher rates of a variety of dis-
orders (Schöllgen, Huxhold, & Schmiedek, 2012). Lower
SES is associated with increased risky health behaviors
(Wray, Alwin, & McCammon, 2005) and poorer follow-
through with health promotion and screening behaviors (Fox
et al., 2004). Educational disadvantage is linked to physical
vulnerability and to worse consequences from that vulnera-
bility (Clark, Stump, Miller, & Long, 2007).
For a variety of reasons, the financial circumstances of eld-
ers tend to deteriorate as they live longer, and it seems likely
that the extent of poverty in retirement is undercounted
(Butrica, Murphy, & Zedlewski, 2009). This finding is less
true for individuals who have more education and financial
resources. Some disadvantaged elders have protective re-
sources that ameliorate the negative consequences of low SES
(Dupree & George, 2011). Among the protective factors are
stable marriage, the presence of adult children, and expecting
to live to age 85. It seems possible that this last is a marker
of optimism and resilience. One potential explanation, which
is considered in Chapter 5, is the differential occupational
patterns in which elders engage—that is, the extent to which
the individual finds life meaningful.
4605_Ch01_001-018 31/10/17 12:01 PM Page 12
12 PART I ■ Global Health and Aging: Implications for Health and Participation
Positive Aging
Physical and psychosocial change is inevitable with age;
however, such change does not necessarily define an individ-
ual’s affective experience of aging. Older adults’ attitudes and
behaviors differ in ways that can dramatically affect their
quality of life and life satisfaction. A number of theories
attempt to describe what characteristics contribute to such
positive outcomes.
Perhaps the most widely known of these is Rowe and
Kahn’s (1998) theory of successful aging. They suggested that
elders could live satisfying lives based on three objectives:
1. Avoiding disease and disability
2. Maintaining high cognitive and physical functioning
3. Staying involved with life and living
This clearly reflects important factors in the aging experi-
ence, but as Rowe and Kahn (2015) recognize, the theory has
been criticized for several reasons. For example, the model
does not address the importance of spirituality (Crowther,
Parker, Achenbaum, Larimore, & Koenig, 2002). And it
does not incorporate subjective aspects of the aging experi-
ence (Pruchno, Wilson-Genderson, Rose, & Cartwright,
2010) or environmental factors (McLaughlin, Connell,
Heeringa, Li, & Roberts, 2010).
Rowe and Kahn’s three goals also seem to suggest that, to a
significant extent, successful aging is outside voluntary control.
After all, even with strenuous health promotion efforts, avoid-
ing disease and maintaining functioning are not always within
an individual’s power. However, individuals with various kinds
of disability or dysfunction may lead very satisfying lives
(McLaughlin et al., 2010). And individuals who are, to all
appearances, healthy may have personal interpretations of their
experience that leave them feeling decidedly unsuccessful.
Because of these concerns, other constructions of positive
later life have emerged, including positive aging, aging well,
and optimal aging (Fernández-Ballesteros, 2011). Fernández-
Ballesteros identified “five independent factors of positive
aging: health, cognition, activity, affect, and physical fitness”
(pp. 27–28). Affective or subjective elements are present
within these five categories so that, for example, health
includes the individual’s perception of his or her health. For
purposes of this book, the focus is on positive aging, examin-
ing both objective and subjective aspects of the factors that
contribute to satisfaction in late life.
Both Rowe and Kahn’s (1998) description of successful
aging and Fernández-Ballesteros’ (2011) discussion of posi-
tive aging incorporate the importance of maintaining activity
and physical capacity. It is this emphasis that makes occupa-
tional and physical therapy interventions so vital to positive
aging. Activity is explicitly identified as the domain of occu-
pational therapy (American Occupational Therapy Associa-
tion, 2014). Furthermore, an emphasis on “enhancing or
enabling participation in roles, habits, and routines” (p. S1)
is interwoven with strategies to maintain cognitive and phys-
ical function. The Canadian Association of Occupational
Therapists (2002) endorses this view as well, embracing the
Canadian Model of Occupational Performance, noting that
“occupational performance refers to the ability to choose,
organize, and satisfactorily perform meaningful occupations
that are culturally defined and age appropriate for looking
after one’s self, enjoying life, and contributing to the social
and economic fabric of a community” (p. 30).
Physical therapists’ scope of practice includes “alleviating
impairment and functional limitation” and “preventing injury,
impairment, functional limitation, and disability, including
the promotion and maintenance of health, wellness, fitness,
and quality of life in all age populations” (American Physical
Therapy Association, 2009, pp. 1–2). Working together, oc-
cupational therapists and physical therapists have the potential
to strongly support quality of life in later life.
Clearly, positive aging is complex, and many of the factors
discussed in this chapter are associated with individuals’ per-
ceptions, as well as professional evaluations, that they are
aging successfully.
SUMMARY
What does all this mean for health-care professionals? First,
there is no unitary description of old age that adequately con-
veys the roles and circumstances of all older adults. Individual
and cultural differences are great. Furthermore, roles and cir-
cumstances change over time. What is true today may not be
true tomorrow, and predictions based on current situations
may or may not turn out to be accurate. For example, in
Chapter 20, Braveman describes current trends in retirement
in the United States. These have changed in the past several
years because of the economic recession that began in 2008.
Changes in cognitive, physical, sensory, and psychosocial
performance occur to some degree in all elderly individuals.
Individual differences exist within the broad parameters of
these predictable changes. Social and environmental events
are also at least somewhat predictable. For example, whether
married, single, or divorced, whether from large or small fam-
ilies, older individuals experience loss of significant others.
We know that functional limitations increase with age and
are most frequent in the oldest-old age-group (McLaughlin,
et al., 2010). However, statistics reflect averages and do not
provide definitive information about a given individual. The
challenge for therapists and other health-care providers is to
understand not only general patterns but also the factors that
mold individual experience of growing older. Every client
must be regarded as a unique individual with special interests,
abilities, and needs. However, the common realities of the
aging process must be addressed to help the individual pre-
pare for probable changes.
Circumstances that influence the performance of older
adults are highly complex, including all the factors described
in this chapter as well as the normal biological, social, and psy-
chological changes that accompany aging and the likelihood
that a person will have two to three chronic conditions. All
health-care providers must be sensitive to myriad interacting
4605_Ch01_001-018 31/10/17 12:01 PM Page 13
considerations that affect function. And the ability to function
is critical for elderly people in all cultures. “Nowhere is
decrepitude valued” (Nydegger, 1983, p. 26).
Interventions risk being irrelevant to the client if they are
planned without attention to the nature of the culture, family
structure, and place and types of residences; demographic fac-
tors; the demands of life both in terms of physical and social
environment and cultural institutions; work and leisure roles
and the value placed on each; the degree of choice of activity
available to the individual; and the unique characteristics of
the individual.
INTERPROFESSIONAL PRACTICE
Understanding Later Life
To fully understand the interaction among the various social
determinants of aging, research from a variety of disciplines is
essential. Contributions from anthropology, economics, political
science, history, biology, and many of the clinical disciplines
help frame a clear understanding of this complex life phase.
Increasingly, occupational and physical therapists and
other health-care providers are being called on to intervene
at the level of the community. Ideas of occupational justice
(Townsend & Wilcock, 2004) suggest that therapists have
an obligation to help structure environments and policies that
enable all individuals, regardless of age or background, to
have access to meaningful occupations. To achieve this goal,
it may be necessary to work toward policy changes as
described in Chapter 3.
As health-care professionals, we must focus on well-being
and quality of life rather than on physical health alone. As
John F. Kennedy (1963) said, “Our senior citizens present
this Nation with increasing opportunity to draw upon their
skill and sagacity and the opportunity to provide the respect
and recognition they have earned. It is not enough for a great
nation merely to have added new years to life—our objective
must also be to add new life to those years” (p. 10).
CASE STUDY
Mr. Sol Pinsky is an 84-year-old widower currently living
in New York City. He moved there with his wife 40 years
ago from the then Soviet Union. Mr. Pinsky has never
returned to his homeland, but he resides in an area pop-
ulated largely by Russian immigrants and prefers friends
with whom he can speak Russian. His four children
live out of town, but he has a large extended family in
New York. These family members have provided emo-
tional and instrumental help since his wife died 4 years
ago. He frequently attends the local senior center, where
he likes playing pool and listening to Russian folk music.
He has mild arthritis that causes him difficulty, particu-
larly when he tries to lift something heavy. He feels for-
tunate to have a good pension from his years as a
CHAPTER 1 ■ Growing Old in Today’s World 13
machinist, but the company is considering reducing re-
tiree health benefits. Although Mr. Pinsky can cook sim-
ple meals, he prefers to eat at the Senior Center as often
as he can. He tries to eat a healthy diet, preferring tradi-
tional Russian dishes like borscht, cabbage, and brown
bread. He has no religious affiliation but does spend a
good bit of time participating in local political activities.
Questions
1. What do you see in this description of Mr. Pinsky
that might contribute to positive aging?
2. What do you note as factors discussed in this chapter
that might affect his experience of growing older?
3. Do you see any particular risk factors in this descrip-
tion of Mr. Pinsky?
Critical Thinking Questions
1. In what ways have attitudes toward aging changed
over time? How can they best be described in the
United States now?
2. What societal and biological factors alter definitions
of old age?
3. How do the social determinants of aging interact to
affect positive aging?
4. In what ways is socioeconomic status an important
factor influencing later life?
5. How is the experience of aging different for women
and for men? For people in rural, suburban, and
urban areas? Why might these differences exist?
6. How does public policy in the United States affect
the lives of older adults? How might changes in
demographic factors alter policy?
7. What is meant by successful aging? Why is the label
controversial and why might positive aging be a more
helpful model?
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Theories of Aging: A Multidisciplinary Review
for Occupational and Physical Therapists
Bette Bonder
“It is better to know some of the questions than all—James
LEARNING OUTCOMES
By the end of this chapter, readers will be able to:
1. Discuss the importance of understanding various theories
of aging.
2. Describe biological theories of aging.
3. Describe psychological theories of aging.
4. Describe sociological theories of aging.
5. Explain approaches to theory as guiding practice with older
adults, emphasizing Dynamic Systems Theory of Motor
Control (Shumway-Cook & Woollacott, 2012) and the Model
of Human Occupation (Kielhofner, 2008).
Clinical Vignette
Mrs. Estelle Arthur is a 73-year-old widow who has the
appearance of a wizened 90-year-old. Her hair is pure
white, and her skin is wrinkled. Because of a long history
of arthritis and a fear of falling, she walks slowly with feet
wide apart. She spends most of her time in her apartment
alone and she complains to family and her few surviving
friends about how her life is not worth living. Over time,
Mrs. Arthur has become skeptical about the intentions of
others and no longer sees family and friends as much as she
did in the past.
In contrast to Mrs. Arthur, Mr. Morales is a 76-year-old
married man who appears much younger than his age. His
hair retains some of its original dark color, and his skin has a
relatively youthful look. Despite ongoing bilateral knee pain
from overuse and old soccer injuries, he provides care for his
infirm wife and helps one of his two adult sons as well. He
enjoys the company of many friends and is busy much of the
time playing pool, going to dominoes tournaments, and driv-
ing friends to the Hispanic Senior Center. He loves to dance,
and he expresses enthusiasm for life.
1. What makes these two stories so different?
2. Why do some people seem to age well, while others
spend their later years infirm and unhappy?
CHAPTER 2
■ Renée R. Taylor ■ Evguenia S. Popova
of the answers.
Thurber
”
T he questions posed in the case vignette raise more
fundamental issues about the life course. Why do we
age? What is the nature of senescence, and can its process
be altered? How can we live healthier and more fulfilling
lives? Why do some people age in a positive way and others
don’t? How can we better address the needs of elderly peo-
ple through physical and occupational therapies to unleash
their potentialities? These are important questions, and to
answer them, scientific theory is required. Theory is an
attempt to explain what we observe in empirical research
or practice. Theories of aging are attempts to go beyond
the what of symptoms or disabilities associated with aging
to examine the why and how of changes related to age. The
need for theory is most obvious in biomedical fields, where
therapies represent the end of a sequence of laboratory
research about causes and effects. But theory is equally
important in psychology, sociology, and public policy. At
the societal level, the rapid aging of populations presents
researchers and policy makers with new and difficult ques-
tions. In all countries of the world, population aging is
altering dependency ratios and dramatically increasing the
number of elders who will need care. Gerontologists—
whether as scientists, practitioners, or policy makers—
concern themselves with these questions.
Challenges of Societal Aging
What Do Gerontologists Want to Explain?
Gerontologists focus on three sets of issues as they attempt
to analyze and understand the phenomena of aging. The first
set concerns the aged: the population of those who can be
categorized as elderly in terms of their length of life lived or
expected life span, often with an emphasis on disability or
barriers to independent living.
A second set of issues focuses on aging as a developmental
process. Here the principal interest is in the situations and
problems that accumulate during the life span and cannot be
19
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20 PART I ■ Global Health and Aging: Implications for Health and Participation
understood separate from developmental experiences and
processes across a lifetime.
A third set of issues involves the study of age as a dimen-
sion of structure and behavior within species. Social geron-
tologists are interested in how social organizations are created
and changed in response to age-related patterns of birth,
socialization, role transitions, and retirement or death.
Although these three emphases are quite different in focus
and inquiry, they are nonetheless interrelated in gerontolog-
ical research and practice.
Sociodemographic Changes
Rapid population aging and higher dependency ratios, as de-
scribed in Chapter 1, will create major challenges for societies
around the world over the next half-century. Less obvious but
equally important is the profound effect that population aging
will have on social institutions such as families. Who will care
for the growing numbers of aging members of human soci-
eties? Will it be state governments? The aged themselves?
Their families? Private care providers? These challenges are
the result of four remarkable socio-demographic changes that
have occurred since the start of the 20th century and particu-
larly during the past 3 decades.
■ Over this period, there has been a remarkable increase in
life expectancy and an astonishing change in the typical,
expected life course of individuals, especially in industrial-
ized societies. The number of older individuals unable to
live independently is expected to quadruple, with direct im-
pact on health-care institutions and social service agencies.
■ Increase in longevity has added a generation to the social
structure of societies. By 2050, the number of older adults
over age 65 is projected to outnumber the number of
children under 5 years (United Nations Department of
Economic and Social Affairs, Population Division, 2005).
■ Changes in population proportions have added a whole
generation to the structure of many families. High divorce
rates, growing incidence of single parenting, and increased
demands on the adult caretakers have placed a significant
burden on families and contributed to changing expecta-
tions regarding the role of the state in the lives of individ-
uals and families.
■ Governmental states in the industrialized world have
slowed or reversed their assumption of responsibility for
senior citizen well-being as states make efforts to reduce
welfare expenditures.
The Current State of Theory
in Gerontology
Since its beginnings in the period after World War II, geron-
tology’s scholarly and scientific interests were broadly defined
because old age was considered “a problem” that was un-
precedented in scope (Achenbaum, 1987). To understand
and explain the multifaceted phenomena and processes of
aging required the scientific insights of biology, biomedicine,
psychology, and social sciences. Over time, the field ex-
panded beyond these core disciplines to include anthropol-
ogy, demography, economics, epidemiology, history, arts and
humanities, political science, and social work, among many
other professions that serve older persons.
To develop theories, scientists most often start with defi-
nitions of concepts and put forward ordered propositions
about the relationships among concepts. Concepts are linked
to empirical phenomena through operational definitions,
from which hypotheses are derived and then tested against
empirical observations. Theories may incorporate knowledge
from multiple disciplines, and can, likewise, inform interven-
tion as framed by many professions, including both occupa-
tional and physical therapy (Krebs & Harris, 2014). Because
such theories are useful in predicting and hence manipulating
our environments, they are considered essential for designing
programs aimed at ameliorating problems associated with
aging, especially for programs designed by the government.
Theories of Aging
Biological Theories of Aging
Biological theories address aging processes at the organism,
molecular, and cellular levels. There are a multitude of theories,
no doubt reflecting the fact that there is no single cause, mech-
anism, or basis for senescence. Biological theories of aging
might explain why one individual remains flexible, while others
lose physical function. Most of these biological theories fall into
one of two general classes: stochastic theories and programmed
(developmental-genetic) theories (Cristofalo, Tresini, Francis,
& Volker, 1999; Troen, 2003). In the past decade, however,
evolutionary senescence theory has gained prominence. These
theories focus on body systems and body function as classified
in the International Classification of Function, Disability and
Health (ICF) (World Health Organization [WHO], 2001) or
as described in the Occupational Therapy Practice Framework
(American Occupational Therapy Association [AOTA], 2014)
as performance skills and client factors. Table 2-1 summarizes
biological theories of aging.
Stochastic Theories
This class of theories explains aging as resulting from the
accumulation of “insults” from the environment, which even-
tually reach a level incompatible with life. The best known is
the somatic mutation theory, which states that accumulation
of mutations and other genetic damage produces functional
failure eventually resulting in death. Recent research has
demonstrated that genetic mutations can indeed affect cell
functioning and ultimately result in organ failure and even-
tually death (Kennedy, Loeb, & Herr, 2012). Another sto-
chastic explanation, error catastrophe theory, proposes that
a defect in the mechanism used for protein synthesis could
lead to the production of error-containing proteins, resulting
in the dysregulation of numerous cellular processes which
4605_Ch02_019-032 31/10/17 12:00 PM Page 21
CHAPTER 2 ■ Theories of Aging: A Multidisciplinary Review for Occupational and Physical Therapists
TABLE 21 ■ Biological Theories of Aging
THEORY NAME MAIN CONSTRUCTS
Stochastic (“insults”) Somatic mutation
Error catastrophe
Developmental-genetic Programmed longevity
Immunological
Neuroendocrine
Immunological
Free radical
Evolutionary Mutation accumulation
Antagonistic pleiotropy
Disposable soma
eventually results in the death of the individual. Although
appealing, there is no convincing evidence for error catastro-
phe (Cristofalo et al., 1999).
Developmental-Genetic Theories
This class of biological theories of aging proposes that the
process of aging is continuous with and probably operating
through the same mechanisms as development and, hence, is
genetically controlled and programmed. Three categories of
developmental-genetic theories have received empirical sup-
port (Jin, 2010; Troen, 2003). These include programmed
longevity that suggests that aging is a part of the genetic code.
A second is immunological theory that focuses on pro-
grammed decrements in the immune system. The third cat-
egory is actually a cluster of neuroendocrine theories that
posit functional decrements in neurons, neurotransmitters,
and their associated hormones as central to the aging process.
A study of changes on neurotransmitter synthesis, availability,
and function showed that these changes are correlated with
the behavioral and cognitive changes observed in delirium
(Maldonado, 2013). A further neuroendocrine explanation,
the immunological theory of aging (Walford, 1969), is based
on the observation that the functional capacity and fidelity of
the immune system declines with age, as indicated by the
strong age-associated increase in autoimmune disease.
Still another neuroendocrine explanation, free radical the-
ory, initially proposed by Harman (1956), suggests that most
aging changes are due to the production of free radicals—
highly chemically reactive agents generated in single electron
reactions to metabolism—during cellular respiration (Frisard
& Ravussin, 2006; Wolkow & Iser, 2006). Research has
demonstrated an age-related increase in oxidative stress and
a corresponding decrease in antioxidant activity (Gil del
Valle, 2011). Furthermore, research on premature aging has
demonstrated higher level of oxidative stress in individuals
with intellectual disabilities compared with the control group
(Carmeli, Imam, Bachar, & Merrick, 2012). Although free
radical theory has gained widespread acceptance, it is not
without its critics. Howes (2006) notes that extensive study
21
CONSTRUCT DEFINITION
Genetic damage leads to functional failure and death
Defect in protein synthesis mechanism leads to errors in proteins
Aging is genetically programmed
The immune system is programmed to decline
Functional decrements in neurons and hormones
Functional decrements in immune system
Damage from highly chemically reactive agents
Genetic errors/accidents over time lead to aging
Late-acting deleterious genes accumulate if they have any benefit in early life
Soma cells have limited durability because they have a short expected
duration of use
has failed to conclusively demonstrate its value and that the
use of antioxidants, which might be expected to reduce
oxidative damage, has not lived up to its early promise.
Linnane and Eastwood (2006) present data to suggest that
oxygen-free radical formation is not a direct cause of aging
and is, in fact, essential for biological function.
Thus, even though theories of aging may give clues about
how one ages, these theories do not promise Ponce de Leon’s
much sought after fountain of youth. Further, as can be seen
in this discussion, despite extensive research, none has been
conclusively demonstrated to be the primary cause of aging.
Evolutionary Theories
Martin (2003) argues that the single most important shift in
biology of aging paradigmatic thinking in the past 20 years
has been the widespread acceptance of evolutionary senes-
cence theory. Evolutionary theories attempt to explain the
origin of aging as well as the divergence of species’ life spans
(Harman, 2006; Kirkwood, 2001). Evolutionary explanations
of aging are based on three major theories. First is the muta-
tion accumulation theory (Medawar, 1952), which states that
aging is an inevitable result of the declining force of natural
selection with age. Mutation accumulation theory supposes
the accumulation of heritable, late-acting deleterious consti-
tutional mutations, as distinct from the accumulation of
somatic mutations. The second evolutionary theory of aging,
antagonistic pleiotropy theory (Williams, 1957), posits there
are genes that have good effects early in life and bad effects
later in life. The third evolutionary theory is disposable soma
theory (Kirkwood, 2001). This theory suggests that an in-
creased rate of aging occurs through optimizing the invest-
ment in reproductive function as opposed to somatic
maintenance functions.
Neuropsychological Theories of Aging
Drawing from the fields of neurology, physiology, and psy-
chology, the neuropsychology of aging is a relatively new dis-
cipline that scientifically investigates, clinically assesses, and
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22 PART I ■ Global Health and Aging: Implications for Health and Participation

develops treatments for age-related and neurodegenerative

changes in brain function and behavior. Contemporary theo-
ries of neuropsychology and aging differentiate between typical
age-related changes in brain function and neurodegenerative
changes. These theories bridge the biological and the psycho-
logical as they attempt to describe organismal factors that in-
fluence behavior. As discussed in greater detail in Chapters 7
and 12, a number of normal cognitive changes occur in later
life, particularly changes to the prefrontal cortex and change
in ability to form declarative memory.
Even though memory resides in a constellation of inter-
acting brain areas, the medial temporal lobe circuitry for
declarative memory appears to be most affected by processes
of both normal and neuropathological aging. A number of
pathological changes are seen in later life, most notably
FIGURE 21 Working puzzles may help maintain cognition. Kmonroe2/
Alzheimer’s disease, but also Parkinson’s, Huntington’s, and
iStock/Thinkstock
many others.
Theories of Alzheimer’s disease relate to its neuropatho-
incorporate elements of many of the theories presented here,
logical mechanisms (amyloid plaques and tangles associated
and others yet to be identified (Troen, 2003).
with neuronal death) and its genetic predisposition (presence
of e4 allele within the ApoE genotypes and other factors
modulating its expression) (Woodruff-Pak & Papka, 1999). Psychological Theories of Aging

✺
PROMOTING BEST PRACTICE
Biochemical Theories
Biochemical theories and related therapies include
manipulating the cholinergic system (acetylcholine),
manipulating brain excitation or signaling (blocking
glutamate’s ability to activate N-methyl-D-aspartate [NMDA]
receptors, controlling the effect of calcium on NMDA
receptors), blocking the formation of beta-amyloid (secretase
inhibitors), and reducing brain inflammation (nonsteroidal
anti-inflammatory drugs, statins) (Walsh, 2004). Therapists
must be cognizant that biochemical changes may affect the
ability of motor and cognitive systems to respond to physical
(PT) and occupational (OT) therapy interventions. In some
circumstances, pharmacological interventions may enhance
therapeutic potential; in others, substitution or compensation
may be most effective.
There are emerging hints that current neuropsychological
theories of aging may be too pessimistic. Increasing evidence
shows that older adults can engage in a variety of lifestyle
choices, including, in particular, exercise, but also, possibly,
challenging cognitive activities (Sudoku and crossword puz-
zles are frequently mentioned in the popular press, as shown
in Fig. 2-1), and eating a healthy diet—the Mediterranean
diet has particular research validation (Opie, Ralston, &
Walker, 2013)—to stave off neuropsychological decline, or
at least to slow it significantly.
It is also clear that although much research has been done
to explore the various biological and neuropsychological the-
ories of aging, much remains to be done. No one theory ad-
equately explains observed phenomena. It seems increasingly
likely that aging is the result of complex phenomena that
The psychology of aging is a complex field with several subfields
(cognitive development, personality development, and social
development) and topic areas (memory, learning, sensation and
perception, psycholinguistics, social psychology, motor skills,
psychometrics, and developmental psychology) (P. B. Baltes,
Freund, & Li, 2005). Theories in the psychology of aging seek
to explain the multiple changes in individual behavior, across
these domains, in the middle and later years of the life span. As
with biological and sociological theories of aging, there is no
defining psychology of aging theory. Psychological theories of
aging focus largely on activity as described in the ICF (WHO,
2001) and on client factors, performance skills, and performance
patterns as discussed in the Practice Framework (AOTA,
2014). See Table 2-2 for a summary of psychological theories
of aging.
Life-Span Development Theory
One of the most widely cited explanatory frameworks in the
psychology of aging, life-span development theory conceptual-
izes ontogenetic development as biologically and socially con-
stituted and as manifesting both developmental universals
(homogeneity) and interindividual variability (for example,
differences in genetics and in social class). This perspective
also proposes that the second half of life is characterized by
significant individual differentiation, multidirectionality, and
intraindividual plasticity. Using the life-span development
perspective, P. B. Baltes and Smith (1999) identify three
principles regulating the dynamics between biology and cul-
ture across the ontogenetic life span: (1) evolutionary selec-
tion benefits decrease with age, (2) the need for culture
increases with age, and (3) the efficacy of culture decreases
with age. Their focus is on how these dynamics contribute to
the optimal expression of human development.
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CHAPTER 2 ■ Theories of Aging: A Multidisciplinary Review for Occupational and Physical Therapists 23

TABLE 22 ■ Psychological Theories of Aging

THEORY MAIN CONSTRUCTS

Life span The second half of life is characterized by significant individual differentiation, multidirectionality,
and intraindividual plasticity
Selective optimization with compensation A model of psychological and behavior adaptation identifying three fundamental mechanisms
(selection, optimization, and compensation) for managing adaptive development in later life
Socioemotional selectivity Describes individual choices in interaction, based on self-interested need for emotional closeness
that leads to selective interactions
Cognition and aging Distal determinant: Factors that affect cognition reside outside the individual, for example, in the
social and cultural environment
Proximal determinant: Specific individual differences are the cause of cognitive change
Personality and aging Theories that focus on the extent and nature of personality stability and change over time

Selective Optimization With Compensation Theory
Life-span development theory has produced one overall
theory to explain how individuals manage adaptive (posi-
tive) development in later life (P. B. Baltes & Smith, 1999).
The theory identifies three fundamental mechanisms or
strategies: selection, optimization, and compensation
(SOC; M. M. Baltes & Carstensen, 1996, 1999). Selection
refers to the increasing restriction of an individual’s life to
fewer domains of functioning because of age-related loss
in the range of adaptive potential. Optimization reflects
the idea that people engage in behaviors that augment or
enrich their general reserves and maximize their chosen
life courses. Like selection, compensation results from re-
striction of the range of adaptive potential and becomes
operative when specific behavioral capacities are lost or are
reduced below a standard required for adequate function-
ing. This life-long process of selective optimization with
compensation enables people to age positively (Schroots,
1996).
Socioemotional Selectivity Theory
In this theory, Carstensen (1992) combines insights from
developmental psychology, particularly the SOC model
(P. B. Baltes & Baltes, 1990), with social exchange theory
to explain why the social exchange and interaction net-
works of older persons are reduced over time (a phenome-
non that disengagement theory tried to explain). Through
mechanisms of socioemotional selectivity, individuals re-
duce interactions with some people as they age and increase
emotional closeness with significant others, such as an
adult child or an aging sibling, with a goal of focusing on
the need for emotional closeness with a specific group of
others.
Cognition and Aging Theories
Researchers of cognition differentiate between types of cogni-
tive abilities: fluid intelligence, reflecting genetic-biological de-
terminants; and crystallized abilities, representing sociocultural
influences on general world knowledge. The primary phenom-
enon to be explained by a theory of cognition is the age-related
decline in fluid cognitive performance (the efficiency or effec-
tiveness of performing tasks of learning, memory, reasoning,
and spatial abilities) (Salthouse, 1999). Fluid abilities have been
shown to decline with age, but crystallized abilities are more
stable across the life span and may even display some growth
with age.
These theories hold that aging leads to a reduction in
the quantity of one or more processing resources, such as
attentional capacity, working memory capacity, or speed of
processing. Cognitive change in later life and theories ex-
plaining this process are discussed in greater detail in
Chapters 7 and 12.
Personality and Aging Theories
Theories of personality and aging focus on the extent and
nature of personality stability and change over the life
span. There are two categories of explanation of age-related
changes in personality. First are the developmental explana-
tions as represented by Erikson’s (1950) stages of develop-
ment (in adulthood and old age, the stages of generativity
versus stagnation and integration versus despair), and D. J.
Levinson’s (1978) stage theory of personality development.
“Stage” theories of personality have fallen out of favor in
recent years. Second are the personality trait explanations, based
on the “big five” factors of personality (neuroticism, extro-
version, openness to experience, agreeableness, and consci-
entiousness). These personality theories postulate that people
show a high degree of stability in basic dispositions and per-
sonality, particularly during the latter half of their life course.
There is growing consensus that personality traits tend to be
stable with age, whereas key aspects of self, such as goals, val-
ues, coping styles, and control beliefs, are more amenable to
change (P. B. Baltes & Smith, 1999). Emphasis is on under-
standing the mechanisms that promote the maintenance of
personal integrity and well-being in the face of social loss and
health constraints (M. M. Baltes & Baltes, 1990; P. B. Baltes
& Smith, 1999).
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24 PART I ■ Global Health and Aging: Implications for Health and Participation

Sociological Theories of Aging The Life Course Perspective

Sociological theories of aging consider the context in which
aging occurs. That is, they focus on participation (WHO,
2001) and on the context in which occupation occurs and
the demands of the activities and the environment (AOTA,
2014). As you will see, several of these theories focus specifi-
cally on activity. These are discussed in greater detail in
Chapter 5. These theories are summarized in Table 2-3.
There are several important theoretical traditions that should
be exploited in developing explanations and understandings
of empirical phenomena.
Historical Foundations of Explanations
in Social Gerontology
A first generation of social gerontology theories (Bengtson,
Burgess, & Parrott, 1997) included disengagement theory
(Cumming & Henry, 1961), activity theory (Lemon, Bengtson,
& Peterson, 1972), modernization theory (Cowgill & Holmes,
1974), and subculture theory (Rose, 1964). The most explicitly
developed of these, disengagement theory (Cumming &
Henry, 1961), attempted to explain human aging as an in-
evitable process of individuals and social structures mutually
disengaging and adaptively withdrawing from each other in
anticipation of the person’s inevitable death. The theory had
attempted to explain both macro- and micro-level changes
with one “grand theory,” but when tested against the cited data,
its validity and generalizability claims could not be supported
(Hochschild, 1975).
In a second period of theoretical development, from about
1970 to 1985, several new theoretical perspectives emerged:
continuity theory (Atchley, 1993), social breakdown/competence
theory (Kuypers & Bengtson, 1973), exchange theory (Dowd,
1975), the age stratification perspective (Riley, Johnston, &
Foner, 1972), and the political economy of aging perspective
(Estes, Gerard, Jones, & Swan, 1984). Since the late 1980s,
many of these theories have been refined and reformulated,
and new theoretical perspectives have emerged. Following is
an overview of contemporary theoretical perspectives in social
gerontology.
This perspective is perhaps the most widely cited theoretical
framework in social gerontology today. Its proponents argue
that to understand the present circumstances of older people,
we must take into account the major social and psychological
forces that have operated throughout the course of their
lives (George, 1996). Researchers using this perspective are
attempting to explain the following:
1. The dynamic, contextual, and processual (that is,
process-driven) nature of aging
2. Age-related transitions and life trajectories
3. How aging is related to and shaped by social contexts,
cultural meanings, and social structural location
4. How time, period, and cohort shape the aging process
for individuals as well as for social groups (Bengtson
& Allen, 1993; Elder, 1992; Elder & Johnson, 2002)
This approach is multidisciplinary, drawing content and
methods from sociology, psychology, anthropology, and his-
tory, and emphasizing the kinds of social and cultural factors
that might influence the experience of growing old for indi-
viduals from differing cultures, as you can see in Figures 2-2
and 2-3.
The life course approach is also explicitly dynamic, focus-
ing on the life cycle in its entirety while allowing for devia-
tions in trajectories (Dannefer & Sell, 1988). Although
studies so far have not incorporated all four of these life
course perspective dimensions in their empirical analyses,
methodological advances suggest such a multilevel, cross-
time model in the future (Alwin & Campbell, 2001).
Social Exchange Theory
Developed and extended by Dowd (1975), the social ex-
change theory as applied to aging attempts to account for
exchange behavior between individuals of different ages as
a result of the shift in roles, skills, and resources that
accompany advancing age (Hendricks, 1995). A central
assumption is that the various actors (such as parent and
child or elder and youth) each bring resources to the

TABLE 23 ■ Sociological Theories of Aging

THEORY MAIN CONSTRUCTS

Life course
Social exchange
Social constructionist
Political economy of aging
Critical perspectives of aging
Focuses on expected and normal changes in life over its entire span
Individuals, including elders, make rational choices about interactions with others, based on their needs and on
norms of reciprocity
Focuses on individual agency and social behavior within the larger structures of society, and on subjective
meanings of age and the aging experience
Focuses on the interaction of economic and political forces in explaining how the treatment and status of
older adults can be understood
Focuses either on humanistic dimensions of aging or on structural components in attempting to create positive
models emphasizing strengths and diversity of age
4605_Ch02_019-032 31/10/17 12:00 PM Page 25
CHAPTER 2
FIGURE 22 An older Japanese couple practices calligraphy, an
activity that may support positive cognitive and motor aging.
mykeyruna/iStock/Thinkstock
FIGURE 23 An elderly African woman whose seated posture shows
the impact of environment on body structure and function. poco_
bw/iStock/Thinkstock
■ Theories of Aging: A Multidisciplinary Review for Occupational and Physical Therapists 25
interaction or exchange and that resources need not be
material and will most likely be unequal. A second as-
sumption is that the actors will only continue to engage in
the exchanges for as long as the benefits are greater than
the costs and while there are no better alternatives. This
theoretical approach also assumes that exchanges are gov-
erned by norms of reciprocity: that when we give some-
thing, we trust that something of equal value will be
reciprocated.
Social Constructionist Perspectives
Social constructivism focuses on individual agency and social
behavior within larger structures of society, and particularly
on the subjective meanings of age and the aging experience.
Examples include Gubrium’s (1993) study of the subjective
meanings of quality of care and quality of life for residents of
nursing homes and how each resident constructs meanings
from her or his own experiences. These meanings emerge
from analyses of life narratives but cannot be measured by
predefined measurement scales, such as those used by most
survey researchers.
Political Economy of Aging Perspective
These theories, which draw originally from Marxism (Marx,
1967/1867), conflict theory (Simmel, 1904/1966), and criti-
cal theory (Habermas, 1971), attempt to explain how the in-
teraction of economic and political forces determines how
social resources are allocated and how variations in the treat-
ment and status of elderly individuals can be understood by
examining public policies, economic trends, and social struc-
tural factors (Estes, 2001). Political economy perspectives
applied to aging maintain that socioeconomic and political
constraints shape the experience of aging, resulting in the loss
of power, autonomy, and influence of older persons. Life ex-
periences are seen as being patterned not only by age, but also
by class, gender, and race and ethnicity. These structural fac-
tors, often institutionalized or reinforced by economic and
public policy, constrain opportunities, choices, and experi-
ences of later life.
Critical Perspectives of Aging
■ Critical perspectives are reflected in several theoretical
trends in contemporary social gerontology, including the
political economy of aging, theories of diversity, and hu-
manistic gerontology. These perspectives share a common
focus on criticizing “the process of power” (Baars, 1991) as
well as traditional positivistic approaches to knowledge.
Critical gerontology has developed two distinct patterns,
one that focuses on humanistic dimensions of aging and
the other on structural components. Moody (1993) postu-
lates four goals of the humanistic strand of critical theory:
(1) to theorize subjective and interpretive dimensions of
aging, (2) to focus on praxis (involvement in practical
change) instead of technical advancement, (3) to link aca-
demics and practitioners through praxis, and (4) to produce
4605_Ch02_019-032 31/10/17 12:00 PM Page 26
26 PART I ■ Global Health and Aging: Implications for Health and Participation
“emancipatory knowledge.” A second strand emphasizes
that critical gerontology should create positive models of
aging focusing on the strengths and diversity of age
(Bengtson et al., 1997). To reach the goals of critical
gerontology, researchers focus on the key concepts of
power, social action, and social meanings in examining the
social aspects of age and aging. Not uncommonly, geron-
tologists will combine insights from all of the theories and
perspectives presented here to guide their research and in-
terpret findings. A number of concerns are evident in cur-
rent efforts: There appears to be increasing concern over
the “microfication” of theories of social gerontology
(Hagestad & Dannefer, 2001). This refers to the overem-
phasis on micro-level analysis, agency, and the individual
subject.
■ In future theorizing, there may be greater emphasis placed
on macro-level phenomena and the structural contexts of
aging. This is because there is increased awareness of struc-
tures as having effects on processes of aging independent
of individual actions, and the recognition that structures
and institutions are not socially constructed but based in
fact (Turner, 2003).
■ Shifting the emphasis from theories of aging to theories
in aging opens up a novel strategy for developing cross-
disciplinary explanations and understanding in gerontol-
ogy (Turner, 2003). The process starts with the collective
identification of the major problems in aging research by
practitioners of various disciplines and theoretical perspec-
tives. The process then inquires what discipline-specific
theoretical knowledge can be brought to bear on illumi-
nating and resolving these problems. Engaging in such a
process holds the potential for forging a cross-disciplinary
fertilization of ideas and possibly new and very practical
approaches.
Client-Centered Approaches
With Older Adults
The various theories just described all focus to some extent on
“function.” However, the meaning of function varies greatly.
Some theories emphasize the function of cells, neurotrans-
mitters, biological systems (e.g., cardiovascular), whereas oth-
ers emphasize the function of societal institutions. Physical
and occupational therapists emphasize function at the level of
activities and participation. The fact that function can be
understood at multiple levels can lead to misunderstanding
(Bailey, Doherty, Rouse, Swank, & Woolcomb, 2012). Ther-
apists must be clear about the meaning of function as relevant
to their areas of concern, so that the theories they emphasize
can help guide their consideration of age and aging.
Among the definitions relevant to therapy, function can
be understood in the context of the ICF (WHO, 2002): “In
ICF, the term functioning refers to all body functions, activ-
ities and participation” (p. 2). Physical therapists emphasize
“the restoration, maintenance, and promotion of optimal
physical function” (American Physical Therapy Association,
2015, para. 1), whereas occupational therapists address
“engagement in occupation” (AOTA, 2014, p. S4).
For purposes of this chapter, and this book, function em-
phasizes the WHO (2008) association of the term with ac-
tivity and participation. Unless otherwise specified, function
refers to the individual’s ability to engage in the physical ac-
tivities that support participation and in occupations that are
necessary or meaningful, or both. This definition is consistent
with both physical and occupational therapy understandings
of the term.
This discussion of the meaning of function is necessary to
explore theories that are specifically relevant to physical and
occupational therapy perspectives on aging. Understanding
the various theories as well as the possible limitations of each
is central to framing intervention for individuals and com-
munities. Aging is associated with declines in motor function,
cognitive processing speed, working memory, and executive
functioning (Zelinski, 2011). Sensory and perceptual deficits
are also common and can include declines in auditory mem-
ory and language comprehension (Zelinski, 2011).
All of these declines have an impact on mobility and phys-
ical capacity and on the areas of occupational or activity
performance that are important to client well-being. These
factors, combined with the two disciplines’ emphasis on func-
tion in daily life, have resulted in a number of conceptual
practice models proposed to guide therapists toward a holis-
tic, client-centered approach to treatment. Client-centered
approaches become particularly important when clients pre-
sent with multiple comorbidities, including mental health
issues. The following sections discuss two widely used, evidence-
based models that may help guide therapists when treating
older adults facing these complexities. The first of these, the
Systems Theory of Motor Control, demonstrates how sys-
tems theory can be applied to a single aspect of client behavior.
The second, the Model of Human Occupation (Kielhofner,
2008), reflects more broad application of systems theory to
understanding of client-centered behavior.
The Systems Theory of Motor Control
The systems theory of motor control postulates that motor
movement can only be understood as an interaction of inter-
nal and external forces acting on the body (Shumway-Cook
& Woollacott, 2012). Individual behavior is presented as a
“nonlinear, self-organizing” system in which input is dispro-
portional to the output and several forces interplay to produce
a single behavior. Variability in movement is viewed as a nec-
essary component of optimal functioning that allows an in-
dividual to make adjustments in response to environmental
change. The level of flexibility that allows the individual to
deviate from a preferred motor pattern is described as an
attractor well (Shumway-Cook & Woollacott, 2012). The
depth of the attractor well directly corresponds with the level.
Deeper attractor wells, for example, represent hardwired
movement patterns that are difficult to modify and change,
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CHAPTER 2 ■ Theories of Aging: A Multidisciplinary Review for Occupational and Physical Therapists
whereas motor movements with shallow attractor wells are
highly responsive to change.
Thus, behavior comes out of interaction of a multitude
of factors within a dynamic system. Within the clinical set-
ting, the therapist must not only be cognizant of the indi-
vidual impairment but also the complex interplay of forces
that are internal and external to the individual, making it
critical to view behavior as a result of a complex interaction
between the individual, the task, and their environment.
This theory is of particular centrality to physical therapy in-
terventions focused on physical capacity that underlies many
daily activities.
✺ PROMOTING BEST PRACTICE
Falls and Aging
Falls are the leading cause of fatal and nonfatal injuries in older
adults (Bergen, Stevens, & Burns 2016) and can significantly
impact an individual from the functional and economic
perspectives. Fall prevention is widely recognized as an
important component of rehabilitation and multifactorial
interventions have been developed to lower the fall risk among
older adults. Evidence from research supports a number of
approaches to the prevention of falls and subsequent injuries
in noninstitutionalized older adults. These range from regular
multicomponent exercise that includes balance and strength
training, home-hazard assessment and modification, the use
of assistive devices, and hip protectors (Karinkanta, Piirtola,
Sievanen, Uusi-Rasi, & Kannus, 2010).
✺ PROMOTING BEST PRACTICE
Decision-Making
In geriatric settings, active participation in medical decision-
making has been shown to decrease with age (Arora &
McHorney, 2000; W. Levinson, Kao, Kuby, & Thisted, 2005). Older
adults are more likely to avoid decision-making processes and
are less likely to request additional information while making a
decision (Mather, 2006). Thus, the therapist must be cognizant
of the fact that some clients may not be comfortable with
taking an active role in their treatment process and would
better benefit from an instructing mode. It is essential that the
therapist knows his or her clients’ interpersonal characteristics
and uses this knowledge to guide his or her mode use in
treatment.
The Model of Human Occupation
The Model of Human Occupation (MOHO) was developed
to provide insight into what motivates a client to engage in
an occupation, how that occupation becomes habituated in
terms of activity patterns and roles, and how the occupation
is performed and supported by the client’s social and physical
environments (Kielhofner, 2008). According to MOHO,
occupational participation—that is, engagement in work,
27
leisure, or activities of daily living—comprises three interre-
lated components: volition, habituation, and performance
capacity (Kielhofner, 2008).
Volition is the innate drive and motivation for occupa-
tion and has been found to be an important contributor to
life satisfaction (Smith, Kielhofner, & Watts, 1986). Voli-
tion comprises three elements: interests, personal causa-
tion, and values. According to Kielhofner (2008), therapists
must enable clients to choose and engage in therapy activ-
ities that they find interesting (i.e., interests), feel capable
of doing (i.e., personal causation), and believe is of value
to self and/or others (i.e., values).
Habituation is the process by which an occupation is
organized into patterns and routines (Kielhofner, 2008).
Habituation guides a person’s ability to exhibit consistent
behaviors during his or her day-to-day activities and interac-
tions. Activities performed in therapy are not likely to gen-
eralize outside of therapy if the client does not choose to
embed them in his or her daily life. An occupation is more
likely to become a part of a person’s daily life if it is volitional.
Thus, when choosing therapy activities, the therapist must
consider both of these variables synergistically.
Performance capacity encompasses the physical and
mental capabilities that underlie skilled occupational per-
formance, including all objective abilities and limitations
experienced by the individual. Performance capacity is not
only assessed objectively by the therapist but is perceived and
experienced interpretively by the client (Kielhofner, 2008).
It is the client’s interpretation of his or her performance
capacity that ultimately predicts occupational engagement and
participation within a lived body context (Kielhofner, 2008,
p. 70), rather than any guideline that might be informed by
a biomechanical definition of normative behavior. MOHO
further emphasizes that human occupation and occupational
participation cannot be fully understood without accounting
for the influences of the physical and social environments in
which it takes place (Kielhofner, 2008). While considering
the individual’s environment, the therapist must be cog-
nizant of the resources available to the individual, the im-
mediate physical environment within which the occupation
takes place, the existing social and cultural expectations, eco-
nomic influences, and the political environment among the
variety of other factors. The environment can be an affor-
dance as well as a barrier to client’s participation in valuable
occupations.
AROUND THE GLOBE: Enhancing Environments
A relatively simple addition to the environment, such as the
availability of a café in a European nursing home facility, can not
only offer opportunities for social interaction but also serve as
an important avenue for maintaining life roles and community
participation (Andrew & Wilson, 2013). Occupational therapists
can assist facilities and communities in identifying these kinds of
environmental enrichments to support quality of life.
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28 PART I ■ Global Health and Aging: Implications for Health and Participation
According to the national survey of therapists who use
MOHO, the theory is highly utilized in geriatric practice and
is perceived to support holistic, client-centered, occupation-
focused, and evidence-based practice (Lee, Taylor, Kielhofner,
& Fisher, 2008). MOHO-based interventions have been ex-
tensively researched, and their utility has been established for
interventions targeted at individual clients (Josephsson et al.,
1993) and client–caregiver dyads (Gitlin et al., 2003; Graff,
Vernooij-Dassen, Hoefnagels, Dekker, & de Witte, 2003).
Implementation of MOHO-based OT intervention in a
community-based setting has also been shown to promote
wellness in the elderly population with a positive impact on
quality of life and perceived well-being (Yamada, Hawamata,
Kobayashi, Kielhofner, & Taylor, 2010).
INTERPROFESSIONAL PRACTICE
Theoretical Considerations
As a complement to theories specifically related to aging, most
disciplines develop theories that reflect their professions’
beliefs and values, as is true for the MOHO in occupational
therapy (Kielhofner, 2008). MOHO draws on general systems
theory and other disciplines to explain human occupation.
However, as Shaw and DeForge (2012) suggest, physical
therapists also draw on multiple belief systems to explain their
beliefs and values. Practitioners from varying disciplines can
often find common ground in examining these disparate
influences on their disciplines.
The International Classification
of Functioning, Disability, and Health
and the Occupational Therapy Practice
Framework, Third Edition
In addition to the many theories just described, several frame-
works or organizing systems have been developed to structure
the strategies by which health-care professionals can concep-
tualize and approach the needs of their clients, whether in-
dividuals, groups, or communities. Two that are particularly
relevant to physical and occupational therapists are the ICF
and the OT Practice Framework.
The ICF
The ICF (WHO, 2001) was designed to serve diverse disci-
plines and sectors across different countries and cultures to:
1. Provide a scientific basis for understanding and study-
ing health and health-related states, issues, outcomes,
and determinants.
2. Establish a common, international language for de-
scribing health and health-related states in order to
improve communication among professionals and with
clients.
3. Allow for comparison of data across countries, health
care disciplines, and health services.
The ICF framework is applicable to all people, regard-
less of their health condition, and emphasizes function
rather than health conditions or diseases. Functioning and
disability are viewed as a complex interaction between the
health condition and personal factors of the individual and
the contextual factors of the environment. Its three main
domains—Body function, Body structure, and Activity and
Participation—can be used to classify the impact of health
on an individual (WHO). The Body component includes
classifications of body functions and body structures (i.e.,
functions of bones and joints, muscle functions). Body
functions are defined as the physiological functions of body
systems and also include psychological functions. Body
structures are the anatomical parts of the body, such as
organs, limbs, and their components. Abnormalities of
function, as well as abnormalities of structure, are referred
to as impairments, which are defined as a significant loss
or deviation (e.g., deformity) of structures (e.g., joints) or
functions (e.g., decreased range of motion or muscle
strength, pain, fatigue).
Activities and participation includes all aspects of func-
tioning from both the individual and societal perspectives.
Activity is the execution of a task or action by an individual
and represents the individual perspective of functioning.
Participation refers to the involvement of an individual in a
life situation and represents the societal perspective of func-
tioning. Difficulties at an activity level are referred to as
activity limitations, and problems an individual may experi-
ence in his or her involvement in life situations are denoted
as participation restrictions (e.g., restrictions in community life,
recreation, and leisure).
The ICF describes the health of an individual according
to how he or she is functioning within his or her environ-
ment. Within this context, functioning is an umbrella term
for body structures, body functions, activities, and participa-
tion, and denotes the positive aspects of the interaction be-
tween an individual with a health condition and the contextual
factors of the individual. Disability is an umbrella term for
impairments, activity limitations, and participation restric-
tions, and denotes the negative aspects of the interaction be-
tween an individual with a health condition and the contextual
factors of the individual.
The domains interact with each other, but not necessar-
ily in a linear manner, are influenced by contextual factors
(environmental and personal factors), and produce a visual of
the person in his or her world through the combination of fac-
tors and domains (WHO, 2001). The contextual factors
represent the complete background of an individual’s life
and living situation: (1) the environmental factors that make
up the physical, social, and attitudinal environment in
which an individual lives and conducts his or her life are ex-
ternal to the individual and can be facilitators (positive) or
barriers (negative) for an individual; (2) personal factors,
such as gender, age, race, fitness levels, lifestyle, habits, and
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CHAPTER 2 ■ Theories of Aging: A Multidisciplinary Review for Occupational and Physical Therapists
social background, are the particular background of an in-
dividual’s life and living situation.
The Occupational Therapy Practice
Framework, Third Edition
The ICF was developed for use across disciplines. Individual
disciplines often create their own systems for categorizing
constructs relevant to their domains (cf, Diagnostic and
Statistical Manual of Mental Disorders, 5th edition; American
Psychological Association, 2013). For occupational thera-
pists, that system is described in the Occupational Therapy
Practice Framework, Domain and Process, Third Edition
(AOTA, 2014). Its principles and characteristics closely align
with the ICF, with a focus primarily on “achieving health,
well-being, and participation in life through engagement in
occupation” (p. S4). It identifies the domain of OT as focused
on occupation and on occupation as reflecting interaction
among client factors, performance skills, performance pat-
terns, and contexts.
For all health-care professionals, practice should be
grounded in conceptual practice models that derive from
theory and are empirically supported. Doing so ensures that
the needs of clients are carefully considered and addressed
in the processes of assessment, intervention, and outcome
measurement.
SUMMARY
Our goal in this chapter was, first, to examine the state of
theory and knowledge building in the field of gerontology
and gauge its prospects for future development and, second,
to present an overview of the major theories in its core disci-
plines: the biology of aging, the psychology of aging, and the
sociology of aging. Theories relevant to physical and occupa-
tional therapy were also considered.
In the quest to understand the diverse phenomena of
aging, gerontologists focus on three sets of issues: biological
and social processes of aging, the aged themselves, and age
as a dimension of structure and social organization. Societal
aging poses new problems for gerontologists. For example,
developing knowledge that informs policies that can effec-
tively deal with the challenges posed by growing numbers of
older persons will be crucial in the coming decades. There are
good practical reasons for theory development in the field of
gerontology.
Researchers need to make explicit their assumptions and
theoretical orientations when presenting their results and in-
terpretations. There is the need to cross disciplinary bound-
aries and develop multidisciplinary and interdisciplinary
causal explanations of broader theoretical scope. Explanation
and understanding in the complex field of gerontology
should draw from a range of theories and theoretical per-
spectives developed by its constitutive disciplines. Gerontol-
ogy builds knowledge not only through the methods of
formal theory development that characterize science but also
29
from the understandings developed by interpretivists and
critical theorists. This diversity of theoretical perspectives can
offer complementary insights. But for this to happen, re-
searchers must pay more attention to the accumulated
knowledge of the field and be explicit in their theoretical
perspectives and insights.
CASE STUDY
At the beginning of this chapter, there is a description of
Mr. Morales, a vigorous, 76-year-old, married, Puerto
Rican man now living in a large Midwestern city. As de-
scribed, he has a wide array of interests, including active
participation at the Hispanic Senior Center. He enjoys the
lunches there, which are typically traditional Puerto Rican
meals. On days that that the weather is too bad for him
to feel comfortable driving, he gets to the center using the
van they provide.
Mr. Morales is in good health, although he has dia-
betes that he developed in his early 20s. Diet and exercise,
along with oral medication, have kept the condition under
good control.
Mr. Morales lives with his wife, who is quite disabled as
a consequence of long-standing rheumatoid arthritis. As a
result of her disability, he does most of the housework, in-
cluding preparing the evening meal, cleaning, doing the
laundry, and small home maintenance tasks. He and his wife
have a good relationship, although he regrets that she is not
able to participate in activities at the Senior Center. He is
committed to providing care for her and takes satisfaction
in finding ways to enrich her quality of life. In particular, he
notes that he likes finding creative solutions to the limita-
tions imposed by her physical limitations. The couple’s two
sons live in town, and see their parents frequently.
Questions
1. How might the various biological theories contribute
to an understanding of the ways in which Mr. Morales
has aged well?
2. What psychological theories might explain
Mr. Morales’s positive aging trajectory?
3. What sociological theories do you think help explain
Mr. Morales’s current status?
4. Knowing his interpersonal characteristics, what
therapeutic modes might be effective when interact-
ing with Mr. Morales? Justify your answer.
5. How would you use the Model of Human Occupation
to inform a treatment plan for Mr. Morales? What
aspects of MOHO would you emphasize and to what
effect?
6. Of the theories presented in this chapter, which
might a physical therapist most helpfully use to guide
intervention with Mr. Morales?
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30 PART I ■ Global Health and Aging: Implications for Health and Participation
Critical Thinking Questions
1. Of the theories presented here, which seem to best
incorporate the array of factors that might explain
the aging process?
2. Which theories seem most focused on specific areas
of aging, as opposed to presenting a comprehensive
model?
3. What are some ways that the various theories
interact? Might a combination of theories provide
the best explanation of the phenomenon of aging?
4. What are unique features of the client-centered
theories that may be helpful to PT and OT
practitioners?
5. Think about an older person you know well. Is
there a theory or group of theories that reflect
what you know about that person’s experiences in
later life?
6. Are there factors or considerations that are missing
from all the theories?
7. What are some specific ways in which each theory
might help guide PT assessment and intervention?
Are there any that do not seem to apply to PT?
8. What are some specific ways in which each
theory might help guide OT assessment and
intervention? Are there any that do not seem to
apply to OT?
Acknowledgement
The authors thank Vern L. Bengston, PhD, for his contribution to a
previous edition of this chapter.
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Public Policy and Advocacy in North America
“We’ve put more effort into helping folks reach old age than into helping—FrankthemA.enjoyClarkit.”
LEARNING OUTCOMES
By the end of this chapter, readers will be able to:
1. Explain the ways in which public policy affects the
experience of growing older.
2. Discuss important federal, state, and local policies that
relate to aspects of aging.
3. Compare U.S. policies with policy initiatives in other
countries.
4. Discuss, compare, and contrast models of advocacy.
5. Describe strategies for influencing policy.
6. Describe strategies for advocating for patients.
7. Discuss the role of occupational and physical therapy
in advocacy.
Clinical Vignette
Mary Consuello is a physical therapist working for a home
health agency in a midsized western U.S. city. Her agency
serves largely inner-city clients, many of whom live almost
exclusively on their social security benefits. These clients tend
to live in small, older apartment buildings that are not well
maintained. Many do not have cars, and public transportation
is not well developed. There are issues of crime and safety in
these neighborhoods, limiting their access to opportunities
for exercise.
1. Are the issues described here relevant to Ms. Consuello’s
activities as a physical therapist? In what ways might she
have responsibility for addressing them?
2. How might Ms. Consuello take action to help her
clients?
T his chapter describes existing U.S. policies that relate
to older adults and briefly compares them to those of
other countries. It then discusses the way in which public
policy emerges and focuses on how new and existing policies
can be influenced. Because advocacy can also focus on indi-
vidual clients, an overview of strategies for advocating for
individuals is discussed. Finally, the role of occupational
therapist (OT) and physical therapist (PT) in advocacy is
considered.
CHAPTER 3
Nancy Richman
It should come as no surprise that our lives are strongly
influenced by laws and regulations that govern such things as
infrastructure, food and drug safety, zoning and other housing-
related issues, environmental safety, social services, health care,
health insurance, retirement income, and many other aspects
of daily life. All of these issues affect all of us, whether we are
attending to them or not. And they are most evident when
focused on matters related to those who are most vulnerable—
children, the disabled, individuals who are socioeconomically
disadvantaged, and older adults.
Many individuals and organizations are active in working
to ensure that these laws and regulations are fair, reasonable,
and appropriately enforced. There are also many who are
active in protecting the rights of individuals. Increasingly,
therapists and their professional associations recognize that
providing effective service to clients must necessarily involve
a role in advocacy.
Public Policy and Aging
Public policy can be defined as actions taken by government
(or others who play a role in policy, like school officials or
city council members) to address problems presented to them
(Birkland, 2011). According to Birkland, policy:
■ Responds to an issue that requires attention
■ May be a law, regulation, or combination
■ Is directed toward a solution to the problem
■ Is made by government
■ Is a continuous process
Consider some examples. Retirement income and health-
care coverage are among the issues governed to a large extent
by federal and state law. Policies about pensions, investments,
and health care can greatly influence the extent to which elders
are secure financially in later life (White House Conference
on Aging Staff, 2015). Policy can also support or impede
function and positive aging (Anderson, Goodman, Holtzman,
Posner, & Northridge, 2012).
As an example of the impact of policy on function, ther-
apists are often concerned with community mobility for their
clients, including those who are older. An array of mobility
33
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34 PART I ■ Global Health and Aging: Implications for Health and Participation
related concerns are addressed through legislation or regula-
tion (Satariano et al., 2012). Does a community require side-
walks? What size and font are required for street and traffic
signs? Are buildings required to be accessible for individuals
in wheelchairs? The answers to these questions all have pro-
found consequences for an individual with a mobility impair-
ment, and all are guided by policy decisions.
Specific disorders like diabetes may call for specific policies
to determine the kinds of public health interventions to be
provided (Caspersen, Thomas, Boseman, Beckles, & Albright,
2012). Educational programs that offer screening, education,
and monitoring of blood sugar control all lead to better
outcomes. Policies that require communities or health-care
organizations to offer these interventions can contribute to
improved health and lower health-care costs that benefit the
individual and the community.
Public health interventions are often policy driven and can
be beneficial in multiple ways. For example, community-
based interventions to increase physical activity, reduce falls,
and improve function can improve quality of life for older
individuals (Anderson et al., 2012).
Policy may be enacted at any level of government, federal,
state, or local, and can be described in law or in rules and reg-
ulations (Gelles, 2011). It will be helpful to examine some of
the key legislation at these various levels because these laws
affect older adults and the provision of care. As described
later in the chapter, once a law has been enacted, a typical
next step is the establishment of the regulations that define
the details by which the law will be implemented
Federal Policy
The U.S. federal government has broad responsibility for the
welfare of the country and its citizens. As enumerated in
Article 1 of the Constitution, it governs taxation and the
federal budget, foreign relations, defense policy, interstate
trade, and many other issues that cross state lines (White
House, n.d.). Here we review a few of the most salient federal
laws affecting older adults.
Social Security
Enacted in 1935 in the depths of the Great Depression, the
Social Security Act was designed to prevent older adults
from living out their lives in poverty (U.S. Social Security
Administration, 2011). It created “a system of Federal
old-age benefits, and by enabling the several States to make
more adequate provision for aged persons, blind persons,
dependent and crippled children, maternal and child
welfare” (Social Security Act, H.R. 7260, 1935, para. 1).
Social Security requires individuals and employers to pay
into a fund set aside for future payments (Social Security
Act, H.R. 7260, 1935). Each quarter—3-month period—
of a year that the individual and employer pay into the fund
goes toward establishment of the person’s eligibility for
future benefits and the amount of those benefits. Benefits are
also calculated based on age at retirement. Age of retirement
was modified in 1983 as a way to ensure the fund remained
solvent (ssa.gov, n.d.).
In 2009, Social Security benefits were the source of
90 percent of income for 22 percent of married couples and
43 percent of nonmarried elders (U.S. Social Security
Administration, 2011). The average monthly benefit was
just under $1,200. Compare this to the poverty level for
older couples at $13,195, and individuals at $10,458 per
year, and it is evident that Social Security alone is not suf-
ficient to ensure comfort. Nevertheless, it is a vital source
of financial support that ensures minimal survival. This is
a vast improvement over the historical situation of older
adults, as described in Chapter 1.
Medicare
The Medicare Act, which resulted in a national health insur-
ance plan for elders, was enacted in 1965. It is designed to
provide financial assistance for those at risk for requiring a
moderate to high level of medical care. Medicare is multi-
generational. Workers put money into the system through
payroll deductions and self-employment tax contributions.
Before Medicare, adult children or others would have been
financially responsible for the health care of older relatives
(Padilla, Byers-Connon, & Lohman, 2011). Both Medicare
and Medicaid (described below) were enacted at a time when
the health needs of elders and the indigent were priorities
(Jacobs, 2010).
In 2016, just under 58,000,000 people enrolled in Medicare
(CMS.gov, 2017a). Of these, roughly 19,000,000 were in
Medicare Advantage plans, which offer slightly different
benefits than traditional Medicare, but are considered a part
of the overall program.
Medicare, Title XVIII of the Social Security Act, origi-
nally covered most people aged 65 years and older but has
been expanded to cover other groups, including those enti-
tled to disability benefits for at least 24 months and those
with end-stage renal disease. Medicare is the largest single
payer of health-care services in the United State. The leg-
islation grants the federal government statutory and regu-
latory authority over services provided. Because of its size
and impact, Medicare policy also influences private insur-
ance company payment policies. There are four components
(Parts A–D) to Medicare ranging from inpatient services to
home health. Therapy services can be reimbursed under
Medicare Part A or Medicare Part B. It is important for
therapists to understand the differences for appropriate
service delivery and reimbursement.
Medicare Part A
To be eligible for coverage, a person must be least 65 years
of age, have been a U.S. citizen or permanent resident for
a least 10 years, and paid (or had a spouse who paid)
Medicare taxes for at least 40 quarters. A person who is has
not paid into the system for 40 quarters can pay a monthly
premium. Individuals under 65 are eligible if they are
permanently disabled, received social security disability
4605_Ch03_033-044 31/10/17 11:58 AM Page 35
CHAPTER 3
payments for at least the previous 2 years, receive Social
Security disability benefits for amyotrophic lateral sclerosis,
or need continuous dialysis or a kidney transplant. Part A
is financed through a tax on earnings paid by employers
and employees, set in 2015 at 2.9 percent (Centers for
Medicare and Medicaid Services, n.d.).
Part A is a progressive benefit. It is expected that the
beneficiary will have experienced an acute medical crisis
requiring hospitalization, followed by a lesser level of in-
patient care in a skilled nursing facility (SNF). Hospital
benefits cover acute illnesses, diseases, or surgical care, typ-
ically for just a few days. Hospital and SNF benefits include
room and board and medically necessary professional serv-
ices such as therapy services that must meet program re-
quirements. When the beneficiary no longer needs the
services provided in the hospital, reached goals specific to
the care setting, or has exhausted his or her benefits, addi-
tional therapy and services can then be provided in the
home setting. Hospice care does not require having used
any of the other benefits. Beneficiary out-of-pocket costs
include a deductible for hospital care and daily co-insurance
fee after 60 days of hospital care and 20 days of SNF care
(Sandstrom, Lohman, & Bramble, 2014). These costs may
be covered by Medigap policies.
Since 1983, the Prospective Payment System (PPS) has
been in effect; this system classifies patients into groups
that predict resource utilization. Criteria used to determine
the specific group include diagnosis, surgery, age, gender,
and discharge destination. There are 751 Medical Severity
Diagnosis-Related Groups (MS-DRGs). A similar system
is used for long-term care hospitals (LTACH). LTACHs
serve beneficiaries with complex medical conditions who
require longer stays.
Medicare structures deductibles and co-insurance on sin-
gle episodes or a benefit period. A benefit period begins with
admission to the hospital and continues until the beneficiary
has been out of a hospital or SNF for 60 days. Services
received during this benefit period are covered by one de-
ductible and co-insurance fee, even if the beneficiary is read-
mitted within the 60 days. Beyond 60 days, even though it
may be the same condition, the beneficiary would pay an
additional deductible (Sandstrom et al., 2014). Details of
coverage for skilled nursing, home health, and hospice care
are provided in Chapters 31–34.
Medicare Part B
Medicare Part B pays for a variety of diagnostic, therapeutic,
and preventative medical services. Health-related professional
services, durable medical equipment, prosthetics, and or-
thotics. Services may be provided by individuals such as
physicians, but it is also delivered by institutions, hospital
outpatient departments, emergency departments, rehabilita-
tion clinics, SNFs, and ambulatory surgical centers. At pres-
ent, beneficiaries pay for about 25 percent of the costs for
Medicare B and are responsible for an annual deductible and
co-insurance of 20 percent.
■ Public Policy and Advocacy in North America 35
People who are eligible for Medicare A without paying
a monthly premium are eligible for the optional Medicare
Part B benefit package. Most people enroll in Medicare
Part B when they become eligible for Medicare Part A
(Medicare.gov, 2012).
All Medicare provider types are reimbursed under the
Medicare Physician Fee Schedule including occupational
therapists and physical therapists. A list of procedures, the
Current Procedural Terminology (CPT) codes, are associ-
ated with a cost, each of which is calculated every year
using the Resource-Based Relative Value Scale (RVRBS).
Adjustments are made for geographic differences in costs
and multiplied by a standard conversion factor (Sandstrom
et al., 2014).
Medicare covers the services by independent occupational
therapists, physical therapists, and speech language pathologists
in hospitals, SNFs, rehabilitation agencies, doctors’ offices,
therapists’ offices, Comprehensive Outpatient Rehabilitation
Facilities (CORF) or at home, with a home health agency or
therapist in private practice (OTPP, PTPP). The intent of the
benefit is to cover the recovery process after an acute illness or
hospital stay. Occupational therapy assistants and physical
therapy assistants can provide services under general supervi-
sion of the therapist. Athletic trainers, kinesiotherapists, recre-
ational therapists, and massage therapists are not eligible to
participate in the Medicare program.
To be eligible for reimbursement, therapy services must
be needed based on the condition of the beneficiary, must be
“reasonable and necessary” as required by the needs of the
individual, the plan of care and the Medicare definition of
skilled therapy services. Table 3-1 describes these criteria.
Jimmo v. Sebelius
One concern of particular relevance to therapeutic efforts
relates to individuals who need care to maintain their status
or to slow loss of function. For many years, therapy goals had
to focus on improvement to be covered by Medicare, and
maintenance was not covered. This meant beneficiaries who
TABLE 31 ■ Medicare Definition of Skilled Services
1. The services shall be considered under accepted standards of
medical practice to be a specific and effective treatment for the
patient’s condition. The amount, frequency, and duration of the
services must be reasonable under accepted standards of practice
under the guidelines and literature of the professions of physical
therapy, occupational therapy and speech-language pathology.
2. The services shall be of such a level of complexity and sophistication
or the condition of the patient shall be such that the services
required can be safely and effectively performed only by a therapist,
or in the case of physical therapy and occupational therapy by or
under the supervision of a therapist.
3. The services must be provided with the expectation that the
condition of the patient will improve in a reasonable and generally
predictable period of time.
cms.gov (2017b). CMS Manual System. Retrieved from https://www.cms.gov/
Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3654CP.pdf
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36 PART I ■ Global Health and Aging: Implications for Health and Participation
had chronic conditions that were not expected to improve but
who could benefit from skilled therapy services to prevent or
slow deterioration were not eligible for coverage. The issue
came to a head with a lawsuit now referred to as Jimmo v.
Sebelius (Centers for Medicare and Medicaid Services
[CMS], 2014a). As a result of the settlement of that suit, in
January 2014 CMS issued clarification of skilled therapy serv-
ices as pertaining to improvement criteria. To be considered
skilled therapy, the services must be of a level of complexity
and sophistication that they require the skills of a qualified
therapist and be “reasonable and necessary for the treatment
of the patient’s condition” (CMS, 2014b).
Specifics of the Jimmo v. Sebelius (CMS, 2014a) suit are
worth summarizing here, both to guide practice and to
demonstrate the ways in which advocacy can help shape im-
provements in policy. Among the recent findings regarding
the case, the following points are particularly important:
■ For about 30 years, home health agencies and nursing
homes that contracted with Medicare routinely terminated
the Medicare coverage of a beneficiary who has stopped im-
proving, even though nothing in the Medicare statute or its
regulations says improvement is required for continued
skilled care.
■ Under a settlement agreement in Jimmo v. Sebelius, the fed-
eral government agreed to update Medicare rules to require
that Medicare cover skilled care as long as the beneficiary
needs skilled care, even if it would simply maintain the ben-
eficiary’s current condition or slow further deterioration.
■ The policy shift affects beneficiaries with conditions like
multiple sclerosis, Alzheimer’s disease, Parkinson’s disease,
amyotrophic lateral sclerosis, diabetes, hypertension, arthri-
tis, heart disease, and stroke. In addition, under the settle-
ment, Medicare beneficiaries who received a final denial of
Medicare coverage after January 18, 2011 (the date the law-
suit was filed) are entitled to a review of their claim denial.
Rehabilitative therapy may be needed and improvement
in a patient’s condition may occur, even when a chronic, pro-
gressive, degenerative, or terminal condition exists. The fact
that full or partial recovery is not possible does not necessarily
mean that skilled therapy is not needed to improve the pa-
tient’s condition or to maximize his or her functional abilities
but rather on whether the services are reasonable and effective
and must be provided by a skilled therapist (CMS, 2014a).
The services might focus on improvement or on delay or pre-
vention of deterioration.
Part C: Medicare Advantage Plans
Medicare managed care programs were allowed by the
Balanced Budget Act of 1997 and administered by private
insurance companies. Insured parties pay their Part B premium
directly to the managed care company they have chosen.
There are four types of Medicare Advantage Plans:
■ Medicare Health Maintenance Organization (HMO)
■ Medicare Preferred Provider Organization (PPO)
■ Private fee for service plan
■ Medicare Special Needs Plans
Medicare Advantage Plans cover all regular Medicare
benefits, may cover more, and may have reduced co-pays
and deductibles. Medicare pays these insurers a fixed
amount per month per beneficiary. The beneficiary may not
be able to choose a hospital, but be restricted to a plan’s net-
work. The plan may waive the 3-day hospital stay needed
for additional benefits. The other differences between orig-
inal Medicare and Medicare Advantage Plans can be re-
duced therapy benefits, but advantages for prescription
costs, wellness visits, and vision and dental care (Jacobs,
2010; Medicare.gov, 2014).
Part D: Prescription Drug Benefit
This is the newest part of the Medicare program, added
in 2003 as part of the Medicare Modernization Act (Leutz,
Gurewich, Thomas, Ryan, & Bishop, 2007).
Participants choose from competing plans with different
out of pocket costs. The beneficiary pays a monthly pre-
mium, possible deductible, and co-payments (Kaiser Fam-
ily Foundation 2013). Each plan creates its own formulary
that classifies drugs into tiers that have different co-pays,
in part based on whether the drug is generic. For some
drugs, prior approval is necessary or initial regimes must
have been tried.
As of 2015, Part D has a coverage gap for annual costs
that exceed $2,850 but are less than $4,550. The beneficiary
is responsible for 100 percent of costs over $2,850 until
$4,550 is reached, and then Medicare D will pay 95 percent
of the costs until the end of the calendar year. As a result of
the health reform law, the coverage gap is slowly being
phased out. It will be phased out by 2020 (Medicare Inter-
active, n.d.).
As this summary demonstrates, important legislation like
Medicare is often updated through court actions or legisla-
tive review. In 2015, the Medicare Access and CHIP Act
(MACRA) was enacted to focus on performance-based care
emphasizing metrics to measure quality, efficiency, helpful
use of electronic records, and improvement of clinical prac-
tice (Sandhu, 2015). At present, the U.S. Senate Finance
Committee is exploring ways to increase coordination
among payers, streamline payment systems to alter incen-
tives toward value rather than quantity, and increase both
efficiency and quality of care (Casey, 2015). Both the Amer-
ican Occupational Therapy Association and the American
Physical Therapy Association have provided input to help
frame these initiatives in the best interests of clients. It is
important to be aware that health-care coverage and regula-
tion are currently under discussion in the U.S. Congress and
it is likely that there will be significant change in health care
laws and policy. But even in the absence of new legislation,
rules change frequently and therapists have an obligation
both to stay informed and to help shape regulation through
advocacy efforts.
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CHAPTER 3
Medicaid
Medicaid is a combined federal and state insurance that
addresses the health care needs of the indigent. The federal
government pays states for a specified percentage of program
expenditures, called the Federal Medical Assistance Percent-
age (FMAP). FMAP varies by state based on criteria such as
per capita income (Medicaid.gov, n.d.a).
States have choices in their approach to delivery system
design under Medicaid, so criteria are complicated. They
establish and administer their own programs and determine
the type, amount, duration, and scope of services within
broad federal guidelines. States are required to cover certain
“mandatory benefits” and can choose to provide other
“optional benefits” through the Medicaid program.
The key element of Medicaid for older adults is its cover-
age of long-term nursing home care (cms.gov, n.d.). As de-
scribed earlier and in Chapter 33, Medicare pays for relatively
brief nursing home stays after hospitalization. Its coverage is
designed to provide a bridge between acute care and home
care for older adults who are not yet able to manage in their
homes. It does not, however, cover stays for chronic and de-
teriorating conditions like dementia, which could lead to in-
stitutional residence for months or years. A variety of private
options (self-pay, long-term care insurance) are common
when this longer term care is needed. But for those who have
no personal resources, Medicaid will step in.
To be eligible for Medicaid, individuals need to satisfy fed-
eral and state requirements regarding residency, immigration
status, documentation of U.S. citizenship, and income. More
than 4.6 million seniors receive coverage from Medicaid,
and all most all of them are also enrolled in Medicare
(medicaid.gov, n.d. b). Medicaid also provides coverage to
8.8 million people with disabilities.
Long-term care coverage is available only to those who
have no financial resources. Recipients with assets are re-
quired to spend them down to become eligible. In 1988, leg-
islation was enacted to provide at least modest protection for
spouses living in the community. The spouse still living in the
community can retain at least some limited savings, including
a jointly owned home, when the other spouse enters a nursing
facility or other medial institution and is expected to remain
there for at least 30 days (Office of the Assistant Secretary
for Evaluation and Planning, 2005).
Older Americans Act
The Older Americans Act (OAA) was passed by Congress
in 1965 in response to concern by policy makers about a lack
of community social services. Its focus was the welfare and
dignity of older adults, and it became a primary mechanism
for organizing community services (Administration on Aging
[AoA], 2011). The original legislation established authority
for grants to states for community planning and social serv-
ices, research and development projects, and personnel train-
ing in the field of aging. The law also established the AoA to
administer the newly created grant programs and to serve as
■ Public Policy and Advocacy in North America 37
the federal focal point on matters concerning older persons.
The OAA is considered to be the major vehicle for the
organization and delivery of social and nutrition services. In
some communities, the Area Office on Aging may have funds
available for home modification, Meals on Wheels, or loan
of durable equipment. These resources are important for
occupational therapists as they prepare their clients to tran-
sition to less restrictive settings or home (U.S. Department
of Health and Human Services, 2014).
Since the OAA was enacted, it has been amended or
reauthorized a dozen times in response to changing needs.
The most recent reauthorization passed into law in 2016
(govtrack.us, 2016). It establishes or continues a wide array
of community services for older adults, including the
following:
■ Promote evidence-based programs for falls prevention and
chronic disease self-management
■ Encourage effective use of transportation services
■ Improve coordination among programs at federal, state,
and local levels
■ Enhance Aging and Disability Resource Center coordina-
tion with Area Agencies on Aging (Notarstefano, 2015)
As of the end of 2015, funding for provisions of the OAA
had been passed (Benjamin Rose Institute on Aging, 2015).
Nutrition programs and services for Native Americans re-
ceived funding increases, while the remainder of the services
authorized was funded at their then-current levels. The bill
was passed into law in 2016.
A wide array of other services that affect community-
residing older adults and care providers serving them is
included in the act. Many of these are described in
Chapters 28 through 31.
Patient Protection and Affordable Care Act
The Patient Protection and Affordable Care Act (ACA;
hhs.gov, 2015) was passed in 2010. Its 10 sections emphasize
mechanisms for ensuring the majority of individuals in the
U.S. through a combination of expanded Medicaid eligibil-
ity, support for purchase of private policies, and a require-
ment that every individual obtain coverage. It deals with
an array of related topics, including improved efficiency
and effectiveness of health care, insurance reforms, and—
importantly for older adults—stipulations about access to
coverage for early retirees. This last has been a concern for
many years, given that Medicare is not available to individ-
uals younger than 65 years.
Several provisions of the ACA address environmental and
social concerns ranging from crime prevention to enhance-
ments to the built environment to improve access (Institute
of Medicine, 2015), efforts that would benefit older adults
along with others. Among the important provisions to support
therapy for older adults are those focused on improving quality
of care under Medicare, preventing hospital readmission,
preventing hospital-acquired conditions, and value-based
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38 PART I ■ Global Health and Aging: Implications for Health and Participation
purchasing of care (Fisher & Friesema, 2013). Unfortunately,
the availability (or lack thereof) of funding for prevention and
public health initiatives has impeded development of some of
these initiatives (Pollack, 2015). Elements of the ACA affect
a wide array of health-care issues for older adults, as you will
see in subsequent chapters. Again, keep in mind that many of
these provision may change depending on the actions of the
115th congressional session.
Other Important Federal Legislation
A large number of other federal laws have relevance to older
adults. These include prevention of age discrimination (Age
Discrimination in Employment Act; U.S. Equal Opportunity
in Employment Commission, n.d.) as well as requirements
for environmental restructuring to increase access to physical
spaces and workforce participation (the Americans with
Disabilities Act; ada.gov, n.d.).
Because of the role of physical and occupational therapy
on quality of life, it is important to be aware of policies that
affect positive aging. A recent review (Gonzales, Matz-Costa,
& Morrow-Howell, 2015) of policies affecting productive
engagement—work, volunteering, and child care, for example—
identified a wide range of laws that address not only health
care but also education, wages, working conditions, and many
other concerns. These laws include the Protecting Older
Workers Against Discrimination Act (H.R. 2852), Schedules
that Work Act (H.R. 5159; S. 2642), Title V of the Older
Americans Act, and many others.
It is difficult to monitor every bill that has implications for
older adults, given the range of concerns that may be relevant.
Infrastructure bills may address environmental accessibility.
Budget bills may affect tax rates for elders. Food and drug
safety legislation may affect access to needed prescription
medications. There are advantages to belonging to profes-
sional associations that can monitor legislation and alert
members to emerging issues; other advocacy organizations
also monitor such legislation.
State Policy
Issues that are not part of the federal government’s responsi-
bility are addressed at the state or local level (White House,
n.d.). Police departments, schools, and intrastate business,
for example, are all regulated by policies governed largely at
the state or local level.
A wide range of issues regulated by state law is important
to older adults (National Conference of State Legislators,
2015). For example, regulations governing nursing homes
and drivers’ licenses are developed at the State level. States
regulate insurance, so have responsibility for monitoring
long-term care insurance policies. Many states have initiatives
addressing health concerns like fall prevention.
In many instances, states are responsible for enacting fed-
eral legislation (Gelles, 2011). As noted earlier, Medicaid is
a federal initiative, but it delegates many specific implemen-
tation decisions to the states. Infrastructure concerns, which
can include access to physical environments, are also often
delegated to the states, even if the federal government has
initiated an action.
Local Policy
Local governments (county and city) are typically granted pow-
ers by the states. Most of the time, oversight of schools, police,
parking regulations, libraries, zoning, and many other matters
are considered best handled locally (White House, n.d.).
Among the initiatives typically handled at the local level
are the Area Agencies on Aging (Shannon, 2014). Although
these were established in the Federal Older Americans Act,
they have been established in local communities, often at the
county level. Given the unique needs of older adults in par-
ticular environments, this is a helpful approach to managing
services. As you saw in Chapter 1, older adults living in rural
areas need different services from those who live in densely
populated inner cities.
Individual communities often have their own services for
older adults, paid either through their own taxing authority
or through funding from the state or the federal government
(Shannon, 2014). So, for example, transportation services,
decisions about the structure of new residential development,
and leisure services for elders are all affected by local policy.
Public Policy in International Context
So far, we have considered the ways in which policies are
developed in the United States. Other countries have similar
concerns, but differences in governmental structure and
process affect the nature of regulations, as well as the expec-
tations of older adults and their families. A small sample of
considerations around the world:
■ Policy in England has focused on encouraging older indi-
viduals to continue to work, but most elders prefer not to
do so (Hofäcker, 2014).
■ In sub-Saharan Africa, a great deal of research and policy
emphasis has been on the nature and role of family in the
lives of elders (Aboderin & Hoffman, 2015).
■ In Canada, increased attention to the needs of rural elders
has become a priority. Findings there suggest these older
adults are disadvantaged in terms of education, income, and
access to services and transportation (Bacsu et al., 2012).
■ The United Nations (UN) has increased its emphasis on
circumstances of older adults around the world, particularly
through the Madrid Plan established in 2002 (Kendig,
Lucas, & Anstey, 2013).
The Madrid Plan has attempted to address attitudes, poli-
cies, and practice at all levels of government so that as
countries around the world experience the aging of their pop-
ulations, they acknowledge and capitalize on the potential of
older adults (Kendig et al., 2013). In some countries where
the governments are not able to provide service adequately,
nongovernmental organizations (NGOs) have been important
4605_Ch03_033-044 31/10/17 11:58 AM Page 39
CHAPTER 3
advocates for older adults. These NGOs often cite UN re-
ports as a way to influence local services.
AROUND THE GLOBE: New Zealand Health and Disability
Advocacy Service
Drage (2012) describes a structured advocacy program developed
in New Zealand with a focus on improving services relevant to
promoting health and assisting those with disabilities. It is a
national, publically funded office that supports an array of
advocacy specialists. These advocates work to support both
individual patients and the needs of the population more globally,
the latter through recommendations about legislation.
The next chapter offers essays from three countries—
Israel, Mexico, and South Africa—describing the circum-
stances of older adults and the services and systems in place
to support them. As you will see, there are many common
concerns and many similar structures to address those con-
cerns. But individual countries also have unique circum-
stances that affect the experience of individuals as well as the
processes through which services are developed and the abil-
ity of societies to address the needs of their elders.
Models of Advocacy
Advocacy has been defined as “pleading in support of” an-
other and defending or recommending in favor of a proposal
(Sykes, 1976, p. 16). Note that this definition encompasses
both the local, specific nature of advocacy as it relates to a
particular client’s needs and the more global advocacy that
focuses on establishing policies and processes that can affect
entire communities or societies. Advocacy takes a variety of
forms. In considering actions relevant to communities or
societies, these forms include, but are not limited to, pro-
grammatic, legislative, and grassroots advocacy; political cam-
paign activity; litigation; demonstrations; and boycotts (Gen
& Wright, 2013). In promoting the well-being of specific in-
dividuals, self-advocacy, peer advocacy, statutory advocacy,
and crisis advocacy all describe specific strategies (Health and
Disability Advocacy, 2009).
A variety of social networking theories can guide the direc-
tion that action might take (Health and Disability Advocacy,
2009). For example, empowerment theory emphasizes sup-
porting individuals and organizations in developing the skills
to advocate for themselves. It focuses on helping individuals
and organizations see themselves as having rights, identifying
and capitalizing on their strengths and skills, and learning how
to approach power structures. The advocate’s role is to serve as
coach and mentor, not to solve the problem. Strength-based
advocacy can be considered an elaboration or subset of empow-
erment theory. It emphasizes that people and organizations are
capable of change and growth, can serve as their own experts,
and that the problem, not the person or organization, is the
focus of attention.
■ Public Policy and Advocacy in North America 39
Although the goal of advocacy is typically to change policy
or to address individual needs, in both its specific and global
forms, advocacy is varied and complex (Gen & Wright,
2013). It is important to establish systematic processes that
allow for evaluation of outcomes and refinement of actions.
Gen and Wright (2013) recommended that the following be
incorporated into plans for particular advocacy initiatives:
■ Necessary conditions (inputs and competencies)
■ Things to do (activities)
■ Near-term outcomes
■ Long-term outcomes
■ Impacts
As each of these is considered, a model can be designed
for a particular activity. Hoefer (2005) recommended “advo-
cacy mapping.” This is a process through which the various
elements in the preceding list are linked. So, for example, it
is important to evaluate existing inputs and competencies in
designing actions that will be taken.
The next obvious link is between activities and outcomes,
both short and long term (Gen & Wright, 2013). If coalition-
building has been the focus of activity, it is to be expected that
coordination of various organizations and their actions would
be a potential—and helpful—short term outcome. If activities
have emphasized securing needed services for a specific indi-
vidual, identifying and initiating those services would be the
desired outcomes.
How Policy Is Made
Most readers will be familiar with the legislative process in
the United States and/or other countries. A brief review is
provided here, with attention to the points in the process
where advocacy may be effective. Advocacy efforts directed
at policy may occur before legislation has even been consid-
ered. For example, a problem—say, lack of access to health
care or insufficient housing for older adults—may be identi-
fied by individuals or by legislators and a determination made
that a new law might be helpful in addressing that concern.
Efforts then shift to drafting legislation that would solve the
identified problem. During the drafting process, expert and
community input may be sought; this is an important period
for public advocacy. Once a bill has been written, the legis-
lation must be introduced to the proper legislative body. In
the United States, at the federal and state levels, this would
be either the House of Representatives or the Senate (U.S.
Senate, n.d.). At the local level, a city council is often the
legislative body. Other countries have comparable entities,
parliaments, national assemblies, and other structures. The
period during which a bill is under discussion by legislators
also offers advocacy opportunities through contact and con-
versation with those individuals.
The specifics of the legislative process—in the United
States, review and vote by committees, review and vote by
House and Senate, reconciliation of versions of a bill, final
vote, and signature of president or governor—is lengthy and
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40 PART I ■ Global Health and Aging: Implications for Health and Participation
often requires considerable back and forth with accompany-
ing revision of the bill (U.S. Senate, n.d.). Typically, negoti-
ation and compromise are required and result in a bill that is
not precisely what anyone intended with provisions that may
be confusing and even contradictory.
Once a bill becomes law, a process of promulgating rules
and regulations is needed to provide details regarding the
enactment of the law’s provisions (Physical Therapy Board
of California, 2015). Typically, bills are written with rela-
tively general wording that requires much greater specificity
if the goals of the law are to be realized. Again, there is an
opportunity for advocacy because the rules can greatly affect
the effectiveness of a law.
Some laws (e.g., the Older Americans Act) specify reau-
thorization on a periodic basis (govtrack.us, 2015). In these
✺ PROMOTING BEST PRACTICE
instances, additional opportunities for advocacy are avail-
able. The White House Conference on Aging (2015) has
provided a venue for discussion among researchers, clini-
cians, and policy makers about the needs of older adults and
potential legislation to address those needs.
Advocating for Policies
Given that there are so many points in the legislative
process at which efforts can be made to influence outcomes,
it is essential to have a clear picture of what outcomes are
desired and what steps can be taken to accomplish those
outcomes (Hoefer, 2005). A wide array of strategies is avail-
able, including the following:
■ Engaging and mobilizing the public
■ Coalition-building
■ Engaging decision makers
■ Information campaigns
■ Reform efforts
■ Policy monitoring
Efforts are most likely to be successful when groups of
individuals and organizations work together toward a com-
mon goal (Fig. 3-1).
FIGURE 31 Groups may advocate most effectively in shaping public
policy. shironosov/iStock/Thinkstock
An array of concerns can and, in the case of older adults,
must be addressed through advocacy efforts. As just one exam-
ple, Rose, Noelker, and Kagan (2015) noted that demographic
changes mean that availability of respite services—temporary
care for dependent older adults to relieve informal caregivers—
is likely to be inadequate in the near future. Policy changes
will be required to ensure that training is available and
employment sufficiently rewarded to attract individuals to
provide this vital service. In efforts to advocate for policies
to address this need, this was a key topic at the 2015 White
House Conference on Aging.
The National Task Group
In response to concerns voiced by the World Health
Organization about the needs of aging individuals with
intellectual disabilities, many of whom develop dementia as
they age, a coalition of individuals and organizations came
together in the U.S. to establish a National Task Group (NTG;
Janicki & Keller, 2014). The NTG has focused on identifying
best practices for serving these individuals; developing
screening mechanisms and procedures; designing
educational materials for affected individuals, their families,
and organizations; and promoting public policy. A four-step
process involved securing support for the formation of the
group, drawing on volunteers, securing pro bono work and
other contributions, and advocating for government and
organizational support. This process has, to date, developed
several information, policy, and screening reports that
address its goals.
Advocating for Individuals
As is true for organizational and policy advocacy, advocacy
for individuals can take many forms (Hardcastle, Powers, &
Wenocur, 2011). In some instances, the advocate will take a
lead role in ensuring that an individual receives the care
needed, has concerns and issues addressed, and is afforded
respect and dignity. In other instances, self-advocacy may be
a more appropriate approach, in which the advocate serves in
a supporting role. Self-advocacy can be thought of as a
process in which an individual (or group) advocates for her
or his own needs (Hagan & Donovan, 2013).
Among the strategies for advocating for individuals, a
relatively recent strategy is the use of navigators, individuals
specifically trained to support and assist patients in maneu-
vering through complex health systems and situations
(Meredith, 2013). Navigators might interpret confusing
information about treatment options, assist individuals to
understand and implement treatment protocols, or simply
provide emotional support. They might also support indi-
viduals in their communication with health-care providers,
ensuring that the individual both feels and actually is
heard.
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CHAPTER 3 ■ Public Policy and Advocacy in North America 41

In some instances, the navigator’s goal is to support the to monitor and interpret patient services mandated by such
patient’s self-advocacy, providing skill training, information, laws, questions may well arise specific to therapy or in the
and support that facilitates the individual’s ability to promote course of a PT or OT treatment session.
his or her own needs (Hagan & Donovan, 2013). The attrib-
utes of a self-advocate include a personal perception of effec- INTERPROFESSIONAL PRACTICE
tiveness in controlling the course of care, assertiveness, and OT/PT and Social Work
awareness and utilization of resources.
The discipline most directly responsible for linking clients
Self-advocacy sometimes becomes group advocacy as in-
to available services is social work. Standard 3 of the
dividuals with common needs find like-minded individuals
National Association of Social Workers (2005) Standards
and use their skills to collaborate and thereby enhance their
for Clinical Social Work states: “Clinical social workers shall
power to influence outcomes. A notable example of a self-
be knowledgeable about community services and make
advocacy effort that became a national movement is that
appropriate referrals as needed” (p. 4). It is important for
of Maggie Kuhn, founder of the Gray Panthers (Thomas,
other disciplines to be aware that a helpful strategy for
1995). Forced to stop working by mandatory retirement re-
serving their clients may be referral to social work for support
quirements at age 65, Ms. Kuhn joined with several friends
and assistance (Fig. 3-2).
to form an organization focused on reducing discrimination
throughout society. Although its goals did not specify age
as the unifying factor, many of its efforts emphasized elim- Advocacy for individual patients is an obvious role for PT
inating policies—like the forced retirement that so dis- and OT. But legislative advocacy is also essential. Numerous
tressed her—that denigrated elders and reduced their legislative initiatives have consequences for service to older
options in society. Ultimately, the Gray Panthers grew to adults. For example, the IMPACT Act, H.R. 4994, “Improv-
become a major advocacy organization for human rights. ing Medicare Post-Acute Care Transformation Act,” which
Strategies at which she and the Gray Panthers excelled was passed by the House in September 2014 (govtrack.us) will
included motivational speaking, coalition building, and collect standardized patient assessment data as well as data on
political advocacy. quality measures from SNFs, home health agencies, inpatient
rehabilitation facilities, long-term care hospitals, acute hospi-
tals, cancer hospitals, and critical access hospitals. These data
The Role of OT and PT in Advocacy will be used to facilitate care coordination and improve
Medicare beneficiary outcomes among postacute care (PAC)
Not all clients are capable of speaking for themselves; in and other providers.
particular, those from disadvantaged backgrounds may feel Additionally, the Department of Health and Human
uncertain of their rights and intimidated by the systems Services will develop regulations and guidance for PAC
with which they must interact. Health-care professionals
must recognize that they have an obligation to help their
clients advocate for themselves and that they also have an
obligation to advocate on behalf of their clients (Sandstrom
et al., 2014).
How does this translate into action for therapists? The
American Physical Therapy Association (2014) strongly
encourages PTs to advocate for their clients. Likewise, the
Occupational Therapy Practice Framework: Domain and
Process (3rd ed., American Occupational Therapy Associa-
tion, 2014) lists advocacy as a significant component of OT’s
domain. Advocacy by these groups and their members can
be highly effective.
In occupational therapy, a driving force for advocacy ac-
tivities is the profession’s emphasis on occupational justice—
a belief that everyone should have access to and support for
engaging in meaningful occupations (Hansen, 2013). The
field of physical therapy also recognizes that it is vital to
advocate for patients and emphasizes that this is an essential
competency in care of older adults (Academy of Geriatric
Physical Therapy, 2014).
Patients may well need assistance simply understanding
their rights under Medicare and other programs (Pollack, FIGURE 32 Social workers help link clients to services. JackF/iStock/
2015). Although it is often thought of as a social work role Thinkstock
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42 PART I ■ Global Health and Aging: Implications for Health and Participation
providers and hospitals to require providers to take into
account quality, resource use, the treatment preferences of
patients, and the goals of care of the patients in the discharge
planning process. It will be important for therapy providers
to be involved in advocacy with these initiatives as they move
forward so the distinctiveness of each therapy is preserved in
the data collection and analysis (Ray, 2014).
It is evident as well that many policy decisions are based
on available data about patient needs, outcomes of inter-
vention, and cost–benefit analyses. A significant component
of physical and occupational therapy advocacy relates to
completing research and analysis that provides evidence of
the value of their services. Although there has been a sig-
nificant increase in research over the past several decades,
much remains to be done to ensure there is a firm founda-
tion on which the best decisions can be made (Sandstrom
et al., 2014).
Advocacy at Work: The Olmstead Act
On June 22, 1999, the U.S. Supreme Court ruled in
Olmstead v. L.C. that the unnecessary segregation of indi-
viduals with disabilities in institutions may constitute dis-
crimination based on disability (U.S. Department of
Health and Human Services, 2014). The court ruled that
the Americans with Disabilities Act may require states to
provide community-based services rather than institutional
placements for individuals with disabilities. Accommoda-
tions, caregiving services, and transportation options are
among these alternatives. Home and community-based
services can maintain dignity and independence at a higher
level and should be available to individuals with disability
and older persons in need of support. There are significant
differences in individual states with regard to the services
available, waiver programs that have been applied for, and
types of interventions covered. Unnecessary institutional-
ization is still a problem for many older adults and people
with disabilities, especially those with lower incomes
(National Senior Citizens Law Center, 2010).
The Olmstead decision has had two significant effects
in public policy and responsibility. First, the decision
confirmed that a state could be sued if its programs led to
unnecessary institutionalization. Second, the Olmstead
decision is widely known throughout the network of aging
services and consumers and influences decision making
with regard to choices for care and services. Many states
have been sued based on the Olmstead Act and are being
required to make significant changes to public policy, fund-
ing, and program initiatives to move people into the com-
munity. These suits have been brought on behalf of
individuals with serious mental illness and intellectual
and developmental disability, as well as older persons. The
American Occupational Therapy Association and other
organizations supported these changes through position
papers (Cohn, Lew, Hanauer, Honaker, & Roley, 2010)
and other advocacy efforts.
SUMMARY
Public policy has a significant impact on the extent to which
individuals can have an experience of positive aging. In the
United States as elsewhere, these policies are complex and
typically have both positive and negative consequences.
Therapists have an obligation to be informed about policies
that affect the quality and success of their care and to assist
clients in navigating these complex systems. Therapists also
have an obligation to advocate for their clients as individuals
and for sensible policies that improve quality of life for older
adults.
CASE STUDY
During the economic downturn that began in 2008, many
cities looked for ways to reduce their financial commit-
ments. One city has been looking at its public transporta-
tion with an eye to cutting service. Many older adults in
the community make use of this system, and they are wor-
ried about losing access. A city councilperson has suggested
eliminating transportation for people with disabilities not-
ing that families should provide this service. There are a
significant number of elders who no longer drive, and many
whose families live at a geographic distance. And because
of their socioeconomic circumstances, they do not have the
resources to pay for alternative transportation like taxis. For
some, physical limitations (use of a walker, limited range
of motion and muscle strength) limit their ability to use
regular public transportation.
Questions
1. What is the role of OT and PT in addressing these
concerns?
2. What are some strategies that might be implemented
to address the issue?
Critical Thinking Questions
1. How might some of the Medicare and Medicaid
policies support therapeutic interventions?
2. What are some ways these policies might limit
effective therapeutic interventions?
3. Why might health-care professions, including OT
and PT, be taking an increasingly active interest in
advocacy?
4. What might be some areas in which these
professions should limit their involvement?
5. Thinking about building coalitions to advocate for
policy, what are some organizations or constituencies
that might be natural partners for PT and OT?
4605_Ch03_033-044 31/10/17 11:58 AM Page 43
CHAPTER 3
6. This chapter does not speak at length about advocat-
ing for laws that directly benefit the professions of
occupational and physical therapy (as opposed to
those that benefit their clients). Do you think OTs
and PTs should advocate for themselves and their
professions? Why or why not?
7. Where might there be overlap in the interests of
OT and PT? Where might there be differences in
their perspectives? How might these differences be
addressed?
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Academy of Geriatric Physical Therapy. (2014). Essential competencies in
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“The old woman looks after the child to grow its teeththeandold thewomanyoungwhenoneshein turnloses looks after
LEARNING OUTCOMES
By the end of this chapter, readers will be able to:
1. Describe the demographics of aging in Israel, Mexico,
and South Africa.
2. Describe cultural beliefs and values associated with aging
in Israel, Mexico, and South Africa.
3. Identify family dynamics, including contributions of elders
to their relatives and the contributions of relatives to care
for elders, in Israel, Mexico, and South Africa.
4. Describe the health-care systems and services
available to support older adults in Israel, Mexico,
and South Africa.
5. Discuss funding mechanisms for services for older adults in
Israel, Mexico, and South Africa.
6. Compare and contrast the circumstances of older adults in
Israel, Mexico, and South Africa.
7. Identify ways in which the issues and systems in these
three countries are similar to and differ from those in the
United States.
Clinical Vignette
Marta Garcia is an 86-year-old widow who lives in Mexico
City with her adult daughter, her daughter’s husband, and
their three children. Mrs. Garcia has lived in Mexico City
for her entire life. She has never held a paying job, staying
home with her four children. Her husband worked for many
years as a clerk in a government office until his death 10 years
ago. Mrs. Garcia has looked after her grandchildren so that
her daughter and son-in-law could maintain employment;
now that the grandchildren are older, she finds she has less
to do and feels frustrated by inactivity.
1. What factors in Mrs. Garcia’s situation seem to support
positive aging?
2. What are concerns about her current and future status
with regard to accomplishing her activities?
3. What might be the similarities and differences in
perspective of occupational and physical therapists?
4. What would a therapist need to know about health-care
and senior services in Mexico to assist Mrs. Garcia?
CHAPTER 4
Aging Around the World
—Akan (Ghana, Ivory Coast) proverb
her teeth.
”
T he phenomenon of aging of the population is one that
is occurring globally, not just in Western countries.
Almost every country around the world is experiencing a
growth in the number and proportion of the population that
is older (World Health Organization, 2015). In some coun-
tries, notably Japan, the shift in population has already caused
significant challenges to social circumstances; in others, like
India, the change is occurring more slowly, and the greatest
impact is probably several decades away.
Cultural and social factors have resulted in different sys-
tems to provide support for individuals as they age, and
unique responses to demographic change. In this chapter,
the situations in three countries—Israel, Mexico, and
South Africa—are explored in depth. Experts from these
three countries present a description of the demographic
changes affecting their populations and the kinds of serv-
ices provided for their growing populations of older adults.
In reading these descriptions, it is possible to see both
similarities and differences, strengths and challenges, in
national responses.
Throughout this text, there is information about the ex-
perience of aging and care for older adults from an inter-
national perspective. While therapists most often live and
work in a single country—and in a single region of that
country—increasingly the clients they see represent many
different nations and cultures. And as the challenges of car-
ing for older adults in the context of changing demograph-
ics and economic circumstances become more pressing,
learning from each other presents an opportunity to enhance
effectiveness.
Services for Older Adults in Israel
Yael Zilberslag ■ Maayan Katz ■ Jenny Brodsky
■ Iris Rasoolu
In response to the aging of Israel’s population over the past
2 decades, the system of services for elders has undergone
rapid development and change. In this essay, we describe
the particular configuration of the aging process in Israel
45
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46 PART I ■ Global Health and Aging: Implications for Health and Participation
and the health and social services developed to address the
changing needs. Patterns of care for the elders in Israel have
their origin in the mix of modern and traditional values. On
the one hand, modern aspirations for a higher standard of
living have propelled industry, education, and technology
into the 21st century. On the other hand, traditional expec-
tations of familial commitment have not vanished, and fam-
ily structure has remained fairly traditional. At present the
vast majority of older adults live at home. Israel has suc-
ceeded in placing an emphasis on care in the community,
with relatively few older individuals in nursing homes. This
can be attributed in part to extensive care provided by the
family. In addition, an impressive set of social and health
institutions have been built to take care of those who cannot
be cared for at home, including elders.
The Demography of Aging in Israel
Israel is a small country with a population of approximately
8.2 million in 2014, 833,000 of whom (10.4 percent) are
aged 65 and older. While still relatively young demograph-
ically, compared with other developed countries, Israel has
aged at a rapid rate since the country obtained independence
in 1948—at double the rate of the general population. The
rate of increase of those aged 75 and older has been even
greater. Thus, in Israel as elsewhere, not only has the gen-
eral population been aging, but also the elderly population
itself has been growing older. It is estimated that the pro-
portion of elderly people will reach 15 percent of the total
population by 2035 (1,660,000 people) (Brodsky, Shnoor,
& Be’er, 2014). Three main factors explain population
aging: a decline in fertility, longer life expectancy, and im-
migration. The total fertility rate (average number of chil-
dren per woman) in Israel declined from 3.93 in 1955 to
3.05 in 2012, yet remained relatively high compared with
other developed countries, thus mitigating the aging of the
population.
An increase in life expectancy, especially at age 65, has
also affected the age structure of the population. Life ex-
pectancy in Israel is high, reaching 79.9 years for men and
83.6 years for women in 2012. Life expectancy at age 65 is
18.8 years for men and 21 years for women, the increase
largely due to the prevention of death among older groups in
the population.
Israel has several unique characteristics that affect
changes in the population’s age structure, the most notable
of which is immigration. In the past, the immigrant pop-
ulation tended to be relatively young, thereby slowing the
rate of aging of the overall population in the first years of
the country, although the aging of these cohorts of immi-
gration has had a significant impact on the aging of the so-
ciety since the late 1970s (Palmore, 1993). Moreover,
large-scale immigration in the 1990s, primarily from the
former Soviet Union, has been characterized by immigrants
who are older than the general nonimmigrant population,
contributing significantly to the increase in the number
of older adults (Soskolne, Auslander, & Ben-Shahar,
2006).
An important demographic feature of Israel is its ethnic
diversity. Approximately 92 percent of Israel’s elderly peo-
ple are Jews, whereas 8 percent are non-Jews (Muslims,
Christians, and Druses), only 24 percent of elderly Jews
were born in Israel, 53 percent immigrated to Israel be-
fore 1990 (from Arab countries in Southwest Asia and
North Africa and from Western or Eastern Europe), and
23 percent are relatively new immigrants who came since
1990, mainly from the former Soviet Union (Brodsky,
Habib, Mizrahi, 2014). Thus, Israel is confronted with the
combined challenge of addressing the needs of an aging
population as well as considerable cultural diversity and
language barriers.
Health and Welfare Services
Israel implemented the National Health Insurance (NHI) Law
in 1995, which mandates universal health coverage and defines
a basic basket of services to which all citizens are entitled. It
includes primary (ambulatory) care, acute hospitalization, med-
ications, laboratory tests, and medical rehabilitation. Clinical
care is organized and provided through one of four publicly
financed and administered nonprofit health plans (similar to
health maintenance organizations in the United States). All
Israeli citizens have the right to register in the health service
plan of their choice.
Most health care services are provided by the health plans.
However, the Ministry of Health is directly responsible for
providing subsidized nursing home care, subsidized rehabil-
itation and ambulatory assistance devices in the community,
mental health services, and public health services including
mother and child preventive services.
The health system is funded through a combination of
direct government budget, individual income-based premi-
ums paid by employees, and general tax revenues. The un-
employed, older adults, and those receiving disability and
income support pay only a minimal tariff. The capitation
formula is based on age, gender, and geographic location to
ensure access to health care for those characterized by
higher need of services, particularly older individuals.
In addition to health-care coverage, through the four
health plans and the additional services through the Ministry
of Health, elders in Israel are eligible for benefits from the
National Insurance Institute (NII) including social insurance
benefits, and community long-term-care services and bene-
fits through the Community Long-Term Care Insurance
(CLTCI) law (discussed later in the essay) for those elders
with disabilities in activities of daily living. Older adults are
also eligible for social services, targeted to those with lower
income. This creates a complex system in which health and
welfare services are provided by different government agen-
cies, each operating within its own defined domain, where
4605_Ch04_045-060 31/10/17 11:57 AM Page 47
responsibility is determined by type of service, level of dis-
ability, and financial situation (discussed in more detail later
in the essay).
Long-Term Care for Disabled Elders
The vast majority of elderly people in Israel live in the com-
munity, with only 3.5 percent residing in any kind of long-
term institutional setting. Even among disabled elders,
nearly 80 percent live in the community. Extensive care is
provided by families and paid personal carers, the latter sup-
ported by social and community services, including funding
the development of formal services (some quite innovative)
intended to reinforce these social constructs and help fam-
ilies cope with the burden of care. Among the few who re-
side in institutional care, about a third are in homes for the
frail (moderately disabled) and two-thirds in nursing homes
(for the severely disabled), with eligibility for government
subsidies according to income and assets of the person and
family.
The Social Formal System of Care
The social formal system of care for elders in Israel has been
structured to complement the informal support system. Since
the mid-2000s, a fair number of services, some quite inno-
vative, have been created with the aim of providing a better
balance between public and family resources (Ayalon &
Green, 2015; Brodsky et al., 2000).
The NII provides community services for severely disabled
and mentally frail elderly individuals under the CLTCI Law.
Because of its innovative components and central role in pro-
viding coverage and incurring public expenditures, we discuss
CLTCI in particular detail.
The Community Long-Term Care Insurance Law
Of the various models available, Israel chose to adopt the so-
cial insurance approach to the provision of nonprofessional
home care. The basic entitlement is for in-kind services,
carefully delineated as a “basket of services” that is closely
related to the direct care functions normally provided by
families, such as personal care and housekeeping. Benefits
may also be used to purchase day-care services, laundry serv-
ices, absorbent undergarments for those with incontinence,
or membership in a 24/7 emergency call system. Actual serv-
ices are provided on the basis of benefit levels, according to
the level of disability (equivalent to 10, 16, or 18 hours of
home care per week). There is a means test for receiving ben-
efits under the CLTCI Law, but it is set at such a high level
relative to the income status of older adults that the majority
of those who meet the clinical requirements are also finan-
cially eligible for the entitlement. If necessary, a nonfamily
live-in caregiver can be hired for 24/7 care with the approval
of the state. Part of the funding for the employment of the
nonfamily caregiver is made by the funds transferred for
CHAPTER 4 ■ Aging Around the World 47
older adults under the CLTCI Law, and the remainder is
paid directly by the family.
The first effect of the CLTCI Law was to tremendously in-
crease the resources earmarked for community care (Borowski,
2015; Schmid, 2005). This decision resulted in a more balanced
allocation of public resources between institutional and com-
munity care, dramatically increasing coverage for disabled eld-
erly people in the community, from 2 percent prior to
implementation of the law to 16–17 percent of the total elderly
population (approximately 152,000 elderly people in 2012)
(NII Annual Report, 2012). The NII has given a great deal of
attention to quality assurance within the program and has in-
vested considerable effort in the development of structured
training courses for personal care workers in the home. A set
of quality standards for home care developed in cooperation
with the JDC-Brookdale Institute has been widely dissemi-
nated among providers and serves as the basis for the surveil-
lance efforts of the NII. Recent policy efforts include
enhancing information transfer between the CLTCI and
health plans to improve continuity and quality of care across
those two systems.
Homemaking Services and Meals-on-Wheels
Israel’s Ministry of Social Affairs provides homemaking
services for the less severely disabled elderly individuals.
This is a means-tested discretionary program that benefits
about 1 percent of the elderly population; the individual
pays the cost of the products, not the service. In addition,
the Ministry, through local authorities and various volun-
tary organizations, provides frail elderly people with two
forms of meals: hot meals delivered daily and frozen meals
delivered weekly.
Day-Care Centers
In addition to some 1,400 social clubs that provide a frame-
work for activities and facilitate interpersonal contact and
socialization for well elders, a network of 170 day care-
centers for disabled elderly adults was developed across the
country. These contribute to the feasibility of the disabled
elderly individuals to remain in the community. The service
also improves the quality of their lives and releases the family
from caregiving duties during the day, freeing them to work
and for other tasks. The Ministry of Social Affairs, in coop-
eration with ESHEL (The Association for the Planning and
Development of Services for the Aged in Israel), local mu-
nicipalities, the NII, Israel’s National Lottery, and the
Claims Conference, is responsible for establishing these cen-
ters. The centers serve about 15,000 elderly adults, compris-
ing approximately 2 percent of the country’s elderly population
(Brodsky et al., 2014). The number of centers has increased
since enactment of the CLTCI Law, which also provides
entitlement to day-care services. Persons attending those
centers are either those eligible for CLTCI benefits, social
services benefits, or through private pay. The centers must
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48 PART I ■ Global Health and Aging: Implications for Health and Participation

be licensed by the Ministry Social Affairs. Standards and
quality assurance criteria that reflect all major aspects of care
in these centers have been developed in cooperation with the
Myers-JDC-Brookdale Institute.
Day-care centers usually operate 5 or 6 days a week and
offer social and recreational activities, personal care, hot
meals, transportation, counseling, and health promotion. In
addition to freeing the family from some care responsibili-
ties, they give elders opportunities for social contact and
provide them with stimulation that helps them maintain
their functional and cognitive capacity. Day-care centers in
Israel differ from centers in other countries because they
emphasize social rather than medical care and thus are rel-
atively lower in cost.
Another significant development in the day-care center
network has been the establishment of special programs for
cognitively impaired individuals with Alzheimer’s disease and
other dementias. This resulted from an increase in the num-
ber of cognitively impaired people and the necessity for a
community-based service to meet their needs. These pro-
grams are operated in community centers and other facilities,
as well as in day-care centers, by specially trained staff. Re-
cently adopted standards for adult day care in Israel mandate
that all new facilities set aside a special place for cognitively
impaired elderly adults.
Respite Care
Respite care, a relatively new service in Israel, provides a
temporary alternative residence for elderly people who usu-
ally live at home and whose primary caregiver is absent, has
become ill, or needs temporary leave from his or her care-
giving responsibilities. It is also used as a transitional resi-
dence after discharge from the hospital following an acute
event before returning home. Short-stay opportunities are
also available in long-term care institutions when beds are
not in use by long-term patients; such stays are usually
financed out-of-pocket.
Supportive Communities
One of the most important and innovative developments in
community care has been the supportive community. The
Ministry of Social Affairs, in cooperation with ESHEL, or-
ganizes supportive communities for elders throughout the
country. The program is designed to emphasize the neigh-
borhood as a force that provides older adults with a sense of
security and access to services, thus delaying or preventing
institutionalization. Elderly people who live in supportive
communities in cities, towns, or rural areas enjoy services that
include the following:
1. A neighborhood facilitator who ensures their personal
safety, as well as the safety and security of their homes,
and also provides home repairs
2. An emergency call button
3. A physician/ambulance on call 24 hours a day
4. Social activities
Elders pay a fee to join the program, which is subsidized
for those with low income. At present, there are about
260 communities throughout the country, with some 51,000
members (about 6 percent of elders; Brodsky et al., 2014).
The Health System of Care
Parallel to the development of community and social services,
the health system is developing outpatient services in the
community and in hospitals to meet the growing needs of the
elderly population in the country.
General hospitals are opening acute geriatric wards des-
ignated to care for older adults, and steps have been taken by
these facilities, using geriatricians and multidisciplinary
teams, to locate elders in their communities.
The four nonprofit health plans are committed to devel-
oping Health Promotion Programs and specific prevention
programs for elders. Additionally, they opened specialized
geriatric clinics that carry out a comprehensive geriatric as-
sessment by a multidisciplinary team and Home Care units,
where a designated multidisciplinary team provides the nec-
essary medical treatments and allied health interventions in
the home. These multidisciplinary teams provide treatments
and interventions for elderly individuals confined to their
home, especially where it is important to intervene in the
client’s natural environment. One example is the occupational
therapists’ functional assessments, home modifications, and
falls prevention training. All are committed to developing
Health Promotion Programs and specific prevention pro-
grams for older adults.
All health services for older adults in Israel are audited and
supervised by the Division of Geriatrics in the Ministry of
Health, including services provided in institutions.
Institutional Care
As noted, the rate of institutionalization in Israel is rela-
tively low: About 3.6 percent of the elders are in institu-
tions, 1.2 percent are in homes for the aged (the responsibility
of the Ministry of Social Affairs), and 2.41 percent are
in nursing homes (the responsibility of the Ministry of
Health) (Brodsky et al., 2014). The government is not gen-
erally involved in the direct delivery of institutional long-
term care service but may refer patients to institutions,
some of which are private (for profit) and some of which
are nongovernmental organizations. The Ministry of Health
and the Ministry of Social Affairs are responsible for about
50 percent of the referrals to institutional settings, and the
government helps finance this care. The other 50 percent are
self-referrals and pay for their own care, without government
assistance.
According to the Old Age Homes Law of 1965, an
old age home (that is, a long-term care institution for the
4605_Ch04_045-060 31/10/17 11:57 AM Page 49
semiindependent and frail elders) must be licensed by the
Ministry of Social Affairs following professional surveil-
lance and inspection by Ministry surveyors. The Ministry,
in cooperation with the Myers-JDC-Brookdale Institute,
has developed a highly structured and fully computerized
quality surveillance system that emphasizes the importance
of giving a voice to the elderly residents as part of the sur-
veillance process.
Long-term care institutions for severely disabled and men-
tally frail older adults are licensed by the Ministry of Health,
which has set professional standards for the physical facility,
the staffing in all health professions, and the structure, process,
organization, and outcomes of care. All such institutions must
meet the standards for the purpose of licensing.
The profile of residents has changed since the early 2000s,
with an increase in the percentage of those requiring assis-
tance in personal care. Thus, institutional long-term care is
now mainly serving the more vulnerable populations, while
the less severely disabled elders find solutions in the network
of services in the community and supported by family
(Schmid, 2005).
Issues and Challenges
In recent decades, Israel has increased the resources it ear-
marks for community care and created an infrastructure of
community services. This has resulted in a more balanced
allocation of public resources between institutional and com-
munity care and a better balance of responsibility between
the family and the state. Although the solutions are still far
from meeting all needs and families continue to be the pri-
mary caregivers, the services provide at least a modicum of
care to all older adults. Moreover, the system implicitly rec-
ognizes the value of caregiving, and the government shares
at least some of the burden of caring for older adults.
Nevertheless, the tremendous growth in the number of
elders has led to a rapid rise in the need for long-term care
and to pressure on the formal system of care. On the one
hand, social policies and the welfare state in general are being
called into question, in part due to pressure to reduce public
expenditures. This provides an impetus to develop home and
community services, which are viewed as the best solution in
both economic and human terms, as “aging in place” is pre-
ferred by older adults and, in the majority of cases, is a less
expensive alternative to institutional care. On the other hand,
there is increasing pressure on families to care for their elderly
relatives precisely when many women (the majority of pri-
mary caregivers) are joining the labor force and have less time
to devote to the care of elderly relatives.
REFERENCES
Ayalon, L., & Green, O. (2015). Live-in versus live-out home care in Israel:
Satisfaction with services and caregivers’ outcomes. Gerontologist, 55,
628–642 15p. doi:geront/gnt122
CHAPTER 4 ■ Aging Around the World 49
Borowski, A. (2015). Israel’s Long-Term Care Social Insurance Scheme
after a quarter of a century. Journal of Aging & Social Policy, 27, 195–214.
Brodsky, J., Habib, J., Mizrahi, I., Team, L. T. C., & World Health Organ-
ization. (2000). Long-term care laws in five developed countries: A review.
Brodsky, J., Shnoor, Y., & Be’er, S. (2014). The elderly in Israel: Statistical
abstract 2013. Jerusalem: Myers-JDC-Brookdale Institute.
National Insurance Institute (2012). Annual report: Poverty and social
gaps. Retrieved from https://www.btl.gov.il/English%20Homepage/
Publications/Poverty_Report/Documents/oni2012-e.pdf
Palmore, E. B. (1993). Developments and research on aging: An international
handbook. Westport, CT: Greenwood.
Schmid, H. (2005). The Israeli long-term care insurance law: Selected issues
in providing home care services to the frail elderly. Health & Social Care
in the Community, 13, 191–200.
Soskolne, V., Auslander, G., & Ben-Shahar, I. (2006). Help seeking and
barriers to utilisation of medical and health social work services among
ageing immigrants to Israel from the former Soviet Union. Health &
Social Care in the Community, 14, 74–84.
Health Care for the Elderly in Mexico
Laureano Reyes Gómez ■ Susana Villasana Benítez
Translated by Ashley Zehel
Sociodemographic Context
The aging of Mexico’s population has begun, and it is an
irreversible phenomenon. Villagómez Ornelas (2010) ex-
plains that “in less than four decades, Mexico’s population
slowed down and reduced its accelerated growth, consoli-
dated its urban profile, intensified its migratory activity, and
stopped being a predominantly young country in order to
begin its transition towards old age” (p. 306).
In Mexico’s demographic history, the growth of the eld-
erly population (60 years and older) has been described as
“unprecedented.” In 60 years, the percentage of the older
population went from 5.50 percent in 1950 to 8.95 percent
in 2010, with a greater percentage increase in women than
men (see Table 4-1). Regarding life expectancy, growth oc-
curred at an accelerated rate; in 1950, life expectancy at
birth was at 46.9 years (45.1 for men and 48.7 for women),
and in 2010, it reached 75.4 years of age (71.3 for men and
77.8 for women). In a span of 6 decades, male life ex-
pectancy increased by 26.2 years, and female by 29.1 years
(see Table 4-2).
The following items stand out from the sociodemographic
characteristics that contextualize the aging process in Mexico:
77.8 percent of the country’s total population live in urban
settlements with more than 2,500 residents, and according
to estimates of the National Council for the Evaluation of
Social Development Policy (Consejo Nacional de Evaluación
de la Política de Desarrollo Social [CONEVAL], 2012), in
2012, 45.5 percent of Mexico’s total population lived in
poverty, 28.6 percent was vulnerable due to social depriva-
tions, 6.2 percent was vulnerable due to income, and only
19.8 percent was not living in multidimensional poverty and
not vulnerable.
4605_Ch04_045-060 31/10/17 11:57 AM Page 50

50 PART I ■ Global Health and Aging: Implications for Health and Participation

in Mexico were the ones who registered the highest rates of

TABLE 41 ■ Population of 60 and Older by Sex illiteracy, marginalization, and extreme poverty (Villasana
According to Census Year, Mexico, Benítez & Reyes Gómez, 2006). This new demographic sit-
1950–2010 (Percentage)
uation shows us that the older population is the most unpro-
YEAR TOTAL MEN WOMEN tected in various ways.
According to information from the 2010 Census of Pop-
1950 5.50 5.34 5.67 ulation and Housing (Instituto Nacional de Estadística y
1960 5.55 5.45 5.66 Giografía,2010), the total population of senior citizens
1970 5.62 5.44 5.79 aged 60 and older in Mexico was 10,055,379 (4,679,538 men
and 5,375,841 women), 8.95 percent of the country’s total
1990 6.14 5.89 6.38
population.
1995 6.55 6.28 6.81 “The future perspectives of Mexico’s population point out
2000 7.13 6.83 7.41 that the aging process will continue into the foreseeable
2005 8.08 7.75 8.39 future” (Partida Busch, 1998, p. 18). According to estimates
of the National Population Council (Consejo Nacional de
2010 8.95 8.53 9.35
Población), it is expected that in the coming decades, life
Note: Authors’ calculations. expectancy will continue to increase and will reach 80 years
Source: Instituto Nacional de Estadística, Geografía e Informática. Cuadro. in 2050, and the percentage of elderly will rise to 28 percent.
Distribución por edad y sexo. Población total por grupo quinquenal de edad según
sexo, 1950 a 2010. Censos de Población y Vivienda, 1950–1970, 1990 y 2000. Mexico will gradually transform into a country with more
Instituto Nacional de Estadística, Geografía e Informática. Conteos de Población y seniors than children (Instituto Nacional de Estadística,
Vivienda, 1995 y 2005. Retrieved from http://www3.inegi.org.mx/sistemas/sisept/
Default.aspx?t=mdemo03&s=est&c=17500 Geografía e Informática [INEGI], 2005; Zúñiga, 2004).
This situation created the conditions to provide the compre-
hensive assistance required by the Law on the Rights of Older
TABLE 42 ■ Life Expectancy at Birth by Sex, Persons (Ley de los Derechos de las Personas Adultas May-
Mexico 1950–2010 ores). The first steps have been taken, but it is essential to
redouble efforts that guarantee the care of the aged population,
YEAR TOTAL MEN WOMEN especially if we consider that according to the Economic Com-
1950 46.9 45.1 48.7 mission for Latin America (Comisión Económica para América
Latina [CEPAL]), Mexico is the only Latin American coun-
1960 57.5 55.6 59.4
try where poverty increased in recent years, with a rise of
1970 60.9 58.8 63.0 0.8 percent. The poverty rate rose from 36.3 percent in 2011
1980 66.2 63.2 69.4 to 37.1 percent in 2012 (Expansión, 2013).
1990 70.6 67.7 73.5
2000 73.9 71.3 76.5 Health-Care Systems
2010 75.4 71.3 77.8 In Mexico, the main health-care systems are the Mexican
Social Security Institute (Instituto Mexicano del Seguro
Source: Instituto Nacional de Estadística, Geografía e Informática. Indicadores
Sociodemográficos, 1930–1998. Consejo Nacional de Población. México Social [IMSS]) and the Institute for Social Security and Serv-
Demográfico, Breviario 1988. Consejo Nacional de Población. Proyecciones de la ices for State Workers (Instituto de Seguridad y Servicios
Población de México, 2005–2050. Instituto Nacional de Estadística, Geografía e
Informática, 2012. “Estadísticas a propósito del día mundial de la población”, Sociales de los Trabajadores del Estado [ISSSTE]). Recent
noticias 11 de julio de 2012. Retrieved from http://www.inegi.org.mx/ policies concerning health care created Popular Insurance
(Seguro Popular), which forms part of the System of Social
Official records indicate that 40 percent of the elderly find Protection in Health (Sistema de Protección Social en Salud
themselves in a state of poverty (Instituto Nacional de las [SPSS]), the interest of which is to include greater coverage
Personas Adultas Mayores [INAPAM], 2012a). In 2010, for health services, increasing the number of beneficiaries that
this sector was reported as the most illiterate population, the are not insured by any social security institution, like the
rate of which rose to 24.6 percent (19.9 percent men and IMSS or the ISSSTE. The 2010 Census of Population and
28.7 percent women; Robles, Narro, & Stevens, 2013). Census Housing recorded a total of 7,296,525 persons aged 60 and
information from 2000 reported that the senior citizen pop- older who claimed to be covered by some health service,
ulation living in indigenous homes (domestic units in which 72.6 percent of the population. Thus, 27.4 percent of seniors
the head of household, spouse, or descendent speaks a native do not have access to any health services (Instituto Nacional
language; Villasana Benítez & Reyes Gómez, 2006) regis- de Estadística, Geografía e Informática [INEGI], 2011).
tered a greater percentage than populations living in non- Of the insured elderly population, 52.5 percent were
indigenous homes (7.6 percent vs. 7.3 percent), and the found to have health services from the Mexican Social
indigenous populations from the 62 ethno-linguistic groups Security Institute, 27.7 percent said they belonged to Popular
4605_Ch04_045-060 31/10/17 11:57 AM Page 51
Insurance, 12.6 percent are entitled to the Institute for Social
Security and Services for State Workers, and 7.2 percent
belong to other health institutions (see Table 4-3).
Institutional Policy and Health-Care Systems Agencies
In recent years, before the population’s accelerated aging
process, the state had implemented a series of actions to
take care of the most pressing needs of the elderly, legislate
regarding the protection of the rights of elderly persons,
and promote geriatric and gerontological research.
Evolution of the National Old Age Institute (Instituto
Nacional de las Personas Adultas Mayores)
INSEN 22/08/1979 → INAPLEN 17/01/2002 →
INAPAM 25/06/2002
On August 22, 1979, during the presidency of José López
Portillo (1976–1982) the Elderly National Institute of Aging
(Instituto Nacional de la Senectud [INSEN]) was created and
functioned for 22 years under this name. On January 17, 2002,
during Vicente Fox Quesada’s administration (2000–2006),
it was decided that the term senectud (one of the words in the
Spanish acronym INSEN, where senecto means “senescence”)
is derogatory, and the name INSEN was changed to the
National Institute of Adults in Fullness (Instituto Nacional
de Adultos en Plenitud [INAPLEN]). “That same year, an
important step was taken in legislative matters upon being
published in the Official Journal of the Federation (June 25, 2002),
the Law on the Rights of Older Persons, in which the cre-
ation of the National Institute of the Older Adults (Instituto
Nacional de las Personas Adultas Mayores [INAPAM]) is
mentioned as a replacement for INAPLEN, and it was con-
ferred to the rectory of public policy for the specific care of
the population of those 60 years of age and older” (INAPAM,
2012, p. 11).
INAPAM sets out as a mission: “To promote integral
human development for the elderly by providing employment,
occupation, earnings, assistance and opportunities necessary
to achieve high levels of welfare and quality of life, and reduc-
ing extreme inequalities and gender inequities.” INAPAM
has five guiding principles that seek to develop its activities:
(1) aging culture, (2) active and healthy aging, (3) economic
security, (4) social protection, and (5) rights of older persons
(pp. 4–5). However, the report from Memoria Documental
TABLE 43 ■ Population of 60 and Older Insured by Type of Institution, Mexico, 2010
ISSSTE INSTITUTO DE SEGURIDAD
IMSS INSTITUTO MEXICANO Y SERVICIOS SOCIALES DE LOS
DEL SEGURO SOCIAL TRABAJADORES DEL ESTADO
3,830,258 920,712
Percent 52.5 12.6
Source: Census of Population and Housing 2010.
CHAPTER 4 ■ Aging Around the World 51
about INAPAM (2012b) recognizes problems in executing
the program: “While the presented Guiding Principles are
based on the concept that older adults are subject to rights, in
Mexico these are still vulnerable violation because there is no
strong culture in the practical order to promote and protect
the acts of the government and the enforcement thereof by
the elderly” (p. 5).
In practice, INAPAM has dedicated itself to implement
an ambitious program giving credentials to the population
over 60 years of age, providing discounts for medicines, trans-
port, in restaurants, and recreation centers, among other serv-
ices. The same applies to the organization of “Third Age
Clubs,” which seek out recreation for its members. “Accord-
ing to INAPAM, in Mexico there are more than 5,500 Third
Age Clubs.... In them, activities that strengthen independ-
ence, decision making, and personal and community devel-
opment for older people are carried out” (Cano, 2010).
Federal Program of Economic Support “70 and Over”
The program “70 and Over” started during the administration
of President Felipe Calderón Hinojosa (2006–2012). Through
the Secretariat of Social Development (Secretaría de Desarrollo
Social [SEDESOL]), 500 pesos (roughly $50 in U.S. dollars)
in cash was invested monthly as economic support by way of
bimonthly installments to more than 2,105,313 beneficiaries
from 76,315 localities throughout the country (Programa 70 y
más de SEDESOL).
As of December 1, 2012, with Enrique Peña Nieto as
president, the 70 and Older program expanded its coverage
to include persons 65 and older. The 70 and Older program
supported almost 3.2 million people. With its transforma-
tion, it will benefit almost 2.5 million more. With a total of
6.5 million senior citizens benefitted, it is covering practically
100 percent of the aged population without some type of
pension (Programa Pensión para Adultos Mayores, 2013),
further increasing the economic value to 525 pesos (about
$40 in U.S. dollars) per month.
Economic Support Program for Older Adults in the States
The Law on the Rights of Older Persons, published in the
Official Journal of the Federation obligates the states and the
Federal District, among other things, to provide social assis-
tance, understood as the “Set of actions aimed to modify and
PEMEX,
ISSSTE DEFENSE POPULAR PRIVATE OTHER
STATE OR NAVY INSURANCE INSTITUTION INSTITUTION
89,360 142,356 2,019,980 149,008 144,851
1.2 2.0 27.7 2.0 2.0
4605_Ch04_045-060 31/10/17 11:57 AM Page 52
52 PART I ■ Global Health and Aging: Implications for Health and Participation
improve social circumstances that prevent an individual’s
comprehensive development, such as physical, mental, and
social protection for those in need, those who are vulnerable,
or the physically and mentally disabled, in order to allow
them to live a full and productive life” (Ley de los Derechos de
las Personas Adultas Mayores, 2002; Artículo 3o. Fracción II).
Senior citizens, under this law, become entitled to certain
rights. Thus, the federation, federal entities, and municipal-
ities implement policies aimed at monitoring health care, to
which, by law, the aged sector has right.
The population of those 60 and older forms a political in-
terest. The states and the Federal District design financial
support programs, goods, and other benefits for its inhabi-
tants. These programs have faced problems of implementa-
tion, given that thousands of senior citizens do not have birth
certificates on record, especially the indigenous, the illiterate,
and widows living in highly marginalized areas.
Meanwhile, the municipalities, through the National
System for Integral Family Development (Desarrollo Inte-
gral de la Familia), basically focus on assistance to the Third
Age Clubs, and, in some cases, the construction of a
“Grandparent’s House” (“Casa del Abuelo”) where they
expect to provide some care, depending on the political sit-
uation, including distribution of basic goods and, in some
cases, “Casas de día,” which function as day-care centers for
the elderly. The medical service that they provide is primary
care, where little or nothing is done regarding chronic or de-
generative diseases, especially diabetes, arterial hypertension,
and heart attacks.
The University of the Third Age (Universidad
de la Tercera Edad)
The University of the Third Age is an institution with
headquarters in the Federal District (Mexico City). Its two
buildings provide activities that serve to develop and boost
the physical, emotional, and intellectual abilities of senior
citizens. In these schools, more than 77 subjects are taught,
including business administration, information technology,
and languages (English, French, and Italian). They also
teach courses in self-esteem, sexuality, nutrition, and liter-
ary creation. In addition, there are classes that teach oil
painting and microwave cooking, and workshops on the
study of death and dying, among others; there are also
courses of human development, neurolinguistic program-
ming, hydroponics, yoga, and social networks (Adulto
Mayor Pleno, n.d.).
To enroll in this institution, senior citizens must be at least
50 years of age and be able to perform activities on their own.
They must present required documentation of identity and
residency, along with a medical certificate and electrocardio-
gram interpretation (Universidad de la Tercera Edad, n.d.).
Group Homes and Public Nursing Homes
Although the concept of “nursing home” is controver-
sial, nursing homes’ efforts seek to exceed the commonly
held negative perceptions about such institutions. Nursing
homes are welfare institutions that survive thanks to public
goodwill, especially from philanthropy like the Lions Club,
the Church, and other private and public institutions.
Evolution of the National Institute of Geriatrics
IG 28/07/2008 → ING 30/05/2012
During his presidency, Felipe Calderón Hinojosa (2006–
2012) began the process of creating the Geriatric Institute
in January 2007, which included a feasibility study by a
group of specialists in aging and health, project validation
by several international organizations, administrative model
design, development of infrastructure and strategic planning.
The Geriatric Institute’s main objective is to contribute to
the improvement of health and welfare conditions of the
aging Mexican population, by way of health research, gen-
erating knowledge and proposals for action leading to the
definition of public policies to promote the Mexican popu-
lation’s healthy aging, with the participation of social and
private sectors.
On May 30, 2012, the Geriatric Institute changed its
name to the National Institute of Geriatrics. Under its new
name, it seeks to strengthen and enhance work with the
National Institutes of Health in cooperation with the
health sector. This will also facilitate coordination of
the social and private sectors. In this way, the health-care
models that are generated, as much for operation as for
the training of human resources, will be implemented in
the National Health System units in three levels of care
(Instituto Nacional de Geriatría, n.d.).
The National Institute of Geriatrics’ policy intends to
employ a model of healthy and active aging, and it has staff
working across disciplines and interinstitutionally, not only
in the country but throughout international networks of
various social and medical specialties.
Conclusion
Old age is the longest period of the life cycle, if we consider
that it could last longer than 40 years. It is a period in which
health demands increase, generally without increase in
income or with unstable income. Consequently, it is often
a time of economic dependence in addition to the need for
care and assistance. The challenge we have as a society is to
provide a dignified old age for our elders—not only through
decrees but also through practical actions.
The creation of an Attorney’s Office for the Defense of
the Elderly leaves something to be desired, especially if we
consider that dispossession is the leading cause of abuse
suffered by the old. In addition to dispossession, we have
to respond to frequent cases of abandonment of a person
near death, which happens when the family collapses
and refuses care, particularly palliative care, to an elderly
person.
4605_Ch04_045-060 31/10/17 11:57 AM Page 53
Geriatric health services try their best; however, it is nec-
essary to implement comprehensive care policies that reach
marginalized and poor communities. Preventative care must
be improved, given that several chronic diseases such as dia-
betes, heart attacks, and obesity, among others, wreak havoc
on all ranges of the population.
Finally, the topic of aging and the aging population has
been a concern and a strong emerging interest of universities
and institutes, who are responsible for setting up human
resources in gerontology, geriatrics, geriatric nursing, psy-
chology, and scientific research in many other disciplines
related to senior citizen concerns. Mexico has entered a
process of population aging, and we should beware that it is
an irreversible phenomenon.
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blogspot.mx/2013/05/talleres-cursos-y-materias-en-la.html
Cano, D. (2010). Clubes de la tercera edad para aprender y divertirse.
Salud 180. El estilo de vida saludable. Retrieved from http://www.
salud180.com/adultos-mayores/clubes-de-la-tercera-edad-para-
aprender-y-divertirse
Consejo Nacional de Evaluación de la Política de Desarrollo Social. (2012).
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nacional y por entidades federativas. Retrieved from http://web.coneval.
gob.mx/Medicion/Paginas/Medici%C3%B3n/Pobreza%202012/
Pobreza-2012.aspx
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donde aumentó la pobreza en 2012. Retrieved from http://mexico.cnn.
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ticas a propósito del día mundial de la población, noticias 11 de julio de 2012.
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salud.gob.mx/
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Ley de las Personas Adultas mayores. (2002). Retrieved from http://www.
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CHAPTER 4 ■ Aging Around the World 53
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Niveles, tendencias y reflexiones en torno a la población de adultos may-
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Federal, Instituto Nacional de Geriatría, Red Temática Envejecimiento,
Salud y Desarrollo Social, pp. 305–313.
Villasana Benítez, S., & Reyes Gómez, L. (2006). Diagnóstico sociodemográ-
fico de los adultos mayores indígenas de México. Comisión Nacional Para el
Desarrollo de los Pueblos Indígenas, Programa de la Naciones Unidas
para el Desarrollo, México.
Zúñiga, E., & Vega, D. (2004). Envejecimiento de la población de México:
Retos del siglo XXI. Secretaría de Gobernación, Consejo Nacional de
Población. Retrieved from http://www.conapo.gob.mx/es/CONAPO/
Envejecimiento_de_la_poblacion_de_Mexico__reto_del_Siglo_XXI
Aging in South Africa
Kim Lewitte ■ Anupa Singh
“
A great shift is happening in Africa. Many other counties are experiencing the
effects of an aging population, but in Africa, this is happening more rapidly (Pew
Research Center, 2014). This unprecedented demographic shift is being fuelled by the
HIV AIDS epidemic. Between 1990 and 2010, the aged population of South Africa
grew from 4 percent to 6 percent of the population, in part due to loss of the adult popu-
lation to AIDS (Nabalamba and Chikoko, 2011). The number of older persons is
expected to grow and along with it the prevalence of frailty, chronic disease and disabil-
ity. By 2050, the population aged 60 and above in South Africa is expected to increase
”
to as much as 15 percent of the population. (World Health Organization, 2015)
The Effect of Apartheid on South African Aged
Many of aged South Africans have lived through the
apartheid rule and have experienced unequal access to social
services. Historical injustices are currently materializing in
society. The unique South African apartheid system resulted
in vast differences in families due to racial segregation. Fam-
ilies were broken up as older persons were forced to leave
areas when they were no longer employed and move to areas
where basic services and support systems were lacking
(Nhongo, 2004). There was a huge disparity between quality
of services offered to white and nonwhite South Africans. The
general belief was that older persons in the non-white com-
munities would be looked after by the extended family. As a
result, many old-age homes were historically built to cater to
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54 PART I ■ Global Health and Aging: Implications for Health and Participation
the white population, with few facilities available for non-
white communities.
At the time of the democratic elections in 1994, South
African cities were characterized by dire housing and services
backlogs, inequalities in municipal expenditure, the spatial
anomalies associated with the “apartheid city,” profound strug-
gles against apartheid local government structures, high un-
employment, and many poverty-stricken households (Pillay,
Tomlinson, & du Toit, 2006). The apartheid government
sought to segregate aspects of South African society by using
designated areas for settlement in areas known as “ethnic
homelands,” resulting in many nonwhite South Africans being
restricted to rural areas.
The Rainbow Nation: Current Status
of Older Adults
The democratic election in 1994 brought new hope of equal-
ization of status and services for the aged in South Africa.
Despite the change in policy and politics, the legacy of unjust
rule persisted. More than 20 years after democracy, the coun-
try’s aged are still experiencing the effect of the disadvantaged
past. In 2004, more than half (51.1 percent) of older persons
had no formal schooling, with the prevalence being higher in
rural areas (Nhongo, 2004). Although poverty rates and dis-
parities are decreasing in South Africa, this is occurring very
slowly (Campbell, 2013).
Older persons are disproportionately located in rural
areas. Seventy percent of the poorest people in South Africa
lived in poverty in rural areas in the early 21st century
(Nhongo, 2004). Rural communities are highly dispersed
and have difficulty accessing appropriate levels of support
and services.
The lack of housing in urban areas resulted in the forma-
tion of informal settlements with detrimental consequences
for humans and their environments (Kinsella & Ferrier,
1997). Many aged persons with frail care needs continue to
live in such conditions with unhealthy living conditions and
are still unable to access adequate health facilities.
Approximately 430,000 or 23.1 percent of older persons
are disabled. The most common disability is the loss of sight
(47.1 percent) followed by physical disabilities (20.4 percent).
Census data showed an increased prevalence in disability with
age, and almost a quarter of all people 80 years and above
having a disability (Department of Social Development
[DSD], 2005).
Policies related to care of the elderly have seen a shift from
institutional care to community care. The state has indicated
that its duty to the aged is to provide care in the case of indi-
gent and frail older persons in need of residential frail care
only. The government has offered subsidies to adapt homes
into assisted living units for older persons and has offered local
authorities 100 percent loans to build special housing units for
older persons (Department of Social Development, 2005). A
study done by the Community Agency for Social Enquiry and
the DSD on the Status of Older Persons in South Africa
showed that only about 17 percent of this group received
municipal assistance, Reconstruction and Development Pro-
gramme aid, or government-subsidized houses. This was de-
spite policy stipulating that recipients of the old age grant were
eligible for the housing subsidy scheme (DSD, 2005).
Health Care in South Africa
Health care in South Africa varies from the most basic
primary health care, offered free by the state, to highly
specialized, hi-tech health services available in the both
the public and private sector. However, the public sector
is stretched and underresourced in places. Although the
state contributes about 40 percent of all expenditures on
health, the public health sector is under pressure to de-
liver services to about 80 percent of the population
(SouthAfrica.info, 2012).
The private sector offers private health insurance, and
services cater to middle- and high-income earners who
tend to be members of medical schemes. It also attracts
most of the country’s health professionals. Private health
care is provided by a large for-profit sector, and a small but
significant workplace-based health care system. Although
there are also numerous, and mainly small, private chari-
table health care institutions, they are often partly or
mainly funded by the state and deliver similar services to
the public sector. The private for-profit hospital sector is
located mainly in urban areas and has expanded rapidly
since the mid-2000s, displacing private-paying patients
from public hospitals.
This two-tiered system is not only inequitable and in-
accessible to a large portion of South Africans, but institu-
tions in the public sector have suffered poor management,
underfunding, and deteriorating infrastructure. Although
access has improved, the quality of health care has de-
creased. The situation is compounded by public health
challenges, including the burden of diseases such as HIV
and tuberculosis (TB) and a shortage of key medical per-
sonnel (Söderlund, Schierhout, & van den Heever, 1998;
SouthAfrica.info, 2012).
Services Offered to the Aged
Government Subsidized Health Care
The current South African public welfare system is excep-
tional among developing countries and a major pillar in its
system is the redistributive social policies (Lam, Leibbrandt,
& Ranchhod, 2003). The impact of an aging population
combined with the social, economic, and political changes
taking place in South Africa necessitated policy transfor-
mation in recent years. The government undertook a revi-
sion of the South African Policy for Older Persons to
facilitate services that are accessible, equitable, and afford-
able to older persons and that conform to the norms and
standards set. The intention is that services should allow
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CHAPTER 4 ■ Aging Around the World 55

older persons to live meaningful lives and be recognized as
important sources of enrichment, expertise, and community
support (DSD, 2005).
Services available for elderly provided by state include the
following:
Although primary health care services are free to the aged,
dedicated geriatric services in the public sector have been
thought to be marginalized and overshadowed by emphasis
on child, maternal, and reproductive health care. There is
dissatisfaction of the inefficient appointment systems, long

Primary health care is free for all indigent South Africans who are
pensioners. Specific focus of the PHC service for the elderly include
identification of common chronic conditions and diseases
associated with aging, identification of older persons at risk, health
Primary promotion activities; case management, including therapeutic
Health-Care education, emergency care, and management of referrals from
(PHC) Services other levels of care; and pharmaceutical services for common
chronic conditions and liaisons with community-based organizations
dealing with older persons.

Older persons receiving a social grant receive free access to public

hospitals. Secondary-level hospitals offering high-levels of health
Secondary care, such as specialist services, deal with diagnosis and treatment,
Health-Care laboratory services, referral to specialist care, support to primary-
Services level health care, pharmaceutical services, and rehabilitation
services including psychosocial services

The full range of services are provided, including medical,

Tertiary psychiatric, surgical, diagnostic, therapeutic, and rehabilitative
services. There is specialist multidisciplinary care for older persons
Health-Care with complex and chronic conditions and diseases. These services
Services support secondary health-care services and engage in research
and care audits. Specialized support services are offered.

Communities, relatives, faith-based organizations, and nongovern-

mental organizations make a significant contribution to the care and
support of elderly persons in South Africa. Some services include:
• Attending to physical needs such as bathing, grooming, shopping,
Community and assistance with home management tasks.
Care and • Ensuing the home is accessible and hygienic.
Support • Providing recreational activities.
• Noting physical and mental conditions and appropriate referral
to the doctor, social worker, or community health-care worker.
• Arranging for older persons to attend hospital or clinic.

waiting times, understaffed facilities, and shortages of med-
ication (DSD, 2005). Communities are seen to complement
services offered by the government. It is generally believed
that the government subsidy only covers a small cost of the
actual cost. Some have attributed the inadequate care, neg-
lect, and abuse to be sequelae of poorly run services as a result
of cost cutting.
An additional grant offered by the state is a grant for full-
time care. In addition to old age, disability or war veteran’s grant
if one is unable to care for oneself and needs full-time care, then
the individual can access an additional monthly payment from
the government called a “grant-in-aid” (Government Commu-
nications and Information System, 2014).
Private Health Care
Private health insurance has a long history in South Africa,
with the first “medical scheme,” the De Beers Consolidated
Mines Ltd Mines Benefit Society, having been established
in 1889. By 1910, there were seven such schemes in existence,
and by the beginning of the Second World War in 1939, a
total of 48 schemes existed.
South Africa now has more than 110 registered medical
schemes, with around 3 to 4 million principal members (and
7–8 million beneficiaries). Private health care consumes more
than 50 percent of total health care spending in South Africa,
but is inaccessible to most of the population and, in many
cases, highly inefficient. Nevertheless, many, if not most,
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56 PART I ■ Global Health and Aging: Implications for Health and Participation
South Africans rely on or aspire to private sector care
(Kautzky & Tollman, 2008).
Historically, medical scheme membership was strongly
linked to employment, and employers generally paid the
larger portion of premiums for workers and retired employ-
ees. Medical scheme contributions paid by an employer on
behalf of employees have not been taxable as fringe benefits.
Many elderly people cannot afford the medical aid costs once
employment ceases and are compelled to use public health-
care facilities (Söderlund et al., 1998). Although these strate-
gies have helped many in South Africa, the country ranks
poorly in its care of elders (Okolo, 2013).
Private medical officers are generally not employed by hos-
pitals but operate as independent contractors with relatively
loose affiliations to hospitals. Approximately 56 percent of
doctors work in the private sector, and they are better qualified
and more experienced, on average, than their public sector
counterparts. The proportion of all doctors working in the pri-
vate sector is not higher in wealthier or urban areas, however.
This illustrates that even in very deprived communities, the
lack of adequate public services creates a market for private
care. More than 80 percent of dentists and pharmacists are
employed in the private sector (Kautzky & Tollman, 2008),
resulting in a small pool of health professionals being available
for aged care who have no access to the private sector.
Up until recently, the South African government, and in
particular, the Department of Health, paid little attention to
the private health-care industry. The size of the industry, its
impact on the public sector, and recent sector trends suggest
that concentrated regulatory efforts, especially on the financ-
ing side, could substantially improve the equity and efficiency
of health care overall. Given commitments to stringent public
spending goals, it is likely that a substantial section of public
health care will be de facto privatized in the forthcoming
years, and regulation might become a more important tool
for health policy implementation than direct provision
(Kautzky & Tollman, 2008). To date, there have been no
advances in privatization of the public health sector.
In terms of total resource use, the private sector is the
dominant vehicle for both financing and provision of
health care in South Africa. Only a limited number of South
Africans have access to this sector on a regular basis. The
results from a government survey showed that a total of
8,057,559 individuals were covered by medical aid, represent-
ing 16.0 percent of the total population in 2011. Although
no significant differences on medical aid coverage were ob-
served by sex, significant differences were observed by age,
population group, and province of usual residence (Statistics
South Africa, 2011).
The Future of Health-Care Funding
The Department of Health is focused on implementing an
improved health system, which involves focusing on public
health, as well as improving the functionality and manage-
ment of the system through stringent budget and expendi-
ture monitoring. Known as the “10-point plan,” the strategic
program is improving hospital infrastructure and human re-
sources management, as well as procurement of the necessary
equipment and skills (Health Systems Trust, 2010).
Under this plan, health facilities, such as nursing colleges
and tertiary hospitals, are being upgraded and rebuilt to lay
the way for the implementation of the National Health
Insurance (NHI) scheme.
The NHI is intended to bring about reform that will im-
prove service provision and health-care delivery. It will pro-
mote equity and efficiency to ensure that all South Africans
have access to affordable, quality health-care services regard-
less of their employment status and ability to make a direct
monetary contribution to the NHI Fund. Fundamentally, it
is about equity, and the redistribution of health-care resources
and benefits (Health Systems Trust, 2010).
The NHI is expected to propose that there be a single
National Health Insurance Fund for health insurance. This
fund is expected to draw its revenue from general taxes and
some sort of health insurance contribution. The NHI was
expected to be phased in over 14 years, beginning in 2012,
but this has not materialized to date.
The Role of Traditional Medicine
Recent work in health-care utilization patterns recognizes the
increasing reliance of South African population on pluralistic
health care—namely, the complementary use of public and
private allopathic services in conjunction with traditional
healers, herbalists, faith healers, and prophets. With South
Africa comprising so many diverse cultures, backgrounds, and
beliefs, many individuals will prefer to turn to traditional
methods for treating ailments. An estimated 80 percent of
South Africans consult with traditional healers alongside
general medical practitioners. The South African government
has acknowledged the strength and limitations of working to
integrate these disparate health-care service providers to im-
prove service coverage and achieve comprehensive care that
is both socially and culturally acceptable
The Medical Research Council (MRC) founded a tradi-
tional medicines research unit in 1997 to introduce modern
research methodologies around the use of traditional medi-
cines. It also intended to develop a series of patents for prom-
ising new entities derived from medicinal plants (Söderland
et al., 1998). There are no reports of the progress of the MRC
in addressing these goals.
The Role of the Aged in the South African
Community
Traditional Roles
The traditional role of elders in South African society was to
advise, direct, and lead families and society in practices, rit-
uals, and ceremonies that allowed for survival, existence, and
continuity not only for the individual, but also for the com-
munity as a whole (Nhongo, 2004). They played an integral
part in ensuring the knowledge norms and values of culture
and society were preserved.
4605_Ch04_045-060 31/10/17 11:57 AM Page 57
It is hypothesized that the advent of formal education, re-
ligious influences, and modernization has altered the roles of
the elderly in a South African society (Nhongo, 2004) and
contributed to the erosion and recognition of the status of
the elderly in society. This has been exacerbated by urbaniza-
tion, the migratory labor system, chronic diseases, and eco-
nomic changes. Nhongo (2004) explores the effect of colonial
and racial capitalist development and its effect on household
forms and whether the African family was able to resist the
changes imposed by external forces such as industrialization
of society.
Until recently, the majority of older people of nonwhite
origin were absorbed into the household of their children,
with extended families providing full-time care, as well as
monetary, physical, and emotional support. Historically the
elders provided care for their children, who would in turn
provide care of the elderly in their old age. This situation has
changed significantly, and older adults are providing the care
of the sick, the dying, and children orphaned or made
vulnerable by the HIV/AIDS pandemic (Nabalamba &
Chikoko, 2011). The elderly, many of whom are already liv-
ing below the poverty level, are now faced with the burden
of care. Older persons are now playing the role of caregivers
and breadwinners with little or no resources at their dis-
posal and little recognition for their efforts (Nabalamba &
Chikoko, 2011).
Older men and women in South Africa continue to make
vital contributions to families. Across the continent of Africa,
64 percent of men over age 60 years continue to work across
the formal and informal sectors (Stanley, 2008). Older
women tend live longer and continue domestic and subsis-
tence farming roles. Many women continue to raise children
of younger adults who have migrated in search of work or
died due to the HIV/AIDS pandemic.
Møller and Ferreira (2003) showed that among house-
holds with aged persons, there are larger numbers of depend-
ent and unemployed members with three or more generations
living in the same household. Less than 10 percent of older
people lived alone. Møller and Devey (2003) reported that
access to a state pension allows the pensioners better access
to services and they express significantly higher levels of sat-
isfaction with their living circumstances compared with non-
pensioner older households.
In many homes, the old age pension is the sole source of
income, and pensions are for the sustenance of the household
members rather that the needs of the aged. It is heartening
to note that the situation for older individuals has improved,
with slightly more than a third of those over 65 years of age
living in poverty in 2011 down from 55 percent in 2006, a
figure that shows significant improvement in the past decade
(Statistics South Africa, 2014).
Economic Sustenance of the Aged
When taking into account the contribution of the older adult,
the diversity of the nation is noteworthy, especially on the
poverty–wealth continuum. South Africa is one of the few
CHAPTER 4 ■ Aging Around the World 57
countries in sub-Saharan Africa that operates on a noncon-
tributory social pension system. Social pensions are paid to
citizens over age 60 years regardless of whether they have
worked. This “Old Age Grant” is the primary source of
income for the majority of elderly South Africans and is
presently R1 350 per month (Government Communication
and Information System, 2014). Citizens over 75 years old
receive R1 370. (Owing to the fluctuating Rand-to-Dollar
exchange rate, this works out to between $83 and $129 per
month.) Even at the highest possible exchange rate, this
amount is meager.
Because of the high levels of youth unemployment and
mortality and the increased amount of persons dependent on
elderly persons, the Old Age Grant becomes the only source
of income in many households. This old age pension has been
deemed to enhance the economic and social status of the eld-
erly, who become wage earners and breadwinners in the
home (Nhongo, 2004).
Challenges for the Aged in South Africa
Many South African individuals of African descent will
return to their birthplace or home place when they are no
longer able to work or live alone independently. The family
setting overall is silently expected to take in and look after
the older individual. The nonwhite population is again very
diverse in this context, where some older adults are taken in
to the family unit, while others are placed in retirement
homes.
Many older people in South Africa continue to be ex-
posed to increasing poverty, discrimination, violence, abuse,
and economic exclusion; denied access to insurance and
credit; and lack entitlement. The Aged Persons Act of 1967
provides for the protection and welfare of older and debili-
tated persons, for the care of their interests, for the estab-
lishment of certain institutions for the accommodation and
care of such persons in these institutions (Department of
Social Development, 2005).
A survey of 15 African countries revealed that the propor-
tion of older people throughout the continent living in
poverty was higher than the national average. This was par-
ticularly the case when older people were living in families
with young children. It is thought that this poverty prevents
the elderly from participating in society and accessing services
and places them at risk of social exclusion (Stanley, 2008).
Older persons’ access to health care is limited by geo-
graphic isolation that affects transport to health facilities, lack
of identity documents proving eligibility for free or subsidized
services, lack of knowledge of what they are entitled to, and
inability to queue to access services.
The need for noninstitutionalized community homes for
social pensioners living in urban and rural communities is
becoming critical, but access to land is becoming virtually
impossible. It is recommended in some provinces that the
community-based housing initiative for vulnerable com-
munities should not be viewed as housing projects but as a
4605_Ch04_045-060 31/10/17 11:57 AM Page 58
58 PART I ■ Global Health and Aging: Implications for Health and Participation
catalyst for community upgrading projects to upgrade all
the community.
The government is faced with various challenges to meet
the care needs of the elderly. These fundamental needs in-
clude the following:
■ Providing secure housing that has been structurally designed
to meet the needs of the elderly who have specific accom-
modation requirements. In light of the escalating crime
prevalence in the country, houses need to be located in a
safe and protected environment (South Africa Parliament
Research Unit, 2007).
■ Additional services such as assistance with shopping,
taking medication, rehabilitation, assisting with personal
hygiene, and mobility assistance are required.
■ The pension scheme and its ability to cover all essential needs
of the elderly must be reviewed (South Africa Parliament
Research Unit, 2007).
■ The management and administration of service delivery to
allow decentralization to ensure that services for elderly
people is planned for in specific communities (South Africa
Parliament Research Unit, 2007).
To date, feedback and updates regarding service delivery
for the elderly in South Africa are scarce.
There have been some reports of progress with regard to
service delivery in some small communities and areas, as well
as scattered reports of poor service delivery in other commu-
nities. The involvement of health-care workers and the pres-
ence of resources for the aged in communities are minimal.
The aged depend on their families for care, but families are
often unprepared or lack skills to care for the frail elderly (Lam
et al., 2003). Overall, the fundamental needs of the elderly in
South Africa require much further attention and intervention.
Conclusion
South Africa underwent its first democratic elections in 1994.
More than 20 years later, the current government still has
many aims to achieve in accordance with national policy, in-
cluding providing more housing, electricity, safe drinking
water, and decent education to youth. Some attention has
been given to the health-care system, but significant strides
have not yet been achieved, especially with regard to primary
care in the government hospitals and health clinics. The basic
outlines of policies and services for the elderly are present on
paper, but they need to be implemented more efficiently and
improved for older individuals to age successfully and con-
tribute to their community and society. Primary health care
still requires significant attention, but so does specialized
health care. Specialized geriatric units, day-care programs,
and dementia resources are scarce and not accessible in an
equitable manner. The role of the family still proves to be a
necessary support for the aging individual. With a rapidly
growing population, the government must look at prioritizing
care of the elderly more specifically in their financial budgets
and planning. Private health-care continues to be accessible
to a minority of the population, with many people being un-
able to afford this type of care. The future of the NHI policy
is uncertain at this stage, and its potential effects on services
and care for older adults cannot be predicted. The problems
of older people in South Africa must be addressed within a
broader context that encompasses reforms at different levels,
including legislative, social, economic, and administrative
processes.
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SUMMARY
The three essays here demonstrate similarities among coun-
tries addressing concerns related to their aging populations.
Among the ways in which they are similar, in each of these
countries:
■ The population is aging rapidly, both in terms of absolute
numbers and in terms of proportion.
■ The majority of older adults live in the community rather
than in institutional settings.
■ Families provide a substantial proportion of the care older
adults need.
■ A form of national health insurance exists, but there is
some fragmentation among service and payment systems.
There are also some unique characteristics and services. So,
for example, Israel’s aging population is influenced more by
immigration than is true in Mexico or South Africa. And Israel
has developed some unique communal services, particularly the
Supportive Community model. This model provides a coordi-
nator, social activities, emergency call services, and full-time
medical and emergency care. In Mexico, health-care coverage
extends to only about three-quarters of the older population.
This is due in part to the large indigenous population, some of
whom lack birth certificates and have limited literacy. There,
“Third Age Clubs” and a “70 and Older” program have been
instituted as strategies to extend social and medical services to
the entire population of older adults. And in South Africa, the
lingering impact of apartheid has contributed to stubborn
health disparities. Further, the prevalence of HIV/AIDS has
altered the age distribution of the population in ways that ex-
acerbate the dearth of potential care providers for older adults.
In considering care for older adults, therapists everywhere
can benefit from exploring the options provided in countries
other than their own. For U.S. therapists, it can be helpful
to consider some of the community-based services described
in this chapter. It can also be reassuring to know that the
United States is not alone in its need to address a culturally
CHAPTER 4 ■ Aging Around the World 59
diverse population. As the world addresses the needs of an
aging population, sharing of resources and wisdom becomes
ever more important.
CASE STUDY
Batya Liebowitz is an 82-year-old widow who lives outside
Tel Aviv. Two of her three daughters live in the same area
with their husbands. Her third daughter emigrated to the
United States 20 years ago but returns at least annually to
visit. Among the three children, there are 12 grandchildren,
all now young adults; most living in Israel.
Mrs. Liebowitz used to work as a librarian. She retired
10 years ago and has spent much of her time since then
with her family and friends. In the past 5 years, her os-
teoarthritis has gotten significantly worse, and she now
has trouble with the stairs from her second floor apart-
ment. She does not drive and finds it difficult to step into
the bus, which has served as her primary means of trans-
portation. Mrs. Liebowitz also has difficulty cooking and
keeping her apartment clean because of her mobility lim-
itations. Her daughters have noticed that in the past year,
she has become much more forgetful. Her two nearby
daughters now do her grocery shopping, and they provide
transportation when they can; however, they and their
husbands all work full time, so their availability is limited.
They are beginning to feel burdened by her need for help,
although they love her and want to be useful.
Mrs. Liebowitz and her family are now considering op-
tions to support her wish to remain in her apartment. The
Long-Term Care community act in Israel offers several
options, including live-in and live-out caregivers. A live-
in caregiver would be full time, whereas a live-out care-
giver would be available for several hours a day.
Questions
1. What would be the advantages of each kind of
formal caregiver?
2. How might occupation therapy and physical therapy
be helpful to Mrs. Liebowitz and her family in
making a decision?
3. What steps would be valuable in helping the family
reach consensus?
REFERENCE
World Health Organization (2015). Aging. Retrieved from http://www.
who.int/topics/ageing/en
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4605_Ch05_061-074 31/10/17 11:56 AM Page 61
Meaningful Occupation in Later Life
“None are so old as those who have—Henry
LEARNING OUTCOMES
By the end of this chapter, readers will be able to:
1. Discuss the role of occupation in the lives of older adults.
2. Discuss theories regarding occupation and well-being.
3. Discuss the ways in which elders engage in various types
of activities.
4. Discuss the ways in which occupation in later life
affects subjective well-being, self-efficacy, and life
satisfaction.
5. Describe the interrelationship between occupation and
health and between poor health and loss of meaningful
occupations.
6. Describe the role of physical capacity in promoting
occupational engagement and well-being.
7. Describe strategies for assessing occupations and their
meanings for elders.
8. Discuss the evidence regarding outcomes of occupational
and physical therapy designed to encourage and support
meaningful occupations.
Clinical Vignette
Claudette Odon is a 76-year-old African American woman
who resides in a large West Coast city where she has lived
her entire life. She is widowed, having lost her husband
6 years ago after 40 years of a marriage she describes as happy.
She has two adult daughters who live in the same city, and
six grandchildren, most of whom are currently at universities
around the United States. She had a son, but he was killed
in a drive-by shooting when he was 16.
Ms. Odon worked for many years in a nonprofit organi-
zation that promoted the arts, especially theatre, in her city,
retiring 3 years ago. She continues to be very involved in the
arts community, serving on the boards of several organiza-
tions and attending frequent performances. She has a large
circle of friends, mostly related to the arts, and she also is very
involved in her Baptist church.
Ms. Odon reports having arthritis that interferes with her
ability to move comfortably. The discomfort has led her to
CHAPTER 5
Bette Bonder
outlived enthusiasm.
David Thoreau
”
give up gardening, and she reports having difficulty preparing
her meals because standing is uncomfortable as well.
1. Do you think that Ms. Odon has a satisfying occupa-
tional profile? What occupations do you think might
be missing from her life?
2. How might the loss of her son and her husband affect
her satisfaction with her current occupations?
3. Which of her occupations might be a focus of attention
for a physical therapist? An occupational therapist?
4. What kinds of typical events in the future might affect
Ms. Odon’s ability to participate in occupations she
values?
L ater life is characterize by significant change—change
in physical capacity, change in roles, change in family
constellations, change in living arrangements. All these
changes can present daunting challenges in the absence of a
sense of purpose and meaning. Occupational and physical
therapy have important contributions to helping elders find
purpose and thereby enhance quality of life. This chapter con-
siders the ways in which older adults construct meaningful
lives, the centrality of occupations to life, and strategies that
occupational and physical therapists can employ to help elders
find meaning.
The Search for Meaning
All of us need a reason to get up in the morning, and those
reasons typically relate to what we plan to do during each day.
“Meaning is a core element of human experience, derived in
daily life” (Shank & Cutchin, 2010, p. 4). Engagement in
meaningful occupations in later life is associated with better
physical and emotional health (Mallers, Claver, & Lares,
2013; Westerhof, Bohlmeijer, van Beljouw, & Pot, 2010);
greater life satisfaction, subjective well-being, and happiness
(Matz-Costa, Besen, James, & Pitt-Catsouphes, 2012;
Oerlemans, Bakker, & Veenhoven, 2011); and longer life
(Jacobs, Hammerman-Rozenberg, Cohen, & Stessman,
61
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62 PART I ■ Global Health and Aging: Implications for Health and Participation
2008). Thus, there is a direct link between engagement in
meaningful occupation and positive aging.
All individuals strive to find meaning in their lives
(Baumeister, 1991; Hasselkus, 2002; P. L. Hill & Turiano,
2014). They ascribe meaning to the objects around them, to
their social relationships, and to what they do with their time.
Aristotle noted that “all human happiness or misery takes the
form of action, the end for which we live is a certain kind of
activity, not a quality” (cited in Lind, 1957, p. xviii).
AROUND THE GLOBE: Happy Life Expectancy
Cross-cultural research has explored subjective well-being across
cultures. George (2006) developed the concept of “happy life
expectancy (HLE)” (p. 331). HLE is highest in Europe and lowest
in Africa and seems correlated not only with affluence, but also
with individualism and human rights protections.
Meaning can be thought of as “the extent to which people
comprehend, make sense of, or see significance in their lives,
accompanied by the degree to which they perceive themselves
to have a purpose, mission, or over-arching aim in life”
(Steger, 2009, p. 679). “In Western culture, ‘meaning’ is a
concept associated closely with purpose, motivation, values,
and individuality” (Shank & Cutchin, 2010, p. 4).
This view is consistent with the fundamental principles
of occupational science (Yerxa, 1998). “The human spirit
for activity is actualized, in a healthy way, through engage-
ment in occupation: self-initiated, self-directed activity
that is productive for the person (even if the product is fun)
and contributes to others” (p. 412). Both physical and
occupational therapy focus on enabling individuals to
maintain function. In doing so, they support the ability to
live a meaningful life.
Western societies often fail to provide meaningful roles
for older adults, such that they must construct meaning
themselves (Westerhof et al., 2010). The notion of retire-
ment commonly found in developed countries allows, even
encourages, withdrawal from paid employment. Children
have been raised and are creating their own lives. Thus, eld-
ers may not participate in two of the most significant occu-
pations of middle age. At least hypothetically, this offers a
greater degree of personal choice, although for some, retire-
ment is not voluntary, and childrearing may be reintroduced
if they assume responsibility for raising grandchildren. Per-
haps because of the diversity introduced by greater choice
and less predictable life course, there is little clarity about
activity patterns among older adults, or the personal mean-
ings of the activities that they undertake. “Meaning in life
(MIL) is typically defined as having a strong sense of pur-
pose, pursuing personally valued goals, or possessing a clear
system of values that guide one’s behavior” (Hicks, Davis,
Trent, & King, 2011, p. 181).
Because U.S. society provides less guidance about ex-
pected occupations for older individuals than for younger
individuals, “we have not, as a nation, channeled equal en-
ergy into defining the nature of those added years or creat-
ing positive roles or meaningful institutions through which
they may be enjoyed” (Kaufman, 1986, p. 4). Thus, for older
adults, the search for meaning is highly individual and
begins with few reference points.
Many disciplines have explored the importance of occu-
pation in later life (J. Morgan & Robinson, 2013; Yerxa,
1998). In addition to occupational scientists, psychologists
have begun to explore “positive psychology” focused on
understanding what makes life worth living (Seligman &
Csikszentmihalyi, 2000). Csikszentmihalyi (1990) described
optimal experience as “flow,” the intense and consuming en-
gagement in occupations that promote a sense of well-being
and happiness. Optimal experiences, as he describes them,
are characterized by concentration, attention, and creative use
of personal skills.
The relationship between occupation and meaning is cen-
tral to quality of life for older adults. However, the creation
of personal meaning is not a one-time event, but a process
(W. J. Morgan, 2010; Steger, Oishi, & Kashdan, 2009;
Webster, Westerhoff, & Gohlmeijer, 2014). In later life,
“searching for meaning entails a motivated process to find
and engage with sources of meaning” (J. Morgan & Robinson,
2012, p. 999). In this chapter, some types of meaning that
have particular relevance in the lives of elders and the inter-
action between meanings and occupations are discussed, as
are some important therapeutic considerations in helping eld-
ers create and maintain meaningful occupational lives.
Occupation and Meaning
Theorists and health-care providers agree that occupation is
an essential component of meaning in later life (Odawara,
2010). At the same time, theorists and practitioners “have
debated how occupational engagement is associated with the
development and maintenance of people’s occupational iden-
tity, and how life meaning and self-esteem are linked to
this concept” (Howie, Coulter, & Feldman, 2004, p. 446).
Occupation plays a central role in identity throughout the life
span, and factors that interfere with occupation, including
life crises, can negatively affect both self-concept and well-
being (Odawara, 2010).
Although most researchers and care providers recognize
that activity or occupation is an essential component of qual-
ity of life in later life, there is a certain lack of clarity about
the essential components of meaningful occupations for eld-
ers. As noted earlier, the inevitable change in performance
skills, client factors, and environmental circumstances that
characterize later life require adjustment in activity patterns.
Davidson (1997), describing the experiences of her husband
in adjusting to Alzheimer’s disease, indicates that “it was hard
to let go … but it’s part of life. The challenge is to let go with
pride and find new things to do” (p. 60; emphasis added).
An important step in determining what constitutes meaning
in later life is to develop a satisfactory definition of meaning.
4605_Ch05_061-074 31/10/17 11:56 AM Page 63
Csikszentmihalyi (1990) offers a three-part definition: meaning
includes achieving purpose, expressing intentionality, and cre-
ating internal harmony. Baumeister (1991) suggested that
meaning represents a coherent worldview, identified by each
individual’s choices among the culturally and societally available
options. Thus, he noted that “life-meanings do not originate
from some mysterious well deep inside the individual. Meaning
itself is acquired socially, from other people and from the culture
at large” (p. 6).
Persson, Erlandsson, Eklund, and Iwarsson (2001) de-
scribe meaning as central to understanding of occupations,
noting “only when the task has been chosen and carried out
by the person does it become an occupation” (p. 9). As the
individual makes choices, occupational value—the individ-
ual’s assessment of the importance of the activity—informs
meaning. The reasons for the choice and the outcomes
from participation in the specific occupation reflect
the meaning as perceived and enacted by the individual
(Persson et al., 2001). Although occupations have socially
constructed meanings, those meanings are filtered through
the screen of personal interpretation to create what we will
call personal meaning.
Themes of Meaning
Many of the psychosocial theories described in Chapter 2
focus on understanding how older adults can live meaning-
ful lives. For example, Erikson (1963) suggested that the
major tasks of later life are generativity (productivity and
creativity) versus stagnation, and ego integrity versus de-
spair. Neugarten (1975) identified acceptance of imminent
death, coping with increasing infirmity, dealing with care
decisions, and maintaining social ties as the important de-
velopmental tasks of later life. Levinson (1986) described
two stages for older adults. The first is a transition stage,
during which tasks involve coping with physical decline and
moving from formal authority to a more informal life struc-
ture. The second, in late adulthood, is characterized by de-
creasing concern with formal authority, status, and formal
rewards, forming a broader life perspective and greater inner
resources, and contributing to the wisdom of others. In each
of these theories, there is an implicit or explicit assumption
that in accomplishing these tasks, elders will find later life
meaningful and satisfying.
A problem with these life-span theories is that they were
developed before it became clear that later life would extend
substantially in duration. It is unlikely that in 1963 Erikson
anticipated that later life might last 2 or more decades.
More recently, Cohen (2005) proposed a life span theory
based on human potential stages. He suggested that in mid-
dle age (35–65), individuals experience a midlife reevalua-
tion, followed by a liberation phase, a summing up, and, by
age 75, an encore, an opportunity for reflection, continua-
tion, and spirituality that lasts until death. He placed par-
ticular emphasis on the importance of creativity in later life,
suggesting that creative capacity is maintained or enhanced
CHAPTER 5 ■ Meaningful Occupation in Later Life 63
with age. This and other more recent theories make it clear that
meaning changes throughout the life course, and that later life
is characterized by gains as well as losses (Boudiny, 2013).
✺ PROMOTING BEST PRACTICE
Meaning and Creativity
An arts-based action research project found that individual
and group music composition supported a sense of wellbeing
through control over materials, opportunities for creativity
and identity making, and social engagement (Habron, Butterly,
Gordon, & Roebuck, 2013).
Although meaning is highly individual, there are some
general considerations in understanding older adults’ occu-
pational choices in that context. A qualitative exploration of
elders’ perspectives on activity (Rudman, Cook, & Polatajko,
1997) found that older adults perceived activity as contribut-
ing to well-being, a means to express and manage identity,
an organizer of time, and a connector to the past, present,
and future. Christiansen (1999) also indicated that creation
of identity is an important meaning of occupation: “When
we build our identities through occupations, we provide our-
selves with the context necessary for creating meaningful
lives” (p. 547). W. J. Morgan (2010) argues that occupation-
ally satisfying life is based on “wholehearted action” (p. 216).
For purposes of our discussion, meanings will be clustered
into four main themes: instrumental meanings, evaluative
meanings, existential meanings, and self-identity. Even though
there are undoubtedly many other ways to organize themes of
meaning—Persson and colleagues (2001) have a conceptual
model identifying concrete value, self-reward value, and sym-
bolic value—the literature about aging seems to suggest that
the four listed here are particularly salient in later life. These
themes overlap to some extent, and the same occupation can
have different meanings for specific individuals or in particular
contexts (Persson et al., 2001). Instrumental meanings are not
completely separate from self-identity or evaluative meanings.
But because ability to complete instrumental activities may be
more tenuous for elders than younger individuals, it is an im-
portant theme to consider separately.
Instrumental Meanings
Instrumental meanings are those typically associated with
occupations that support daily life. For younger individuals,
accomplishing daily tasks is habitual. As performance skills
diminish with age, those habits may be disrupted. Elders
may need to focus much greater attention on bathing,
dressing, and taking nourishment than do their younger
counterparts. And these activities become imbued with im-
portant meanings, particularly in terms of the individual’s
perceptions about independence and dependence. Instru-
mental tasks structure meaning in later life in that they
provide everyday routines (Wright-St Clair, Kerse, & Smythe,
2011). Elders who can accomplish instrumental tasks ex-
perience less disability and greater satisfaction than their
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64 PART I ■ Global Health and Aging: Implications for Health and Participation
more disabled peers (Ferreira, Maciel, Costa, Silva, &
Moreira, 2012).
Subjective usefulness and self-rated functional ability cor-
relate with mortality; that is, elders who perceive themselves
as capable are likely to live longer than others (Okamata &
Tanaka, 2004). A variety of functional activities, including
exercise, productive activities such as work or volunteering,
and social activities contribute to perceptions that life is sat-
isfying (Jacobs et al., 2008). In particular, physical activity is
associated with happiness in later life, a finding important to
physical therapists who can promote meaning in older adults’
lives by helping them maintain physical capacity (Oerlemans
et al., 2011).
Aging is associated with some degree of decline in per-
formance skills as well as change in contexts such as family
and social networks. Ability to adapt and maintain routines
can, in itself, be a meaningful attribute of instrumental oc-
cupations (Shank & Cutchin, 2010).
✺ PROMOTING BEST PRACTICE
Activity and Home
J. Sixsmith and colleagues (2014) undertook a qualitative study
to explore the ways that older adults in five European countries
understood healthy aging in the context of the home. They
discovered five primary themes, of which three related to
activities. Those three reflected keeping active, managing
lifestyles, and balancing social life. These occupations, in the
context of the home, contribute to meaningful and positive
aging.
Evaluative Meanings
For most of us, occupations contribute to our evaluation of
well-being and happiness. Life-span theories suggest that
this evaluation is a central concern of later life, and research
confirms that for older adults, occupation has a central role
in subjective assessments about satisfaction with life. A num-
ber of interrelated constructs are used in the research exam-
ining this issue: happiness, life satisfaction, subjective
well-being (SWB), and quality of life (Pruchno, Wilson-
Genderson, & Cartwright, 2010). There are subtle distinc-
tions among these constructs. Happiness refers to a sense of
pleasure or a positive effect in the present, and life satisfac-
tion refers to an overall life evaluation with which one is con-
tent. Well-being reflects a feeling that current circumstances
are, in general, positive. Quality of life is perhaps the most
inclusive of these evaluative terms, because it conveys satis-
faction with circumstances and health, and also reflects ex-
ternal, concrete markers of well-being, such as income, type
of housing, and education.
A great deal of research literature suggests that these
positive evaluations of life are associated with occupation.
Some of the literature examines specific performance areas
such as leisure (Hutchinson & Nimrod, 2012), productive
activities like volunteering (Nesteruk & Price, 2011), and
social participation (Johnson & Mutchler, 2014). Other lit-
erature examines more global aspects of the association be-
tween occupation and well-being (Salmela-Aro & Schoon,
2005). Although there are differences among nations in re-
ported SWB, work and social occupations are associated
with SWB around the world. Research examining the op-
posite side of the same coin finds that decreased activity
is associated with decreased happiness (Menec, 2003). And
stressors such as retirement or loss of a spouse that affect
highly valued roles erode meaning (Krause, 2004). “Engage-
ment in meaningful activities contributes to good health,
satisfaction with life, and longevity, as well as providing a
potentially effective means of reducing costs of physical and
emotional illness in later life” (Butler, 2002, p. S323).
There is somewhat less clarity about what constitutes op-
timal engagement; to a large extent, the purpose of the occu-
pational therapy process in later life is to ascertain this for each
individual and to facilitate the individual’s ability to sustain or
regain those occupations. A third option is to substitute new
occupations that convey similar meanings. Freund and Baltes
(2002) referred to these three options as composing a process
of substitution, optimization, and compensation (SOC), as
described in greater detail in Chapter 2. Because meaningful
occupation is so closely tied to successful aging (Knight &
Ricciardelli, 2003), elders who are able to satisfactorily manage
this SOC are more likely to perceive life as worth living.
Therapists must also recognize that while active physical
engagement is both meaningful and supportive of well-being,
quiet activities such as reading and reflection can also confer
meaning (Jacobs et al., 2008). Further, for some elders, too
much activity can feel oppressive (Nesteruk & Price, 2011),
so that attention to life balance is important (W. J. Morgan,
2010).
Existential Meanings
Of course, the question about whether life is worth living de-
fines the existential challenge of living, a challenge that cer-
tainly becomes more critical as death nears. When describing
tasks associated with various stages during the life course,
early life course theorists discussed age as a time to address
the tension between ego integrity and despair (Erikson,
1963). One of the major ways in which elders maintain ego
integrity and avoid despair is through engagement in mean-
ingful occupations. These are the occupations through which
elders address important philosophical questions about their
lives: Has my life been worth living? Have I made a contri-
bution to the world around me? Hicks and colleagues (2012)
label this “eudaemonic well-being,” a sense that one is living
a life of meaning. Elders must draw on “human strengths that
act as buffers against mental illness: courage, future minded-
ness, optimism, interpersonal skill, faith, work ethic, hope,
honesty, perseverance, and the capacity for flow and insight”
(Seligman & Csikszentmihalyi, 2000, p. 5). Meaningful oc-
cupations allow elders to sustain these attributes in the face
of the challenges of later life.
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CHAPTER 5 ■ Meaningful Occupation in Later Life 65

Spirituality, identified as a contextual factor in the

American Occupational Therapy Association (AOTA)
Practice Framework (2014), is a form of occupation whose
central purpose is to address existential meanings. Spiritu-
ality has relatively recently received greater attention in oc-
cupational and physical therapy and is discussed in greater
detail in Chapter 26. Gerontology literature is replete with
studies of participation in religious or spiritual occupations.
Religious occupations are those undertaken in association
with formally constituted religious organizations, such as
churches, mosques, or synagogues. Spiritual occupations
are those that individuals identify as connecting them to a
higher power (Ai, Wink, & Ardelt, 2010). These occupa-
tions may not have an obvious association with organized
religion, so that, for example, someone who enjoys hiking
and canoeing might report that being close to the natural
world has a spiritual component.
Both religion and spirituality are associated with positive
outcomes in later life. Individuals who participate in religious
activities report higher levels of life satisfaction, self-esteem,
and optimism, a finding that is particularly pronounced
among some minority groups in the United States (Hodge,
Horvath, Larkin, & Curl, 2012). Religious or spiritual occu-
pations are associated with a number of positive outcomes. FIGURE 51 This grandmother shares her love of music with her
Religious and spiritual activities are associated with lower lev- granddaughter. Buccina Studios/Photodisc/Thinkstock
els of chronic illness and higher levels of activity (Benjamins,
Musick, Gold, & George, 2003) and with lower mortality
Reminiscence has long been identified as an occupation that
(T. D. Hill, Angel, Ellison, & Angel, 2005; Pandya, 2005).
is important to elders (Gallagher & Carey, 2012), one that
Religion and spirituality help individuals cope with chronic
also allows elders to convey a legacy. These occupations all
pain (Rippentropp, 2005). Religion can reduce the stress as-
reflect the fact that “we want to leave something positive
sociated with the transition from independent living to resi-
behind and exhibit an optimism that allows us to find some-
dential care (Lowis et al., 2005).
thing positive even in the darkest of situations” (Hunter &
Individuals who scored high on religiousness expressed
Rowles, 2005, p. 344).
less fear of death and dying than those who were less reli-
What individuals choose to leave varies among individu-
gious (Wink & Scott, 2005). It is important to note here,
als, just as spiritual expression varies among individuals
however, that low religiousness was also related to less fear
(Wilding, May, & Muir-Cochrane, 2005). There can be no
of death and dying. Individuals who demonstrated inconsis-
doubt, though, that a large number of older adults find com-
tency between religious beliefs and practices had the greatest
fort and optimism in the opportunity to engage in occupa-
fear of dying.
tions with religious or spiritual significance, or that enable
Spiritual and religious occupations clearly address exis-
them to leave a legacy for others. These occupations provide
tential meanings, but they are not the only occupations to
comforting answers to questions about the meaning of life.
do so. Leaving a legacy (Hunter & Rowles, 2005) or other-
wise connecting with past, present, and future (Rudman
et al., 1997) also allows elders to resolve existential ques- Meaning and Identity
tions. Elders feel a need “to be remembered positively, to To a great extent, we are what we do. Thus, a fourth meaning
pass along beliefs, values and ideals they felt made them of occupations in later life is the maintenance of a sense of
strong and contributed to positive aspects of their identity” identity (Howie, Coulter, & Feldman, 2004). Occupations
(Hunter & Rowles, 2005, p. 344). The woman shown in allow elders to explore possible selves (Smith & Fruend,
Figure 5-1 derives great satisfaction by combining her love 2002). This is particularly important as the self changes with
of music with her love of family. By teaching a grandchild age. Conversely, “the loss or change of occupation related to
to play, she might pass along some of her heritage, and by identity can thus be seen as a particular challenge during age-
playing at family gatherings, she might provide her family ing” (Tatzer, van Nes, & Jonsson, 2012, p. 139). Discovering
with positive memories of her. Other individuals become through occupation that it is possible to experience positive
more interested in family history and genealogy as a way to personal growth and to continue to make a contribution to
leave information for families, or they may keep journals to the world enables elders to sustain a sense of hope both in
pass their own stories along to children and grandchildren. the present and the future (Howie et al., 2004).
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66 PART I ■ Global Health and Aging: Implications for Health and Participation
For elders, later-life occupations allow a continued sense
of mastery and control in the face of significant physical and
social change (Tovel & Carmel, 2014). Self-efficacy, context-
specific control, is strongly associated with occupation
(McAuley et al., 2005). Elders who retain a sense of personal
agency and control sustain function later into life than those
who do not (Biggs, 2005), and individuals who perceive con-
trol as resting largely with others tend to have higher rates of
depression and general dissatisfaction with life than those
who continue to feel they are in control (Kunzmann, Little,
& Smith, 2002).
Several personal factors seem salient in supporting per-
ceived control for elders (Infurna, Gerstorf, Ram, Schupp,
& Wagner, 2011), including a sense of optimism (Leung,
Moneta, & McBride-Chang, 2005). Positive self-perceptions
have long-term benefits for functional health (Biggs, 2005),
and in all probability, function has long-term consequences
for self-perceptions.
What, then, are the essential elements of occupations that
provide for a sense of control? Among the factors that seem
most important are perceived usefulness and competence
(Ranzijn, Keeves, Luszcz, & Feather, 1998), maintaining
personal control (Holahan & Chapman, 2002), and ability
to sustain physical activity (McAuley et al., 2005). Individuals
who are able to provide social support for others, as well as
to receive it, typically experience a greater sense of mastery
(Schieman & Meersman, 2004). Although predictable rou-
tines are important, adaptability and incorporating new oc-
cupations into identity also affect perceived control (Tatzer
et al., 2012).
Consider the example of volunteering, a late-life occu-
pation in which many elders participate (Nesteruk & Price,
2011). Volunteering is a socially recognized contribution
to others, one that enhances a sense of purpose and com-
petence. It has thus been identified as an occupation that
has major implications for older adults as a way to maintain
identity (Greenfield & Marks, 2004). Note that it also can
support evaluative meanings by promoting a sense of well-
being and existential meanings by giving life a purpose
beyond the self.
There is growing evidence with regard to the importance of
meaningful occupation in later life. Research by Vaillant and
colleagues (Vaillant, 2002; Vaillant, DiRago, & Mukamal,
2006) has demonstrated the importance of sense of purpose
and meaningful activity in later life. Physical and occupational
therapists have an important role to play in assisting elders to
maintain or modify occupations that contribute to that sense
of purpose.
Supporting Meaning in Occupational
and Physical Therapy Interventions
Throughout this volume, you will read about particular as-
pects of function and the performance skills necessary to en-
able them. You will also read about the contexts in which
older adults engage in activities. As you do so, it will be im-
portant to remember that it is meaningful occupation that is
critical later in life. Activities that support generativity are
critical to successful aging (Versey & Newton, 2013). Strate-
gies for selecting the most salient occupations, optimizing the
ability to engage in those occupations, and compensating for
those that must be abandoned can greatly enhance life satis-
faction and subjective well-being (Lang, Rieckmann, &
Baltes, 2002; Matz-Costa et al., 2012).
The Occupational Therapy Practice Framework, Third
Edition (AOTA, 2014) identifies the steps in occupational
therapy intervention. These include evaluation, composed of
completion of an occupational profile and an analysis of oc-
cupational performance; intervention, composed of establish-
ing an intervention plan, implementing it, and reviewing its
effectiveness; and outcomes defined in terms of engagement
in an occupation to support participation. Such participation
is also described in the International Classification of Func-
tion (ICF; World Health Organization, 2013). At every step
in this process, having a model or framework that organizes
the kinds of questions and forms of intervention can help en-
sure that the therapist works with the client to establish a
helpful, comprehensive, and meaningful plan.
Similarly, physical therapy emphasizes the contributions
of physical function to quality of life for older adults (Tomey
& Sowers, 2009). Tomey and Sowers emphasize in particular
the relationship of environmental factors and physical func-
tion, noting “the degree to which individuals can and do deal
with diminished abilities and environmental challenges de-
termines how well they will function in their real-life setting”
(p. 705). And the extent to which they function effectively
can affect life satisfaction and well-being. Thus, both physical
and occupational therapy emphasize the importance of sup-
porting older adults’ ability to maintain the activities that
matter most to them.
As you saw in Chapter 2, numerous theories have at-
tempted to explain the human need to engage in occupation.
Although they differ in some details, identifying a theory of
occupation can organize conceptualization of a client’s needs
and can improve intervention outcomes. Table 5-1 summa-
rizes several of these theories.
In the 1920s and 1930s, Russian psychologists proposed a
theory of human activity that holds that the need to meet a
goal is the primary human motivation for activity (cf. Vygotsky,
1978). This and other theories, including the Model of Human
Occupation (MOHO; Kielhofner, 2008), emphasize not only
doing activities but also what motivates that engagement. As
explained in Chapter 2, MOHO describes a volition subsystem
that encompasses personal causation, values, and interests
(Kielhofner, 2008). According to Kielhofner, an important
early discovery in life is the connection between personal in-
tention, action, and consequences. The individual must identify
those actions that are important and that he or she wishes to
pursue.
The desire to act is insufficient to ensure the ability to
act, however. Roles must be identified and habits developed.
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CHAPTER 5 ■ Meaningful Occupation in Later Life 67

TABLE 51 ■ Summary of Selected Theories of Activity of Older Adults

THEORY THEORISTS CONSTRUCTS DISCUSSION OF MEANING

Model of Human Kielhofner (2004) Individual is open system Volition subsystem reflects meaning/
Occupation Subsystems are volition, habituation, performance importance of occupation to
Effectiveness of development of each subsystem individual
reflects successful performance
Meaningful Activity and Eakman (2013) Meaningful activity affects both psychological Participation in meaningful activities
Life Meaning Model needs and meaning in life supports psychological needs and
contributes to life meaning
Selection, Optimization, Freund & Baltes (2002) Elders adapt through these three mechanisms to Ability to choose activities, optimize
Compensation change in functional ability performance, and compensate for
losses enables enactment of
meaningful occupations.

These processes constitute the habituation subsystem. In
many ways, roles dictate activity patterns. For example, the
role of grandmother may involve such activities as playing
with grandchildren, attending their sporting events, and ad-
vising their parents. Roles alone, however, are not sufficient
to fully explain activity. Grandmothers differ greatly in the
specific types of activities they undertake in that role, se-
lecting from the many possible activities that can make up
the role. One might take her grandchildren to see her office,
whereas another might sew elaborate Halloween costumes.
Even when values, goals, and roles have been identified,
the ability to accomplish them affects activity. Skills must be
developed that permit the grandmother to talk with her
grandchildren, to bake cookies for them, and so on. Skills in-
clude the ability to perceive and respond, to process informa-
tion, and to communicate.
In determining what activity means to older adults in this
framework, each of the subsystems must be considered
(Kielhofner, 2008). A problem that becomes immediately
obvious is the absence of prescribed roles for older adults,
other than “retiree” (if indeed the person has retired) and
grandparent (if indeed the person has grandchildren). In ad-
dition, elders vary greatly with regard to values, habits, and,
to some extent, even skills.
More recently, Eakman (2013) has proposed the Mean-
ingful Activity and Life Meaning Model (MALM). This
model posits a relationship among basic psychological needs,
meaningful activity, and meaning in life. Research findings
suggest that meaningful activity has both a direct impact on
meaning in life and an indirect impact through its effect in
addressing psychological needs.
Lawton’s Ecological Model of Aging (Lawton, 1983)
focuses on the fit between individuals and environments. It
proposes that when the demands of the environment, which
Lawton called environmental press, match the skills of the
individual, function will be enhanced. The Selection, Op-
timization, and Compensation model (SOC; Freund &
Baltes, 2002), described in Chapter 2, is another theory
with particular applicability to occupations in late life. SOC
suggests ways in which elders and their caregivers can en-
sure good fit among the person, the environment, and the
occupation. Tomey and Sowers (2009) propose a closely re-
lated model they call “Physical Functioning Assessment in
Your Environment” (PF-E), which emphasizes the contri-
butions of physical function to ability to undertake impor-
tant activities.
Assessing meaningfulness in occupations and identifying
strategies for selection, optimization, and compensation can
be challenging. Certainly, it is easier to determine whether a
client can dress independently than it is to discern whether
this occupation has meaning for the individual, or whether
he or she would rather get help with this and invest energy
in other occupations. One recommended strategy is the use
of a “personal projects” approach (Christiansen, Little, &
Backman, 1998). To accomplish this, the therapist first asks
the individual to list important projects and then to rate these
along the dimensions that matter in the assessment process.
The client might be asked to rate each project for importance,
for impact on stress management, meanings, or other vari-
ables that help prioritize the projects in terms of centrality
for the intervention process.
In addition to this kind of qualitative assessment, a num-
ber of instruments can assess particular aspects of occupa-
tional meaning. The Spirituality Index of Well-Being
(SIWB) (Frey, Daaleman, & Peyton, 2005) is one such in-
strument that explores self-efficacy and life scheme as re-
lated to spirituality. The Spiritual History Scale in Four
Dimensions (SHS-4) (Hays, Meador, Branch, & George,
2001) measures factors labeled “God helped,” “family his-
tory of religiousness,” “lifetime religious social support,” and
“cost of religiousness.” Other quantitative measures de-
signed for elders capture different elements of life satisfac-
tion or well-being. These include the Life Satisfaction
Index (Havighurst, Neugarten, & Tobin, 1968) and the
Satisfaction With Life Scale (SWLS) (Pavot & Diener,
1993). The SWLS, in particular, is quick and easy to ad-
minister and can provide a global view of the elder’s well-
being, and it has been adequately tested for reliability and
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68 PART I ■ Global Health and Aging: Implications for Health and Participation
validity. The Life Satisfaction Inventory has questionable
validity and is particularly problematic when used with
individuals from cultures with different values (Bonder,
2001). In administering this instrument to Maya elders in
Guatemala, it was clear that the constructs did not translate
conceptually, despite the careful linguistic translation that
had been done. Because it is based, to some extent, on com-
paring current circumstances with the past and with other
individuals, it did not fit Mayan values, because Mayans
view comparison as promoting jealousy or dissatisfaction.
One instrument that incorporates both qualitative and
quantitative methods is the Canadian Occupational Per-
formance Measure (COPM) (Law et al., 2005). Like the
personal project assessment, this instrument asks the indi-
vidual first to identify important occupations. These are then
rated numerically in terms of satisfaction with ability to per-
form it and its importance in the individual’s life. These
numbers can be tracked throughout the intervention process
to determine whether progress is being made toward en-
abling those important occupations. Likewise, the Engage-
ment in Meaningful Activities Survey (EMAS; Eakman,
2012) can provide numerical scores that reflect subjective
qualities of participation.
A wide array of late life activities can support well-being
and meaning (J. Morgan & Robinson, 2013). Likewise, those
that encourage expression and management of identity and
those that connect the elder to the past, present, and future
(Rudman et al., 1997) can enhance the individual’s sense of
meaning and purpose in later life. Once meaningful occupa-
tions have been identified and their characteristics explored,
intervention can focus on what the Practice Framework
(AOTA, 2014) calls “Create, promote; Establish, restore;
Maintain; Modify; Prevent” (p. S33).
INTERPROFESSIONAL PRACTICE
Collaborative Intervention
Effective strategies for supporting meaningful occupations
often involve close collaboration among disciplines.
Occupational therapists help clients identify those activities
that they most want to pursue. Physical therapists address the
physical capacity required to undertake activities of choice.
Music, art, and recreation therapists can provide opportunities
to explore or hone interests in specific occupations.
In designing intervention plans, it is helpful to consider
specific occupations that can be meaningful to older adults.
Evidence suggests that occupational therapy interventions
emphasizing wellness and meaningful occupation promote
mental health, social functioning, functional status, and phys-
ical functioning (Clark et al., 2001; Matuska, Giles-Heinz,
Flinn, Neighbor, & Bass-Haugen, 2003). It is noteworthy
that some of this research (Clark et al., 2001) has compared
occupational therapy intervention to a nonintervention con-
trol group and a generalized group activity group. The occu-
pational therapy intervention, perhaps because of its emphasis
on meaningful occupation, was superior to the two other con-
ditions, in one of the few well-controlled studies of occupa-
tional therapy interventions with elders.
AROUND THE GLOBE: Cultural Difference in Well-Being
A study exploring the factors contributing to a sense of
well-being among Thai elders (Ingersoll-Dayton, Saengtienchai,
Kespichayawattana, & Aungsuroch, 2004) found that, in direct
contrast to Western components of well-being, such as
independence and autonomy, these individuals identified
acceptance, interdependence, and harmonious relationships as
primary factors.
There has been a tremendous growth of attention to the
importance of interventions that emphasize spirituality
(Rote, Hill, & Ellison, 2012). Certainly, recognition of the
centrality of religion in some cultural groups has increased
awareness in occupational therapy of the importance of fa-
cilitating the ability to attend church or otherwise participate
in faith-based occupations and to express spirituality through
creative expression.
Among other occupations, reminiscence is particularly val-
ued by elders (Cully, LaVoie, & Gfeller, 2001). This is an oc-
cupation that relates directly both to leaving a legacy and to
the importance of connections with the past, present, and fu-
ture. Life review contributes to resilience in later life (Randall,
2012; Westerhof et al., 2010). Likewise, creative occupations
like writing offer opportunities for self-reflection, connection
with others, and meaning-making generally (Wolf, 2005).
Physical activity has particular salience in later life
(Perkins, Multhaup, Perkins, & Barton, 2008). It is mean-
ingful in and of itself but also contributes to the ability to par-
ticipate in other important activities including work and other
productive occupations (Matz-Costa et al., 2012; Versey &
Newton, 2013). The contributions of physical therapy in sup-
porting older adults’ physical capacity can be essential to sus-
tained meaning in old age.
How does this process translate into an individual life?
Mrs. Anthony was a 72-year-old widow who had been work-
ing full time for the past 30 years. However, her hearing had
worsened, and her hearing aid was not effective in addressing
this loss, making it difficult to continue her job as a social
worker. Her daughter was recently divorced and was a single
parent with two young children. An occupational therapist
and Mrs. Anthony reviewed her occupational profile and oc-
cupational performance, as well as performance patterns,
skills, contexts, and client factors. Applying the SOC model,
Mrs. Anthony and the therapist considered a careful selection
of meaningful occupations, and strategies for optimizing her
performance and satisfaction in those occupations. In addi-
tion, they considered ways to substitute new occupations for
those she could no longer perform. On the basis of this eval-
uation, Mrs. Anthony decided to retire and to assume a sub-
stantial role in the care of her grandchildren. The specific
4605_Ch05_061-074 31/10/17 11:56 AM Page 69
constellation of activities that constituted the roles of “retiree”
and “grandparent,” in Mrs. Anthony’s view, included spend-
ing days with her grandchildren, arriving early enough that
her daughter could get to work on time, taking them to
school, or, on days when they had no school, helping them
with homework and baking cookies.
Unfortunately, as much as she loved her grandchildren,
Mrs. Anthony did not like baking cookies and felt personally
unfulfilled in the new roles she had identified. She was frus-
trated by what she perceived as a lack of productivity. She
was also concerned at what she perceived as a loss of mobility
and endurance as a result of diminished physical activity dur-
ing retirement. Thus, the outcomes of this first plan were un-
satisfactory, so the therapist and Mrs. Anthony revisited her
occupational profile and reconsidered her decisions. This led
to a new set of choices. One possibility was to redefine “re-
tiree” and “grandparent” to reflect more adequately her per-
sonal values and beliefs. This included substituting some
activities that Mrs. Anthony perceived as productive because
this is an important value for her. She decided to volunteer
at a hospital while her grandchildren were in school and to
give guest lectures at the local school of social work. She op-
timized her involvement with her grandchildren by engaging
with them in more “productive” kinds of activities as well, in-
cluding homework and visits to museums to enhance their
education. She also considered whether her volunteer and
grandparenting roles compensated for the worker role she
had relinquished, along with the possibility of returning to
work, and alternatives such as part-time employment. If she
decided to do so and felt that she was abandoning her daugh-
ter, providing financial assistance might resolve the dilemma.
She also visited with a physical therapist for a comprehensive
evaluation and began to implement an exercise program to
regain some of the endurance and mobility she had lost. Con-
cerns about her decreasing ability to work effectively could
be assuaged by a visit to an audiologist to determine whether
newer hearing aid technology might improve her hearing to
the point that it did not interfere with her work performance
or identifying a job in which she could function despite any
decline in abilities.
Therapists must recognize that individuals may enact a
particular occupation in highly personal ways. For example,
religious participation may be quite different from one person
to the next, as in the case of two women who described reli-
gion as being very important in their lives (Bonder & Martin,
2000). One went regularly to church, rarely missing a Sunday,
and participated in a number of church committees and ac-
tivities. The other never went to church services but instead
choreographed intergenerational dance at the church.
These two women were actively engaged in an array of other
occupations as well. Within a given category or role, variability
in the occupations that were undertaken and the meanings par-
ticipants assigned to them were so great as to make the role
label almost meaningless. For example, one woman enacted her
role of grandmother as one of having fun with her new grand-
daughter through such activities as Halloween trick-or-treating.
CHAPTER 5 ■ Meaningful Occupation in Later Life 69
She looked forward to providing child care as a way to get to
know her granddaughter. The other enacted grandparenting
through child care provided on days when school was closed
and during the summer. She experienced these activities as
somewhat burdensome but expected. Reducing activity patterns
through simple categorization on a single dimension may mask
issues of vital importance to the individual—in particular, the
unique contribution of each occupation to meaning and qual-
ity of life.
Throughout this book, evidence is presented with regard
to the importance of various occupations in the lives of older
adults and the outcomes of interventions focused on enabling
occupational performance. This evidence clearly indicates that
occupation contributes to sustained health, function, and even
survival (Avlund et al., 2004; Bukov, Maas, & Lampert, 2002;
Krause, 2002; Lennartsson & Silverstein, 2001; Lovden,
Ghisletta, & Lindenberger, 2005). There is also a growing
body of evidence that occupational therapy intervention is
central to enhanced outcomes of care (Stav, Hallenen, Lane,
& Arbesman, 2012). Therapists interested in fostering positive
aging can look to this literature for guidance about how best
to proceed. They can also use these findings to support efforts
to improve the context in which aging occurs through inter-
ventions focused on policy change and on access to care for
older adults.
SUMMARY
The ultimate goal of occupational and physical therapy serv-
ices is well-being, a status that goes beyond health. This pre-
sents dilemmas for care providers who design programming
or individual interventions for older adults. Public policy too
often emphasizes self-care as the sole desired outcome of care
and provides reimbursement according to guidelines that re-
flect this emphasis. Although this focus is understandable,
given the lack of clarity about what occupations contribute
to life satisfaction in later life, it may well be misguided be-
cause it is clear that “there is more to life than putting on your
pants” (Radomski, 1995, p. 487). As will be seen in subse-
quent chapters, physical therapists and occupational therapists
must consider strategies other than direct care in hospital set-
tings, and community-based and population-based care has
grown considerably.
Pursuing an evaluation that incorporates all aspects of oc-
cupational performance is challenging, as is designing mean-
ingful intervention plans. Further, intervention is not complete
until reevaluation has occurred and outcomes are carefully ex-
amined. Simply developing a list of occupations is inadequate
because the nature of the occupation, the context in which it
occurs, and individual skills, performance, and patterns are es-
sential considerations. Roles can be expressed in many ways,
and thus the job of the health-care team, and the occupational
therapist in particular, is to help the individual examine not
only the occupation but also the activities that constitute the
occupation for the individual. The next step is to facilitate the
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70 PART I ■ Global Health and Aging: Implications for Health and Participation

substitution, optimization, and compensation process through

which the individual establishes new occupational performance
patterns that are meaningful. A number of methods for ac-
complishing these goals are presented in the chapters that fol-
low. It is clearly crucial that both evaluation and intervention
must be undertaken with recognition of meanings that are im-
portant to the client.
Positive aging has become the focus of considerable re-
search interest. Comprehensive review supports the idea that
individuals who have lives with purpose are most likely to be
among successful (as opposed to usual, or even unsuccessful)
agers. As Swensen (1983) noted, “People live as long as they
have something to do that needs to be done” (p. 331). Health-
care providers, policy planners, and older adults must develop FIGURE 52 Art in the Afternoon is an engaging and meaningful
a clear understanding of what it means, both to the individual activity. A group studies a massive wall relief depicting a winged
and to society, to have something that needs to be done. genie at the Cleveland Museum of Art (reprinted with permission
of Cleveland Museum of Art).

CASE STUDY enrich the experience. Caregivers who participate note

One strategy for supporting meaning for older adults is
through activities in community settings tailored to their
interests. As an example, the Cleveland Museum of Art
has developed a program called “Art in the Afternoons.”
Modeled on the “Meet Me at MOMA” program at the
Museum of Modern Art in New York, Art in the After-
noon involves gallery tours and other activities for indi-
viduals with dementia and their caregivers.
Art in the Afternoon has modified the MOMA pro-
gram by focusing its objectives on socialization and emo-
tional expression, rather than on education about specific
works of art and their interpretation. Participants attend
monthly sessions scheduled for 90 minutes during the early
afternoon. The time of day was chosen to reduce pressure
to rush with dressing in the morning and to avoid poten-
tial late afternoon increases in disorientation and agitation.
As described by its facilitators, the first 30 minutes of the
session, when participants are gathering and greeting each
other, may be the most important component of each
event because of the potential for socialization and emo-
tional expression. Objects chosen for each gallery tour are
identified on the basis of opportunities for participants to
relate to the content, so, for example, paintings of older
adults, families, or familiar stories might be included.
Modern works have proven to be popular with partici-
pants because of the rich opportunities for interpretation
in the absence of factual content. Docents attempt to use
multimedia, incorporating smells and sounds as appropri-
ate for example. They also focus on making each tour fun,
sometimes wearing costumes or bringing amusing artifacts
to enrich the tour. Participants, even those who have sig-
nificant cognitive impairment, are attentive and engaged
during sessions, as can be seen in Figure 5-2.
Participants have bonded over time, often recognizing
each other even if they cannot remember names. And
they have added social encounters like holiday parties that
that a welcome aspect of the program is the opportunity
for engagement in a “normal” occupation that allows
them a time to enjoy being with their loved ones without
having to focus on disability or dysfunction.
Occupational therapists may support program planning
to provide emotional support and to encourage mainte-
nance of cognitive skills. Physical therapists may focus on
encouraging movement through the galleries to help
maintain physical capacity or on identifying alternative
mobility strategies to facilitate participation.
Questions
1. What aspects of the Art in the Afternoon program
provide meaning for participants?
2. Why might the art museum be a good venue for this
kind of activity?
3. What similar kinds of activities might offer these
kinds of benefits?
Critical Thinking Questions
1. How is occupation associated with meaning in
later life?
2. Discuss the importance of environment and context
to meaning.
3. Think about an older adult you know. What kinds of
occupations seem most meaningful to that person?
What needs do you think those occupations fulfill?
4. Describe the characteristics of the theories of disen-
gagement, activity, continuity, life span, human
occupation, occupational adaptation, person–
environment–occupation, and substitution,
optimization, and compensation.
4605_Ch05_061-074 31/10/17 11:56 AM Page 71
5. Think again about the older person you considered
in question 3. Which of the theories described in
this chapter seem to best describe that person’s
occupational choices?
6. What is meant by instrumental meanings? Evaluative
meanings? Existential meanings?
7. How can occupational and physical therapy
interventions support meaning?
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Culture, Ethics, and Elder Abuse
Bette Bonder
LEARNING OUTCOMES
By the end of this chapter, readers will be able to:
1. Describe cultural factors relevant to older adults and aging.
2. Discuss how cultural beliefs affect activities of older adults.
3. Identify key ethical issues relevant to the experience of
growing old.
4. Describe how culture and attitudes about aging affect
understanding of these ethical issues.
5. Define elder abuse.
6. Describe factors that contribute to elder abuse.
7. Discuss the responsibilities of care providers in addressing
elder abuse.
8. Discuss the relationships among attitudes about aging,
cultural factors, and ethical challenges in working with
older adults.
Clinical Vignette
Caleb Johnson is an 87-year-old widowed former postal
worker who lives in a small cottage in an inner city in
the Bay Area of California. His four grown children and
18 grandchildren all live in California, but most have
moved away and see Mr. Johnson only at Thanksgiving and
Christmas. Until recently, Mr. Johnson participated ac-
tively at his church, but increasing mobility limitations
related to long-standing diabetes and mild cognitive im-
pairment have reduced his current involvement. His chil-
dren hired a neighbor to spend a few hours a day with
Mr. Johnson to make sure he gets his meals and that he
has companionship. During a visit home, Mr. Johnson’s
son notices that the sink is piled high with dirty dishes, the
refrigerator is empty, and Mr. Johnson’s treasured collec-
tion of silver dollars is missing.
1. What are some possible explanations for what the
son discovered?
2. What steps can and should the son take?
3. If an OT or PT were to be involved in providing care
for Mr. Johnson, what are some strategies they might
recommend?
CHAPTER 6
■ Georgia J. Anetzberger
“Everyone is—Guatemalan
the age of their heart.
Proverb
”
A s described in Chapter 1, individuals grow old in a
complex social, physical, and cultural environment.
That environment colors perceptions about later life, framing
attitudes of society, social networks, and elders themselves.
It also affects care providers’ attitudes toward aging and the
ways in which they approach the inevitable ethical challenges
they face in providing the best possible care.
This chapter explores cultural and ethical considerations
in working with older adults, including ways in which the ex-
perience of aging is culturally mediated, the ways in which
culture affects care strategies, and the ethical dilemmas that
emerge in the context of specific cultural environments. The
chapter also examines the phenomenon of elder abuse, which
is a legal, moral, and ethical concern.
Culture and Aging
Individuals experience the world in the context of culture.
Culture can be thought of as “shared symbols and meanings
that people create in the process of social interaction,” which
orient “people in their ways of feeling, thinking, and being
in the world” (Jenkins & Barrett, 2004, p. 29).
Cultural values can help elders make sense of life, develop
personal goals, and cope with existential fears (Fung, 2013).
For example, culture affects perceptions of what constitutes
a “good” old age. In Greece, subjective quality of life is asso-
ciated with positive affect and ability to adapt to old age
(Efklides, Kalaitzidou, & Chankin, 2003), while among older
Chinese, functional status and productive involvement are
associated with positive aging (K. Chou & Chi, 2002). Fre-
quent contact with friends is especially important in China.
These are subtle differences, but they are potentially impor-
tant in thinking about health-care interventions.
This chapter emphasizes national/ethnic cultures, but it is
important to keep in mind that culture encompasses many as-
pects of individual and group identity. Religion, work cate-
gory, gender identity, and many other identifiers are also
cultures (Bonder & Martin, 2013). For example elders who
are lesbian, gay, bisexual, or transgender (LGBT) may identify
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76 PART I ■ Global Health and Aging: Implications for Health and Participation
more with LGBT culture than with their ethnicity, or they
may identify with both. Throughout this text are references to
many forms of culture, which must be considered when
health-care professionals incorporate cultural values and be-
haviors into intervention strategies.
Both the International Classification of Function (ICF)
(World Health Organization, 2001) and the American
Occupational Therapy Association (AOTA) (2014) Prac-
tice Framework list culture as a contextual factor—that is,
a factor that affects health and function through environ-
mental influence. Most health-care professions identify
culture as a critical factor in understanding and helping
their clients. Identifying culture as a factor affecting devel-
opment across the life span and provision of health care is
a major step forward in acknowledging its centrality to
human function.
Aging in International Context
Older adults have different experiences in the context of spe-
cific cultures. Some of these differences were discussed in de-
tail in Chapter 4; around the world, cultural and societal
values affect the ways in which older adults behave and ways
in which they are perceived. In rural Africa, for example,
older adults may have vital roles in their communities
(Fig. 6-1). At the same time, during periods of drought and
famine, the traditional support for older adults, particularly
those who are frail, becomes less certain, creating a sense of
vulnerability (Cliggett, 2007).
FIGURE 61 Elders in Africa may play central roles in family and
community life. poco_bw/iStock/Thinkstock
As another example of these cultural and societal differ-
ences, in China, the older population is growing more rapidly
than any other age-group, projected to increase by 243 per-
cent by 2050 (Cheng, Rosenberg, Wang, Yang, & Li, 2009).
Several factors have led to this situation. These include the
impact of the “one-child” policy, the resultant shift in pro-
portion of elders relative to the total population, and the his-
torical economic difficulties that most older adults in China
have experienced (Zhang, Guo, & Zheng, 2012). These
realities have a profound impact on the availability of care,
despite—or perhaps because of—the strong tradition of
familism—a valuing of family as a central element of life—
in China. China has relatively few institutional services for
older adults because the culture has long emphasized caring
for older adults in family settings. However, there are far
fewer young people in each family available to provide care,
and those young people are more likely to have migrated away
from family homes to cities to secure employment (N. J.
Zhang et al., 2012). The situation has become sufficiently dire
that China is now attempting to enact Family Support
Agreements (R. J. Chou, 2011) to ensure that the cultural
value of family care will be continued.
Japan is already dealing with a “super-aging” society
(Muramatsu & Akiyama, 2011). It currently has the highest
proportion of older adults in the world. Like China, it has a
strong cultural belief in familism, but like China, changing
demographics—low fertility, outmigration of younger peo-
ple to urban areas—have affected those traditional values.
Japan has attempted to introduce policies that reinforce
traditional values, for example, in efforts to incorporate tra-
ditional neighborhood values in urban apartment complexes
(Muramatsu & Akiyama, 2011).
In contrast, cultural and demographic factors in India lead
to a somewhat different set of societal challenges. India has
a relatively young population compared with other countries
and perceives this as a “demographic dividend” (Singh, 2014).
This suggests that there should be ample available family sup-
port for older adults. At the same time, cultural beliefs, par-
ticularly based in Hindu religion, hold that old age is
characterized by one of two processes: a second childhood-
like period, or a voluntary withdrawal from worldly activities
in preparation for the renewal that is thought of as part of
the life cycle (Menon, 2013). These expectations lead to a sit-
uation in which elders contribute and receive relatively little
in the context of family life.
Although cultural values and beliefs, as well as societal
demographics, vary from country to country, they also vary
within countries. This is true everywhere, but it is particularly
salient in countries that have considerable ethnic and religious
diversity. For example, the majority of the population of
Chile is of European descent and Catholic religion, but there
are eight indigenous groups that comprise 5 percent of the
total population (Gitlin & Fuentes, 2012). The older adult
population is roughly 13 percent of the total, and the country
is facing some of the same issues as other aging populations,
although the dependency ratio in Chile is not as skewed as
4605_Ch06_075-090 31/10/17 11:55 AM Page 77
in countries such as Japan. As Chile experiences rapid eco-
nomic growth, traditional cultural values have been disrupted
so that, for example, a rapidly growing number of older adults
are now living alone instead of in extended families. There is
a significant discrepancy in morbidity and mortality among
elders associated with socioeconomic status with minority
groups particularly disadvantaged.
As the preceding examples demonstrate, shifting demo-
graphics and economic situations worldwide have resulted in
a variety of disruptions in traditional cultural practices around
aging, accompanied by political and social unrest. In France,
for example, there have been numerous strikes and demon-
strations protesting a move to raise the legal retirement age
(Beland & Durandal, 2013). Even where such protests have
not occurred, the needs and roles of older adults have been
a source of tension and on-going examination as the older
population grows.
It is worth noting that a common thread among these
many countries and cultures is the centrality of family for
older adults (Mair, 2013). As discussed in Chapter 24, family
relationships are complex. Furthermore, older adults increas-
ingly may have limited family circles, leading to the kinds of
cultural changes now facing countries such as China, Japan,
and some European countries.
Culture and Aging in the United States
The United States is a particularly heterogeneous society, in
which an array of cultures can be seen to influence the expe-
rience of aging. In addition to a demographic shift toward a
larger proportion of older people, there is a shift toward a
larger proportion of individuals from diverse racial and ethnic
backgrounds at every age, including among older adults
(Whitfield, Allaire, Belue, & Edwards, 2008). Consequently,
some of the typically used labels—Hispanic, for example—
obscure differences among cultural groups included in that
cluster. For instance, individuals from Puerto Rican back-
grounds (who are labeled as Hispanic) were found to have
significantly higher rates of depression than other Hispanic
groups (Yang, Cazoria-Lancaster, & Jones, 2008). Further
complicating the picture, some cultural groups have experi-
enced systematic socioeconomic disadvantage, contributing
to disparities in health and wellness that persist into late life
(Haas, Krueger, & Rohlfsen, 2012).
Culture is not static (Bonder & Martin, 2013). Among
the various Hispanic groups, there are individuals who
are newly arrived from Central or South America or from
Europe, as well as individuals who are third, fourth, or fifth
generation U.S. citizens. Over time individuals integrate
elements of their cultures of origin with those of their new
(or not so new) countries. These cultural changes must be
considered in understanding the needs of the older individ-
ual as well as family dynamics that influence availability of
social support.
Research has identified several racial and ethnic differ-
ences in late-life experiences. Although it is essential to keep
CHAPTER 6 ■ Culture, Ethics, and Elder Abuse 77
in mind that every individual is different, health professionals
must understand key factors that may affect aging for partic-
ular groups. African Americans, for example, are more pes-
simistic about health than whites (Spencer et al., 2009).
African Americans living in the South are less likely to make
use of mental health services, a difference not seen in other
regions (Kim et al., 2012). There are also positive aspects to
the aging of this group, in particular, their reliance on and
comfort from religious participation (Brown et al., 2013).
Furthermore, although racism is a pervasive and negative
experience, it seems to provide this group with resilience in
dealing with serious illness and other life challenges (Becker
& Newsom, 2005). African American elders report a need to
pass along to younger generations lessons learned from the
suffering caused by racism (Black & Rubinstein, 2009).
Comparisons of aging in white, Hispanic, and African
American communities have found that African Americans
have the highest rate of multimorbidity in late life, and
Hispanics have the lowest (Quiñones, Liang, Bennett, Xu,
& Ye, 2011). This finding may have to do with socioeco-
nomic factors and social support.
Native American communities may focus on what it
means to be an elder, rather than on aging as a phenome-
non. This involves a cultural description of the elder’s role,
incorporating emotional well-being, spirituality, community
engagement, and physical health (Lewis, 2011).
Immigrant populations have a unique set of challenges,
particularly in terms of acculturative stress, which can reduce
quality of life (Jang & Chiriboga, 2009). Such stress can also
contribute to high rates of depression (Dong, Chang, Wong,
& Simon, 2011). Maintaining traditional cultural activities
can ameliorate these difficulties. For example, religious par-
ticipation and social support improve life satisfaction among
older Korean immigrants (J. Park, Roh, & Yeo, 2011).
Aging, Culture, and Function
Every aspect of function, including occupational choice and
enactment, physical capacity, and mobility is influenced to
some extent by culture. The impact may have to do with
preferences, with contextual factors that support or impede
performance, or with other cultural variables. A review of
various areas of occupation, as well as the factors that support
occupation demonstrates the ways in which culture influ-
ences performance.
Occupations
Activities of Daily Living
Although it may not be immediately apparent, culture
strongly influences activities of daily living (ADL). This cat-
egory includes dressing (sari or slacks?), eating (fork or chop-
sticks?), hygiene (bath or shower?), and other basic self-care
functions. Among the important factors to consider is the par-
ticular set of cultural standards for competence (Rubenstein
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78 PART I ■ Global Health and Aging: Implications for Health and Participation

& de Medieros, 2004). Two individuals with the identical have resulted in loss of retirement benefits in Asia so that
ability to perform self-care tasks as viewed by an observer may older men are increasingly likely to be working; for older
perceive their own competence quite differently. women in some Asian countries, rates of participation in the
Instrumental activities of daily living (IADL) function is workforce are lower but increasing (Knodel, Ofstedal, &
strongly mediated by gender role expectations in particular Hermalin, 2002). Those who have not worked are already at
cultures. In Hong Kong, women are at high risk for poverty a financial disadvantage, and those who are now working will
in later life because their life expectancy, as in many countries, have to manage the same retirement benefit changes that are
is higher than that of men (Lee, 2003). In addition, they are affecting male workers.
unlikely to learn to manage their finances, increasing the For elders, “work” really includes an array of productive
challenge of coping with their limited resources. Community occupations such as child care or volunteering that have eco-
mobility can be a problem for women in cultural groups that nomic value but do not come with a paycheck.
do not allow them to drive, notably Saudi Arabia. Men can
also be disadvantaged by gender expectations because in some Leisure and Play
cultures they may never learn to cook or to maintain a home.
There are substantial differences across countries and cultures
Certainly culture plays a role in IADL choices. Food pref-
related to leisure and play. In less developed nations and in
erences and cooking styles are clear examples. Making a stir-
agrarian cultures, individuals may be expected to make eco-
fry requires different skills and abilities than roasting a turkey.
nomic contributions until they are too frail to do so, and work
Money management varies by cultures. For example, Islam
may extend throughout the day and evening. Among the Maya
proscribes interest-bearing loans (Allied Media Corporation,
in Guatemala (Bonder, Bazyk, Reilly, & Toyota, 2005), occu-
n.d.). Informal lending structures have arisen in these com-
pations undertaken purely for purposes of leisure are rare.
munities to fill the void requiring that interventions empha-
At the same time, culture influences the specific leisure
sizing money management must be modified to suit these
occupations chosen by elders. Older Spanish women are
kinds of arrangements.
less likely than men to engage in physical activity; this
Therapists may forget that culture encompasses the main-
results in poorer health-related quality of life for women
stream or majority culture as well as various minority groups.
(Guallar-Castillion, Sendino, Banegas, Lopez-Garcia, &
Consider the kinds of cultural influences on ADL and IADL
Rodriguez-Artalejo, 2005). In China, tai chi is a common
performance in mainstream U.S. culture. Although gender
occupation that has leisure and social elements (Fig. 6-2).
roles have changed over time, for the current cohort of elders,
In Italy, a similar set of outcomes is achieved by playing
men typically handle house repairs and maintenance of the
bocce ball.
yard, and women cook and keep the interior of the home
clean. These different activities require different skills and
physical capacity. Social Participation
The nature of social engagement, the kinds of social networks,
and the frequency of contact are all mediated by culture. So,
Education
for example, for older African Americans, religious activities
Cultural values related to education are often gender based. are particularly important (Moon, 2012). However, research
In some Asian countries, older women are more likely than suggests that African Americans have smaller social networks
men to be illiterate (Knodel, Ofstedal, & Hermalin, 2002). and lower levels of social engagement than whites (Barnes,
In contrast, in African American communities in the United
States, women are much more likely than men to have at-
tended college (Babco, 2001). Therapists in the United States
working with recent Asian immigrants who are older females
would need to ascertain both the client’s language skills and
level of literacy. In working with African American men who
are older, understanding educational level is critical to pro-
viding instructions for wellness strategies.

Work
Cultural factors have significant impact on work activities. In
the United States, African American women have longer
paid work histories than other women but have less pension
income because their work is more likely to be low paying
(Carstensen, 2001). In the Asia-Pacific region, work activities
such as rural semi-subsistence farming carry no retirement
benefits so that many elders must work until they are no FIGURE 62 Practicing tai chi in a Chinese park. XiXinXing/iStock/
longer physically able (Phillips, 2000). Policy changes that Thinkstock
4605_Ch06_075-090 31/10/17 11:55 AM Page 79
Mendes de Leon, Bienias, & Evans, 2004). This would suggest
to therapists that when working with an African American
elder, it is important to ascertain whether the church is central
to her or his social network. If so, facilitating attendance at
church would be an important goal. Helping the person dress
in what is considered appropriate churchgoing attire, finding
transportation to the church, managing stairs if the church is
old and not Americans With Disabilities Act–compliant would
all be helpful goals in such a situation.
The findings about the importance of social connections
are fairly consistent across cultures. For example, socially
active Japanese elders have better self-reported health, espe-
cially if they co-reside with younger generations (Tanaka &
Johnson, 2012).
Performance Skills
Although less frequently reported than its impact on occu-
pations, culture has interesting interaction with performance
skills. Culture can affect human factors typically associated
with biological processes, and therapists must recognize the
extent to which physical capacity—endurance, flexibility,
strength, and motor control—affects older adults’ ability to
participate in the occupations that matter to them. Culturally
mediated beliefs about the acceptability of physical activity
can dramatically affect physical capacity.
Motor Skills
Even though there is not a large body of research on this
point, evidence suggests that motor skills are developed con-
sistent with the occupation demands in particular cultures.
Aging Maya weavers are able to sit on the ground, either with
legs extended or with knees flexed, or to kneel on the ground,
for long periods of time (Bonder, 2001). Other culturally
mediated occupations are also associated with similar devel-
opment of particular motor skills.
These considerations are particularly relevant in consid-
ering physical therapy interventions. Mobility underlies
many aspects of function, but differing cultural experiences
can affect both the mobility of the older adult and the re-
quirements of the activities in which he or she participates.
For example, older adults in largely agrarian cultures might
need considerable physical strength and endurance; fortu-
nately, their lifestyles would promote such motor capacity.
City dwellers are faced with a different set of physical
challenges—navigating crowded and uneven sidewalks,
managing steps to subways, stepping on buses—that re-
quire attention to motor capacity as well.
Process Skills
There is a growing literature focused on the ways in which cul-
tural factors influence cognition (e.g., Kastanakis & Voyer,
2014; Zaroff, D’Amato, & Bender, 2014). In particular, culture
shapes reasoning and categorization (Atran, Medin, & Ross,
2006). East Asians tend to process information in a holistic,
CHAPTER 6 ■ Culture, Ethics, and Elder Abuse 79
contextual fashion, and Europeans process information in an
analytical fashion (Zaroff et al., 2014).
Culture affects many aspects of Alzheimer’s disease, in-
cluding not only prevalence but also diagnosis and interven-
tion strategies (Manly & Espino, 2004). Assessment must
include awareness of cultural factors that could influence
client needs and the expected course of the condition. How-
ever, it is also important to recognize that culture is just one
of many variables that must be considered.
Communication and Interaction Skills
Elders, particularly older immigrants, often have communica-
tion challenges. The research literature makes it clear that
language acquisition diminishes with age. This is a significant
concern because learning the language of the new country may
be an important factor in establishing social networks, accom-
plishing important daily tasks, and being comfortable in new
surroundings. For example, among older Mexican immigrants
to the United States, strong English-language skills pre-
dicted ability to live independently or serve as head of house-
hold (Burr & Mutchler, 2003). Language proficiency among
older immigrants affects access to health care and support
services (Lebrun, 2012). Although federal law requires that
translators be made available when needed, such services can
interfere with understanding between clinician and patient,
and can lead patients to hesitate to seek care (Bonder &
Martin, 2013).
Performance Patterns
Like occupational choices, patterns of engagement are influ-
enced by culture. For example, ethnic minority elders in the
Netherlands are less likely to participate in voluntary social
organizations than those in the majority population (van
Ingen & Kalmijn, 2010).
Habits and Routines
Long-standing habits can support occupation (van der Ploeg
et al., 2013). For example, most individuals dress in a partic-
ular pattern that does not require careful attention to each
step. Morning routines are typically well established and
require little specific thought. These are examples of positive
habits and routines that reduce the energy required to manage
daily life. Expectations about the probability of discrimina-
tion or about the absence of resources have been shown to
result in stressful fears for African American elders (Weitzman,
Dunigan, Hawkins, Weitzman, & Lefkoff, 2001). These
experiences may alter their habits with regard to use of services
where they fear they will encounter discrimination (Dixon &
Richard, 2003).
Roles
In Western countries, where retirement is a life-course ex-
pectation, roles for elders are less clearly defined than those
for younger individuals. This can be positive for elders who
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80 PART I ■ Global Health and Aging: Implications for Health and Participation
feel more freedom than others to self-identify important roles
or difficult for those who feel a need for structure. In devel-
oping countries, and in some ethnic or religious groups, elders
have specific roles that enable them to retain a sense of self
and of self-esteem. Grandparenting among Native Americans
includes the highly valued role of “cultural conservator”
(Weibel-Orlando, 2001). Likewise, grandparenting can be
an essential role in immigrant families as they adapt to their
new surroundings (Zhou, 2012).
A dilemma in terms of roles is the impact of cultural
change. Immigration can adversely affect roles as traditions
are lost. Among Asian immigrants to the United States, re-
spect for the knowledge of elders is diminished because it does
not apply in the new environment (Carstensen, 2001). For
Japanese American elderly individuals, acculturation of sub-
sequent generations changes sense of filial responsibility, al-
though increased affectional ties may lead to similar levels of
interaction and satisfaction (Yamaguchi & Silverstein, 2003).
Changing roles result from other societal factors, too. In
Ghana, older adults are increasingly expected to be self-
reliant, because their adult children may be working at occu-
pations that do not offer the needed time to provide care
(Aboderin, 2004). In addition, in Ghana, a significant num-
ber of adult children have been lost to AIDS.
Context
Function does not occur in a vacuum. The environment in
which occupations are undertaken has strong influence on
what they are and how they are enacted.
Cultural
As can be seen from the discussion so far, cultural context is
a major factor in occupational choice. Beliefs about the role
of family, independence and dependence, and proper societal
supports can influence basic decisions, including residence
and support networks.
Culture affects sources of meaning derived from occupa-
tions. A study of young-old and older-old Israeli Jews and
Arabs found that family and communal values were ranked high
for all four groups but higher for Arabs. Autonomy, independ-
ence, and interpersonal relationships were ranked high by all
but were higher for older-old Jews. Having good relationships
was important but less so for the older than the younger women
in both groups (Bar-Tur, Savaya, & Prager, 2001). This is but
one example of the differences in cultural values in late life.
Physical
An important aspect of the physical environment, and one that
has received considerable attention in the research literature, is
residential choice. In particular, decisions about whether to stay
in the home, to migrate, or to live with adult children are asso-
ciated with cultural values (Rubenstein & de Medeiros, 2004).
Other aspects of culturally mediated physical environ-
ments affect the experience of aging. “Many Asian urban and
rural areas offer an environment that is in effect hostile to
older people” (Phillips, 2000, p. 25) including dense traffic,
uneven surfaces, and wide roads. Individuals in wheelchairs,
with unsteady gait, or with poor balance are at risk trying to
manage damaged public walkways, but in developing coun-
tries, upgrades to provide adequate access may not be at the
top of the list of priorities for spending on public health.
Social
Social factors related to aging are strongly culturally mediated
(Fung, 2013). Families are at the center of those networks,
but as families change, so does the character of interaction
with elders. In Japan there is a “dual structure” for familial
caregiving, one modern and one traditional. Japanese elders
who are in traditional families, those valuing generational
co-residence and filial piety, report high levels of well-being.
Those in modern families, where co-residence is less likely
and both men and women are working at jobs outside the
home, are similar to Japanese Americans in terms of worries
about the future. Studies in Hong Kong have had similar
findings (Lee & Hong-kin, 2005; Ng, Phillips, & Lee, 2002).
There is concern that changes in the valuing of filial piety will
have significant consequences for elders. Everywhere, widows
or widowers living alone may be at highest risk for isolation
(Williams, Sawyer, & Allman, 2012).
Spiritual
The spiritual context for occupation can have profound impli-
cations for quality of life (Ardelt, Landes, Grelach, & Fox,
2013). As just one example, Native American elders indicate
that those who pray frequently and perceive their faith as im-
portant to them tend to have better mental health, regardless
of their living situation or their age (Meisenhelder & Chandler,
2000). Spirituality is discussed in greater detail in Chapter 26.
Temporal
Cultural groups often have particular perceptions about time
and its importance in life (Zimbardo & Boyd, 2008). In
Hispanic and Native American cultures, time may be less
rigidly focused on the clock. Time perspectives change during
later life as well, with some elders experiencing time as some-
thing outside daily experience, less important than it was when
they were in the workforce where promptness and time man-
agement were important to job performance (Wiersma, 2012).
These factors can combine to affect older adults’ interactions
with the world around them, which may have different expec-
tations for conformity to promptness and efficiency.
Activity Demands
A study of weaving in Guatemala and in the United States
described the differences between the backstrap looms used by
Maya weavers and table and floor looms used in the United
States (Bonder, 2001). Such differences can be found in tools
used for numerous activities including cooking, writing, and
4605_Ch06_075-090 31/10/17 11:55 AM Page 81
housekeeping, and in each case, this affects the individual’s
ability to participate. Maya weavers sometimes had to abandon
the activity because they developed arthritis that made sitting
on the floor impossible. In some of those women’s homes,
cooking required grinding corn on a stone mill by hand, an-
other activity that was difficult for those with arthritis.
Cultures differ with regard to perceptions about appropri-
ate locations and spaces for work, prayer, and other occupa-
tions. Likewise, living arrangements differ among cultural
groups such that the living space for elders may vary greatly.
This can have dramatic consequences for occupational per-
formance. In cultures that encourage co-residence, older
adults may continue to have meaningful responsibility in the
home (e.g., looking after grandchildren) and to assist with
daily activities such as laundry. Both might be more difficult
in cultures with nuclear family structures, with grandparents
living on their own at some geographic distance.
Societal expectations can either support or impede per-
formance. In places where retirement is publicly supported
and expected, elders who might prefer to continue in paid
employment may experience pressure to leave work. Like-
wise, pressure to stay “busy” can be difficult for elders who
might prefer more placid and reflective lives (Ekerdt,
1986). Cultures such as that of the mainstream United
States that place particular value on youth may leave elders
feeling marginalized.
Client Factors: Body Functions
and Body Structures
Because culture mediates the way in which particular occu-
pations are undertaken, the required body functions and
structures will also vary. Some older Mayan weavers struggle
because of developing limitations in joint mobility or vision
(Bonder, 2001). Simple adaptations to the occupation might
have allowed them to move weft through warp, but in their
view, this is no longer weaving.
Culture and the Intervention Process
There is now a large body of literature describing cultural dif-
ferences in use of health-care services (Andersen & Newman,
2005; Smedley, Stith, & Nelson, 2003). Underrepresented
minorities, including their elders, tend to have poor access
to mental health services and to be less likely to use them
(N. S. Park, Jang, Lee, Schonfeld, & Molinari, 2012). Native
Americans have substantially worse health and poorer access
to adequate care (John, 2004), a finding that is consistent
with the circumstances of indigenous populations in many
countries (cf. Lenari, 2012).
Cultural Competency
Growing recognition of the cultural aspects of occupation
and health has led to growing attention to ensuring that care
providers are culturally competent. Cultural competence is
CHAPTER 6 ■ Culture, Ethics, and Elder Abuse 81
“a set of congruent behaviors, attitudes, and policies that
come together in a system, agency, or among professionals
that enables effective work in cross-cultural situations” (U.S.
Department of Health and Human Services Office of the
Secretary, 2000, p. 80865).
Culturally sensitive intervention can improve outcomes.
It is therefore important that practitioners have the needed
knowledge, attitude, and skills to recognize and respond to
the cultural beliefs and values of the client. It is also impor-
tant to be aware of the complex interaction of factors that
include age, gender, cultural identification, socioeconomic
status, and many other factors. Knowing some general be-
liefs of specific cultures is helpful but not sufficient to cul-
turally competent practice. Throughout this chapter, an array
of examples are provided; these can in no way reflect the
whole of cultural information but rather offer some sense of
the array and interaction of factors influencing the experi-
ence of aging.
Careful assessment of the individual’s values, beliefs, and
needs is required. Ethnographic strategies, those used by
qualitative researchers in the social sciences, can be helpful
in ensuring culturally thoughtful care (cf. Bonder & Martin,
2013). As described in Chapter 24, ethnographic interview-
ing is a strategy for eliciting important information through
the use of open-ended questions and careful observation.
Analysis of Occupational Performance
For occupational therapists, the occupational profile should
guide the analysis of performance (AOTA, 2014), while
physical therapists focus on the specific physical capacity re-
quired for the individual’s occupations (Academy of Geriatric
Physical Therapy, American Physical Therapy Association,
2011). If an elder prefers traditional methods of Thai cooking,
she may sit on the floor to do much of the preparation. This
requires a different degree of flexibility and endurance than
standing at a kitchen counter. Donning a hijab involves dif-
ferent movement patterns than donning slacks.
If standardized instruments are used, therapists should
know how they have been developed, and whether they have
taken cultural factors into account (Fernández-Ballesteros et
al., 2004; Shulman & Feinstein, 2003). Some instruments
used in occupational therapy, such as the Assessment of
Motor and Process Skills (AMPS) (Goldman & Fisher,
1997) and the Canadian Occupational Performance Measure
(COPM) (Law et al., 2005), have been examined extensively
with regard to their applicability across cultures, but for other
instruments, this may not have been addressed.
✺ PROMOTING BEST PRACTICE
Family Decision-Making
In Native American communities, family group decision-
making is the preferred method for addressing treatment
planning. African American and Hispanic families may also
prefer this structure (Poupart, Baker, & Red Horse, 2009).
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82 PART I ■ Global Health and Aging: Implications for Health and Participation
Intervention
The acceptability of various kinds of intervention has a clear
cultural component. Even routes into care vary based on eth-
nicity. For example, in the United States, African Americans
are most likely to enter hospice care from a hospital and to rely
on Medicaid, whereas whites are more likely to enter hospice
through assisted living (Carrion, Park, & Lee, 2012). Inter-
vention planning and implementation will be effective largely
to the extent that unique cultural and individual preferences
are addressed. Programs that emphasize cultural heritage can
improve quality of life for elders (Hersch et al., 2012).
Intervention Implementation
Intervention must be provided in ways that are consistent with
cultural expectations. For example, in working with older
adults, therapists commonly involve the family. In some in-
stances, the care provider must mediate differing expectations
about the roles and contributions of different family members.
The Intentional Relationship Model (Taylor, 2008), described
in Chapter 24, can guide therapists in addressing these con-
siderations. In the case of an East Indian immigrant to the
United States, the elder might expect, on the basis of cultural
norms, that his or her adult children (particularly daughters)
would provide care. If the adult children have acculturated to
mainstream U.S. culture, they may live at a distance, have full-
time jobs, and have developed attitudes more consistent with
Western views of the importance of independence and self-
sufficiency. As discussed in Chapter 24, this can lead to serious
family conflict and may leave the elder feeling depressed and
abandoned.
Intervention Review
In some cultures, it is considered rude to directly challenge an
authority figure. In such a situation, the care provider may be-
lieve that the client agrees with a plan and then be disappointed
when the plan is not implemented. This “noncompliance” sug-
gests that the process of negotiating intervention has not been
successful, and a return to the plan to revisit the client’s prefer-
ences would be in order. In fact, the term “compliance” is being
replaced by “adherence,” a word thought to have a less negative
connotation (Julius, Novitsky, & Dubin, 2009). Regardless of
which word one chooses, a client’s choice not to pursue inter-
vention recommendations often suggests the intervention was
not consistent with the person’s needs and wishes.
Ethical Issues in Later Life
Working with older clients can raise a variety of ethical dilem-
mas, some similar to those in any therapeutic encounter, some
more specific to this particular area of practice. For example,
decision-making about where an older adult should live may
require balancing concerns about safety with consideration of
the individual’s wish for independence (Gawande, 2014).
Gawande notes that decisions about whether or not to institute
a potentially life-extending treatment that may also damage
quality of life can be a more difficult one in the face of the re-
alities of an older adult’s probable life expectancy.
Cultural factors affect the ways in which ethical dilemmas
are perceived. Consider, for example:
■ A frail 75-year-old Hispanic widow is unable to manage
her medications, particularly because she has severe arthri-
tis in her hands and some mild forgetfulness. However, she
expresses a strong desire to remain in her home, where she
lives alone. Her adult daughter, reflecting the importance
of familia as a cultural value, is insistent that the mother
come live with her.
■ An 82-year-old Saudi woman has been referred to physical
therapy. She is unwilling to be treated by a male therapist
because her Muslim religion does not allow her to spend
time with an unrelated male.
Each of these cases raises ethical issues, some culturally me-
diated, all mediated in some way by the individual’s life stage.
In the United States and most Western cultures, consideration
of ethical dilemmas usually focuses on beneficence—doing
good; nonmaleficence—avoiding harm; autonomy—personal
choice and freedom; and justice—equal access to services
(Beauchamp & Childress, 2001). These ethical principles are
not universal, however. In more communal cultures, autonomy
may be much less important. Therapists may need to consider
other conceptualizations, including, for example, narrative
ethics (Lo, 2010). The system of narrative ethics focuses on the
patient’s lifeworld and experiences.
Among the many ethical concerns common in later life
are end of life, focusing on the identified client, and balancing
independence with safety (Gawande, 2014). These concerns
raise troubling and challenging questions with no easy or
absolute answers. Some of the ethical dilemmas presented by
late life may require different thinking about cultural and
societal values (McArdle, 2012).
Undertreatment is a significant issue. Elders may be de-
nied expensive interventions on the basis of cost–benefit
analysis rather than personal need and preference (Craig,
2010; Jecker, 2013). Decisions about organ transplantation,
aggressive cardiovascular surgery, and access to expensive
medications may be based on the individual’s age. Although
there is reason to be concerned about skyrocketing health-
care costs, and recognition that scarce resources must be al-
located thoughtfully, there are no easy answers about the
point at which older adults should be denied care—and
whether it is acceptable to do so solely on the basis of age.
Therapists need to carefully consider their responsibilities to
individual patients and to whole populations.
Overtreatment is also a problem. Elders may wish to refuse
some forms of treatment on the basis of personal preference
and despite strong pressure to accept the intervention. One
90-year-old woman did not want surgery to amputate her sec-
ond lower extremity when she developed gangrene from dia-
betic ulcers. Her daughters and the surgeon were insistent
despite the woman’s repeated assertions that she understood
4605_Ch06_075-090 31/10/17 11:55 AM Page 83
the consequences of her decision but absolutely did not want
the surgery. Older adults may wish to refuse aggressive cancer
treatment, preferring to focus on quality as opposed to quan-
tity of life. These refusals can be troubling to health-care pro-
fessionals and family members who believe in introducing any
treatment that might extend life (Gawande, 2014). Such sit-
uations are all too common. Therapists, too, need to be sensi-
tive to clients’ rights to refuse treatment, while also recognizing
when that refusal may be due to depression or lack of under-
standing of the intervention. In these latter cases, efforts to
encourage and inform clients are essential.
Occupational and physical therapists may face unique
challenges in making intervention decisions. As you will see
in Chapter 22 decisions about whether an older adult should
continue to drive have profound impact on the individual’s
quality of life but also on his or her safety and the safety of
the community. Such a decision becomes an ethical question,
rather than a straightforward treatment decision.
INTERPROFESSIONAL PRACTICE
Ethical Dilemmas in Later Life
Ethical dilemmas, including end-of-life decisions, are complex
and require input and discussion from multiple perspectives
(Pleschberger et al., 2011). In addition to the individual when
she or he is able to participate, these include ethicists, direct
care providers, and family members. Occupational and physical
therapists can contribute findings regarding the older adult’s
occupations and quality of life, as well as prospects for change
in physical capacity.
Clearly, ensuring older adults access to care and to a full
range of occupations can present significant dilemmas. Spe-
cific questions include whether to treat, what kinds of treat-
ment to provide, when to terminate treatment, and whose
wishes should be primary in framing occupational therapy
and physical therapy intervention. By definition, ethical
dilemmas have no single “right” answer but require careful
consideration based on appropriate ethical values.
✺ PROMOTING BEST PRACTICE
Restraints as an Ethical Issue
Use of bedrails can raise ethical as well as safety issues.
Although caring for older adults imposes requirements for
careful attention to safety, autonomy and dignity are also
important values. Individualized assessment with all these
considerations in mind can minimize the need for unduly
restrictive interventions (Shanahand, 2011).
Elder Abuse
Elder abuse is a concern worldwide, although its perception
and incidence varies among countries and cultures. Podneiks
and colleagues (2010) conducted a global survey on the
CHAPTER 6 ■ Culture, Ethics, and Elder Abuse 83
phenomenon, with 53 countries responding representing
every region recognized by the World Health Organization.
They found that the problem existed among all responding
countries. However, the way elder abuse was defined varied
as did the responses to it, with widespread acknowledgment
of inconsistent laws and policies at all levels of government
and little effort directed at problem prevention. Fraga and col-
leagues (2014) examined seven European countries, and found
that elder abuse overall was lower in Greece, Italy, and Spain
(at roughly 13–16 percent of elders reporting abuse) and
higher in Germany, Lithuania, Portugal, and Sweden (rang-
ing from 26 to 31 percent). The authors believe that these
overall differences may be the result of cultural interpretations
of abuse, with northern countries having greater expectations
for comfort and care. They also note that various kinds of
abuse are dependent on education and financial situations,
with individuals in poorer circumstances experiencing more
neglect, those in better educated situations experiencing more
psychological abuse.
Definition and Forms
Elder abuse has no universally accepted definitions and forms,
although advocates have emphasized the need for them over
the past 3 decades (e.g., National Research Council, 2014;
University of New Hampshire, 1986). Standardized defini-
tions and forms are important for comparison of research
results and government reporting statistics. Without them,
generalizations are impossible.
Recently the U.S. Departments of Justice and Health and
Human Services (2014) funded the development of a roadmap
intended to inform and help identify strategic priorities for re-
search, policy, and practice in addressing elder abuse. That
roadmap defines elder abuse as physical, sexual, or psycholog-
ical abuse, as well as neglect, abandonment, and financial ex-
ploitation of an older person by another person or entity that
occurs in any setting (e.g., home, community, or facility) either
in a relationship where there is an expectation of trust or when
an older person is targeted based on age or disability.
Prevalence and Incidence
A study in the United States surveyed 3,005 community-
dwelling persons aged 57 to 85 about their past year experi-
ence with three elder abuse forms (Laumann, Leitsch, &
Waite, 2008). The results suggested that 9 percent had been
verbally mistreated, 3.5 percent financially mistreated, and
0.2 percent physically mistreated. In addition, women and
persons with physical disabilities were more frequently sub-
jected to verbal mistreatment, and African Americans and
persons without a spouse or intimate partner were more fre-
quently subjected to financial mistreatment. Another U.S.
investigation surveyed 5,777 community-dwelling persons
aged 60 and older and 813 proxies about five elder abuse
forms (Acierno et al., 2010). About 1 in 10 respondents
reported at least one form of past year mistreatment. More
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84 PART I ■ Global Health and Aging: Implications for Health and Participation

specifically, 5.2 percent experienced financial exploitation by the level of attention that should be directed at the problem.
family members, 5.1 percent potential neglect, 4.6 percent Examples are illustrations of elder abuse. They have been
emotional mistreatment, 1.6 percent physical mistreatment, observed or reported by reputable sources, such as a nurse
and 0.6 percent sexual mistreatment. Also, spouses or inti- witnessing an older adult being hit by her son. Among the
mate partners were more likely than adult children to perpe- three concepts, examples provide the highest evidence that
trate all forms but financial exploitation. elder abuse exists and requires attention.
Signs are the consequences of elder abuse examples. They
offer less assurance that the problem has occurred because
AROUND THE GLOBE: Elder Abuse signs can be due to phenomena other than elder abuse, for
example, falls. However, the existence of signs should raise
■ From interviews with 2,111 community-dwelling persons
suspicion of elder abuse, which is a sufficient standard for
aged 66 and older in the United Kingdom, it was found that
reporting the problem under most state laws. Signs of elder
2.6 percent had been mistreated, with neglect most common
abuse include bruises (Fig. 6-3) or emaciation.
(Biggs, Manthorpe, Tinker, Doyle, & Erens, 2009).
Finally, risk factors indicate the possibility of elder abuse.
■ A survey of 2,401 Spaniards over age 64 and 788 persons
They represent characteristics of victims, perpetrators, or en-
providing care to dependent older people uncovered
vironments found through research to be associated with the
past year abuse occurrence at 0.8 percent for the first group
problem. Like signs, they can be associated with phenomena
and 1.5 percent for the second group (Marmolejo, 2008).
other than elder abuse. Elder abuse risk factors for the per-
■ In a cross-sectional study of 1,106 rural Egyptians whose
petrator include alcoholism and stress from life events, which
average age was 68, 43.7 percent reported that they had
may be risk factors for depression as well.
been mistreated by family members, with neglect eight times
Most state reporting laws require referral of any known or
more common than abuse (Rahman & Gaafary, 2012).
suspected instances of elder abuse. This means reporting
awareness of examples or signs but not of risk factors.
Reporting
Screening or Assessment Instruments
Lachs and Berman (2011) examined both self-reported and doc- for Elder Abuse Detection
umented case data on elder abuse among New York community-
Detecting elder abuse examples, signs, and risk factors is en-
dwelling persons aged 60 years and older, discovering that only
hanced through the use of screening or assessment instru-
1 in 24 cases were referred to agencies charged with helping
ments. Such tools are important for ensuring that clues to
older victims, dropping to just 1 in 44 for financial abuse.
case identification are not missed, organizing information
All American states and territories have enacted laws
collected about abuse victims and their circumstances, and
authorizing adult protective services in elder abuse situations
systematically documenting data for court proceedings or re-
(American Bar Association Commission on Law and Aging,
search purposes. However, the U.S. Preventive Services Task
2005). With rare exception, these laws require reporting of
Force (2013) has concluded that thus far there is insufficient
the problem minimally by select categories of health and so-
evidence about whether screening successfully identifies
cial service professionals. Those professionals most likely to
be identified as mandatory reporters include physicians,
nurses, mental health practitioners, and social workers.
Low reporting rates suggest that mandatory reporting laws
alone do not guarantee professional referral of the problem.
Indeed, there are numerous reasons why professionals fail to
report, including lack of confidence in the referral agency, stan-
dards around confidentiality, concern about eroding rapport es-
tablished with clients, fear of litigation or reprisal by the victim
or perpetrator, and desire to avoid possible court involvement.
Still, the number of elder abuse reports has grown. A 2012 sur-
vey of adult protective services programs in all 50 states found
that 87 percent had seen reports and caseloads increase in the
last 5 years, with some programs experiencing an increase of
100 percent during that period (Quinn & Benson, 2012).

Examples, Signs, and Risk Factors

Three concepts are critical to decision-making in identifying,
referring, and treating elder abuse (Anetzberger, 2001). Each FIGURE 63 Visible bruises should raise concerns about possible
concept is unique in the degree it evidences elder abuse and elder abuse. joebelanger/iStock/Thinkstock
4605_Ch06_075-090 31/10/17 11:55 AM Page 85
abused older adults to recommend their routine screening in
primary care offices.
Many elder abuse screening or assessment instruments
exist. However, none has universal acceptance, and few have
been tested for reliability and validity (Daly & Jogerst, 2005;
Pisani & Walsh, 2012). Among the most widely used instru-
ments are the Hwalek-Sengstock Elder Abuse Screening Test
Short (Neale, Hwalek, Scott, Sengstock, & Stahl, 1991);
Indicators of Abuse Screen (Reis & Nahmiash, 1998); Actual,
Suspected, and Risk of Abuse Tools (Bass, Anetzberger, Ejaz,
& Nagpaul, 2001); and Elder Abuse Suspicion Index (Yaffe,
Wolfson, Lithwick, & Weiss, 2008).
Signs
The signs of elder abuse can be physical, behavioral, psycho-
logical, or social in nature (Anetzberger, 1997). Physical signs
range from injuries to death. Those most commonly identified
in hospital emergency departments, at autopsy, or in medicole-
gal reports are traumas to the arms 44 percent; face, teeth, and
neck 23 percent; skull and brain 12 percent; legs 11 percent;
and torso 10 percent (Murphy, Waa, Jaffer, Sauter, & Chan,
2013). Research suggests that elder abuse victims, regardless
of form of abuse, die up to five times sooner than nonvictims
(Dong et al., 2009). Behavioral signs include anger, helpless-
ness, and suicidal actions. Psychological signs include fear,
anxiety, and depression. Depression in particular has been
found associated with elder abuse victims (Burnett, Coverdale,
Pickens, & Dyer, 2006; Dong, Beck, & Simon, 2010). Finally,
social signs include limited contacts and withdrawal. Elder
abuse victims are more likely than nonvictims to have limited
social resources (Schafer & Koltai, 2014).
Risk Factors
Risk factors have greater power for predicting elder abuse
when found in combination or complex interaction. In addi-
tion, those risk factors that are characteristic of the perpetra-
tor tend to be more predictive of abuse occurrence than those
that are characteristic of either the victim or environment
(Anetzberger, 2000; Reis & Nahmiash, 1998). Many risk
factors have been proposed. However, only a few have been
validated by substantial evidence.
Although elder abuse is associated with advanced age,
lower income, and ethnicity (Acierno, Hernandez-Tejada,
Muzzy, & Steve, 2009; Laumann et al., 2008), the most im-
portant risk factors for victims are reduced functional capacity
and problem behaviors such as aggression or making de-
mands of caregivers (Dong, Simon, & Evans, 2012). Re-
duced functional capacity can render victims dependent on
perpetrators, unable to leave abusive situations, or unaware
that help is needed. Such behaviors can spark anger and re-
sentment in perpetrators, which may ignite abusive actions.
Considerable research links dementia and elder abuse (e.g.,
Post et al., 2010; Yan & Kwok, 2011). Dementia also may
result in both reduced functional capacity and problem be-
haviors. Indeed, various studies suggest that up to two-thirds
CHAPTER 6 ■ Culture, Ethics, and Elder Abuse 85
of family members who provide care for persons with demen-
tia have abused the care recipient (Dong, Chen, & Simon,
2014; Wiglesworth et al., 2010).
Among various proposed perpetrator risk factors, pathol-
ogy and dependency receive the most support from empirical
investigation. Research suggests that more than nonabusers,
abusers tend to be self- or other-identified as having an alco-
hol problem and to drink regularly (Amstadter et al., 2011;
Reay & Brown, 2001). In addition, perpetrators are more
likely to have a mental illness and to have spent time in a
psychiatric hospital (Acierno et al., 2009; Wolf & Pillemer,
1989). Perpetrator dependence on the victim usually takes the
form of finances or housing (Anetzberger, 1987; Greenberg,
McKibben, & Raymond, 1990). It may result from unem-
ployment or underemployment, mental disorders, or greed.
The environmental risk factors best supported by research
are shared living arrangements and social isolation. Typically
the victim and perpetrator reside together (Lowenstein,
Eisikovits, Band-Winterstein, & Enosh, 2009; Wolf &
Pillemer, 1989). Such close proximity can produce tension
and conflict, and sometimes even violence. Elder abuse vic-
tims and perpetrators also tend to feel alone and to have little
social support (Acierno et al., 2009; Lachs, Berkman, Fulmer,
& Horwitz, 1994). The isolation may be self-imposed due to
deviance or estrangement or result from conditions such as
poor health or forced confinement.
Addressing Elder Abuse
Approaches
Seven major approaches emerged for understanding and re-
sponding to elder abuse over the past half century (Anetzberger,
in press). Together they represent multiple distinct perceptions
of elder abuse and differing lead disciplines, systems, or pro-
grams. No single one dominates, and there is broad consensus
around the importance of multidisciplinary efforts to best ad-
dress the issue. The approaches reflect the following:
■ Elder abuse as a social problem. Key activities include re-
ceipt and investigation of reports, assessment of client sta-
tus and service needs, arrangement or provision of services
to treat harm or prevent its recurrence, and obtainment of
legal interventions as indicated.
■ Elder abuse as a geriatric syndrome. Definitive diagnosis
(typically using screening tools to identify established signs
and risk factors) and clinical management (employing in-
tervention protocols) are essential methods for treating and
improving the victim’s presenting condition.
■ Elder abuse as an aspect of family violence. The domestic
violence approach defines the issue as one of coercive tac-
tics used by the perpetrator to gain power and control over
the victim. Interventions focus on empowering the victim
through information, support, and safety planning, as well
as holding the perpetrator accountable.
■ Elder abuse as an aging issue. Strategies include establish-
ment of programs such as the long-term care ombudsman
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86 PART I ■ Global Health and Aging: Implications for Health and Participation
and elder abuse prevention to advocate for rights of vul-
nerable elders, raise awareness, and educate the public.
■ Elder abuse as criminal action. The criminal justice approach
focuses more on the perpetrator than the victim. Activities
seek to protect society, maintain order, enforce law, control
crime, and punish perpetrators (while preserving their rights).
■ Elder abuse as a human rights violation. This approach to
elder abuse requires government action and social will to
enact legislation for incidence reporting and interventions
such as information centers and hotlines.
■ Elder abuse as a public health concern. In this approach,
the emphasis is on government initiative to protect the
public, using problem prevention strategies, such as public
education, screening, social action, and surveillance.
There is little evaluative research on elder abuse ap-
proaches or service systems and programs. Therefore, we do
not know what does or does not work in addressing elder
abuse (National Research Council, 2003; Ploeg, Hutchison,
MacMillan, & Bolan, 2009).
Multidisciplinary Teams
The effective involvement of several service systems and pro-
fessional disciplines in addressing elder abuse is best realized
through multidisciplinary teams (M-teams). These are groups
of systems or professionals assembled for the purpose of iden-
tifying elder abuse and developing recommendations to treat
it (Teaster & Nerenberg, 2004). Some M-teams are formed
to serve the needs of a particular organization, and others
work on behalf of entire communities or regions. Some
M-teams have a specific focus, such as the Fiduciary Abuse
Specialist Teams or those that do fatality review.
For occupational and physical therapists, a key role is
identifying individuals at risk for abuse, and, in particular,
signs of abuse with their clients (Saliga, Adamowicz, Logue,
& Smith, 2004; Waite, 2014). Because therapists are often
in the home, they may identify situations and physical mark-
ers that other team members do not see. Therapists can con-
sult with the team to ascertain the best way in which to report
problematic situations so that the client is protected and the
abuse ameliorated. Occupational therapists may work with
clients and caregivers to identify coping skills that reduce
frustration that can lead to abuse, whereas physical therapists
can encourage use of physical activity as a stress relieving
mechanism. It should be noted that these strategies have not
been adequately evaluated for effectiveness.
M-teams usually provide case analysis, program planning,
education, and advocacy (Teaster & Nerenberg, 2004). Most
have formal structures, with select membership and written
proceedings (Twomey et al., 2010). M-teams work to improve
elder abuse interventions by offering a more holistic perspective
on the problem than possible with a single system or discipline,
sharing the responsibility for case handling, and promoting
professional relationships toward a community-wide approach
to elder abuse (Anetzberger, Dayton, Miller, McGreevey, &
Schimer, 2005). Challenges to M-team effectiveness can
include lack of participation by key disciplines or systems, in-
adequate administrative support, and inability to sustain in-
volvement over time (Anetzberger, 2011).
SUMMARY
The issues addressed in this chapter are vital components of
the context in which care is provided for older adults. Cultural
factors and attitudes toward aging raise an array of ethical con-
siderations, among these, the extent to which elder abuse oc-
curs, is recognized, and is addressed. Occupational and physical
therapists must be attentive to these factors as they plan and
implement interventions to support function and quality of life.
CASE STUDY
Mrs. Anahita Shakiba is a 90-year-old immigrant to the
United States from Iran. She has lived in the United States
for the past 4 decades; however, her command of English
is not very good; her children speak Farsi with her. She
and her adult son and daughter, all of whom live in the
United States, are Shia Muslims but are not particularly
observant. Mrs. Shakiba reads the Qur’an from time to
time but does not fast during Ramadan or wear the hijab.
Her children do not identify themselves as Muslim.
Mrs. Shakiba has been a very involved grandmother.
She also enjoyed involvement at the local Iranian Cultural
Center, and cooking large meals for her family. She par-
ticularly enjoys making traditional Iranian foods to remind
her grandchildren of their cultural heritage. However,
Mrs. Shakiba’s behavior is not what would stereotypically
be expected of a Muslim woman. She is strong and inde-
pendent and had a relationship with her late husband
based on equality.
Last year, however, Mrs. Shakiba began to have mem-
ory lapses that have now become quite profound. She has
become increasingly unwilling to leave her home, believ-
ing that she is being persecuted for her Muslim faith. She
now has very little contact with her grandchildren and no
longer goes to the Cultural Center. Not only is she no
longer making family meals, but her children believe she
is not eating regularly.
She is also having significant functional difficulties as-
sociated with complications from her long-standing dia-
betes. Her children are very concerned about her and are
insisting that she come to live with one of them. They are
somewhat at odds about which of them she should live
with, and they are also at odds because Mrs. Shakiba has
given her power of attorney for health care to her son, who
is now refusing to share information with his sister.
Questions
1. What do you see in this description that might
contribute to positive aging?
4605_Ch06_075-090 31/10/17 11:55 AM Page 87
2. What attitudes and cultural factors might affect
Mrs. Shakiba’s experience of growing older?
3. What ethical dilemmas can be seen in this situation?
Critical Thinking Questions
1. What factors have you observed that reflect attitudes
toward aging in the United States? How might
negative attitudes be minimized through the
establishment of different messages?
2. Do you believe that attitudes toward older adults are
different in other countries? What information leads
to your conclusion?
3. Think about your own cultural background. How
might the beliefs and values of your culture affect the
experience of aging? Have you observed these effects
in older adults you have known?
4. How might cultural factors affect family dynamics
in meeting the needs of an older adult? What are
some unique features of cultural difference in the
United States that would affect these interactions?
5. Of the four primary cultural values in Western cultures,
what is one you think might not be shared in some
other places? What is your rationale for your belief?
6. What might be some strategies for addressing ethical
dilemmas common in caring for older adults? How
might your discipline contribute to the resolution
of some of these dilemmas?
7. Have you ever been in the position of witnessing a
form of elder abuse? Why might elder abuse be
so prevalent, and what might be the role of your
discipline in reducing its incidence?
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Neglect, 20, 276–300. http://dx.doi.org/10.1080/08946560801973168
Yamaguchi, M., & Silverstein, M. (2003). The impact of acculturation and
ethnic identity on the intergenerational relations and psychological well-
being of Japanese-American elderly in a retirement residence. Hallym
International Journal of Aging, 5, 1–17.
Yan, E., & Kwok, T. (2011). Abuse of older Chinese with dementia by
family caregivers: An inquiry into the role of caregiver burden. Interna-
tional Journal of Geriatric Psychiatry, 26, 527–535. http://dx.doi.org/
10.1002/gps.2561
Yang, F. M., Cazorla-Lancaster, Y., & Jones, R. N. (2008).Within-group
differences in depression among older Hispanics living in the United
States. Journal of Gerontology: Psychological Sciences, 63B, P27–P32. http://
dx.doi.org
Zaroff, C., D’Amato, R. C., & Bender, H. A. (2014). Understanding differ-
ences in cognition across the lifespan: Comparing Eastern and Western
cultures. In M. J. Davis & R. C. D’Amato (Eds.), Neuropsychology
of Asians and Asian Americans: Practical and theoretical considerations
(pp. 91–116). New York, NY: Springer Science + Business Media.
Zhang, N. J., Guo, M., & Zheng, X. (2012). China: Awakening giant
developing solutions to population aging. Gerontologist, 52, 589–596.
http://dx.doi.org
Zhou, Y. R. (2012). Space, time, and self: Rethinking aging in the contexts of
immigration and transnationalism. Journal of Aging Studies, 26, 232–242.
http://dx.doi.org
Zimbardo, P., & Boyd, J. (2008). The time paradox: The new psychology of time
that will change your life. New York: Atria Books.
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PA RT II
Aging: Body Structures
and Body Functions
Section 1: Normal Age-Related
Changes
Part I of this text considered the sociocultural factors that
affect late life, as well as theoretical considerations. The focus
now turns to individuals, and to the issues that affect occu-
pations and performance.
Throughout life, people’s bodies change. These changes
affect both structure and function of specific systems as well
as the organism as a complex whole. When people are young,
these changes typically involve growth and acquisition of new
skills. In later life, the normal course of aging involves many
gains—wisdom, experience, patience, perspective—but also
decrements in function. Joints wear out, senses are dulled
by exposure to sensory input, and even the most physically
fit individuals lose some musculoskeletal and cardiovascular
capacity.
Both the Occupational Therapy Practice Framework
(American Occupational Therapy Association, 2014) and the
International Classification of Function (World Health
Organization, 2001) acknowledge that an individual’s ability
to participate fully in life is dependent to some extent on his
or her biological and psychological function. A clear under-
standing of normal physiological development is one essential
factor in a therapist’s ability to frame effective interventions
to support meaningful life.
The next five chapters address this topic. Each considers a
major body system and provides an overview of the normal
changes that accompany aging. These are changes that are
very likely to affect every older adult to some extent, although
individuals experience such change to different degrees and
in different systems. So, for example, almost every older adult
will need eyeglasses for near vision, but some require them
by age 40, while others may not need them until a decade
later. Every older adult will lose muscle mass and cardiovas-
cular capacity, but marathon runners are likely to experience
slower loss (and from a greater initial capacity) than sedentary
individuals.
In reading these chapters, some specific considerations are
important to keep in mind:
1. The various systems change to varying degrees for
particular individuals.
2. There is an interaction among these changes. Although
they are presented here as if these systems function
independently, the reality is far more complex.
3. These changes occur in the context of the sociocultural
factors described in Chapters 1 through 6.
4. And perhaps most important, these changes are only
loosely related to alteration in occupation and partic-
ipation. Some individuals are able to find ways to
manage change such that valued activities can be
continued into very old age. Others struggle to cope
with very minor differences in physical, cognitive, or
sensory capacity.
Subsequent chapters consider some of the reasons that in-
dividual coping skills vary and address strategies for support-
ing normal development in later life to the greatest extent
possible.
American Occupational Therapy Association. (2014). Occupational therapy
practice framework: Domain & process (3rd ed.). American Journal of
Occupational Therapy, 68(Suppl. 1), S1–S48. http://dx.doi.org/10-5014/
ajot.2014.682006
World Health Organization. (2001). International Classification of Function.
Geneva: Author. Retrieved from www3.who.int/icf
91
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92 PART II ■ Aging: Body Structures and Body Functions
Section 2: Age-Related Health
Conditions, Impairments,
and Limitations
The normal age-related changes described in Section 1 affect
all older adults as they age, even though the speed with which
they progress and their impact on function differs. In addition
to these normal changes, a number of diseases and disorders
are common in late life, although they certainly do not affect
everyone. In the United States, 80% of older adults have
at least one chronic condition, and 50% have at least two
(Centers for Disease Control and Prevention [CDC], 2011).
As is true for normal age-related change, a particular disease
may differ in severity among individuals, may progress more
rapidly for some than others, and will have differential impact
on occupation and participation.
One of the major criticisms of Rowe and Kahn’s (1997)
conceptualization of successful aging is its emphasis on avoid-
ing disease (Katz & Calasanti, 2015). It is obviously helpful
to find ways to delay the onset of disease and disability. How-
ever, most elders will experience one or more (CDC, 2011),
so identifying ways to minimize their impact on function and
quality of life can help extend the years during which older
adults can experience meaningful and positive existence.
Older adults often have multiple conditions that interact
to affect function. Some of these will be chronic—
osteoporosis, arthritis, and diabetes, for example—but
superimposed may be acute illnesses—urinary tract infec-
tion or influenza—that further compromise well-being.
Therapists and other health-care providers must take into
account these interacting factors as they frame interven-
tions to maximize quality of life.
These conditions do not exist in a vacuum. They are
overlaid on normal age-related changes, they occur in com-
bination, and they affect function based not only on the
conditions themselves, but also the individual’s coping
mechanisms and sociocultural contexts. The importance of
these considerations will be evident in subsequent sections
of the text that address strategies for interventions to sup-
port positive aging.
Centers for Disease Control and Prevention. (2011). Healthy aging: Helping
people to live long and productive lives and enjoy a good quality of life. Re-
trieved from http://www.cdc.gov/chronicdisease/resources/publications/
aag/aging.htm
Katz, S., & Calasanti, T. (2015). Critical perspectives on successful aging:
Does it “appeal more than it illuminates”? Gerontologist, 55, 26–33.
doi:10.1093/geront/gnu027
Rowe, J., & Kahn, R. (1998). Successful aging: The MacArthur Foundation
study. New York: Pantheon.
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SECTION 1: Normal Age-Related Changes
Katherine S. Judge
“Few of us, however, butmakethethemind,mostifofweourwillminds. The body ceases to grow in a few years;
LEARNING OUTCOMES
By the end of this chapter, readers will be able to:
1. Understand the underlying assumptions and key tenets
of healthy cognitive aging across the life span.
2. Describe methodological issues that should be considered
in review of research regarding healthy cognitive aging.
3. Discuss current literature regarding healthy cognitive
aging across the life span including basic and higher
order cognitive processes.
4. Describe current theories of healthy cognitive aging.
5. Identify strategies to assist individuals with the promotion
of positive aging including cognitive health.
Clinical Vignette
Bill Thompson is a 75-year-old retired man who has been
happily married for 50 years. Bill is in good physical health
and has not experienced noteworthy changes in his cognitive
abilities. He stays active by swimming 4 days a week, volun-
teers at a youth center, and regularly socializes with friends
and family. Throughout Bill’s life, he has been engaged in
physically and mentally stimulating activities, such as playing
chess, walking his dog in the park every day, and coaching the
local youth swim club. Overall, Bill is as mentally sharp as he
was when he was younger, and compared with middle-aged
adults, his performance on a wide range of neuropsychological
assessments is similar. To some, Bill may not fit the stereo-
typical image of what happens when you age (i.e., forgetful,
withdrawn, dependent on others, physically frail). Bill, how-
ever, exemplifies healthy cognitive aging.
1. What is healthy cognitive aging? What characteristics
of healthy aging does Bill demonstrate?
CHAPTER 7
Cognitive Function
■ Nicole T. Dawson
let it, may grow almost as long as life lasts.
—John Lubbock, The Pleasures of Life
”
2. What factors impact cognitive health? Which of these
factors are seen in Bill’s circumstances?
3. How do older adults develop and maintain healthy
cognitive processes across the life span?
W hat happens to our cognitive abilities as we age?
Do we gain new knowledge and information? Do
we experience decreases in how fast we mentally process
information? Do we perform similarly to younger adults on
certain tasks? Surprisingly, the answer to each of these
questions is “yes!” You may be wondering how this can be.
The answer reflects several essential tenets of cognitive
aging that we will discuss in further detail. Historically, it
was thought and widely believed that individuals inevitably
experience cognitive decline as they age. Furthermore, it
was thought these cognitive changes were experienced uni-
versally across individuals and across cognitive abilities
(e.g., memory, language, decision-making). However, re-
search has found a more complex (and interesting) pattern
of results. Healthy cognitive aging does not occur in a vac-
uum, nor does it start at a specific age. For example, an in-
dividual does not wake up on his or her 50th birthday and
experience notable cognitive (or physical) changes. Cogni-
tive aging is a process that unfolds over decades. In fact
some cognitive processes begin to change as early as age 25.
This chapter reviews healthy, normal, age-related effects
on cognition, including basic and higher order cognitive
processes, and theories of cognitive aging. Implications of
these age-related effects are discussed in terms of how to
optimize cognitive functioning across the life span and spe-
cific strategies that may be used to enhance rehabilitative
outcomes.
93
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94 PART II ■ Aging: Body Structures and Body Functions
Bases of Cognitive Aging
Key Tenets of Cognitive Aging Across
the Life Span
When describing differences between older and younger
adults, cognitive aging studies typically use language that dis-
proportionately reflects negative aspects of the aging process,
such as “deficits,” “losses,” “decrements,” and “impairments.”
It is important to note these findings are based on lab-based
experiments that reflect differences in reaction time (in the
range of milliseconds) or decreases in accuracy (by 1–2 stimuli)
between younger and older adults. These results and the lan-
guage used to describe findings can be misleading in under-
standing how cognitive aging unfolds in real-world and clinical
settings and can perpetuate negative stereotypes of older adults.
It is therefore important to consider the implications of using
potentially negative or emotionally charged language that may
have unintended consequences for older and younger adults,
laypersons, clinicians and professionals, and policy makers.
To illustrate, Levy, Slade, Kunkel, and Kasl (2002) re-
ported that 85 percent of adults over age 50 years have expe-
rienced ageism and that an individual’s attitudes toward aging
have been found to predict mortality. Additionally, it has been
found that older adults are more likely to internalize these
negative stereotypes of aging (Golub & Langer, 2007; Levy
et al., 2002). Older adults exposed to negative stereotypes
showed declines in performance on memory, math, and hand-
writing tests as well as increased level of self-induced depend-
ence, which may lead to learned helplessness (Golub &
Langer, 2007; Meisner, 2011). Additionally, assumptions of
these negative stereotypes can lead to less optimal or appro-
priate treatment (Minichiello, Browne, & Kendig, 2000). We
have made a conscious decision in this chapter to avoid stereo-
typical or negatively charged language and to use words that
more accurately describe cognitive aging, such as “changes”
and “differences” and, when appropriate for describing the na-
ture of these difference, “gains,” “declines,” and “stability.”
When studying cognition across the life span, it is impor-
tant to use conceptual frameworks that aid in the understand-
ing and interpretation of results. For the purpose of this
chapter, the following tenets are used collectively to under-
stand and interpret cognitive changes and to delineate how
best to optimize cognitive aging throughout the life span.
Clinicians and rehabilitation professionals should take these
tenets into account collectively when assessing and imple-
menting any plan of care because cognitive aging is influ-
enced by a wide array of factors.
Tenet 1: Cognitive aging is best understood using a devel-
opmental life span approach that considers cognitive devel-
opment a lifelong process that begins with conception and
end with death. The developmental life span approach takes
into consideration normative age-graded influences, norma-
tive sociohistorical influences, and nonnormative life events
(Baltes, 1987). Normative age-graded influences are biological
or environmental life influences or experiences that are the
same for all individuals at a given developmental timeframe.
An example of a biological or maturational process would be
puberty or the social norm of adolescents driving at age 16.
Normative sociohistorical influences are biological or environ-
mental life influences or experiences that are generation or
cohort specific. An example would be differences across
generations in nutrition, education, or technology because
these have changed dramatically over the past 100 years. An-
other example would be exposure to cohort-specific experi-
ences such as the Great Depression or 9/11. Nonnormative
life events are biological or environmental life influences or
experiences that are unusual or atypical for an individual. An
example would be the loss of a parent at a young age, becom-
ing a widow at age 20, or having a serious medical condition
as a child. This tenet is important because it underscores the
importance of lifelong development and the concept of plas-
ticity. Plasticity is the ability of the brain to learn, adapt, and
modify across the life span. The concept of neuroplasticity is
discussed further in Chapter 25. The implication of this tenet
is that what happens early in life, in terms of factors such as
nutrition, illness, or education, has an impact on development
later in life, and as a developmental process, cognition is mal-
leable or pliable rather than unchangeable.
Tenet 2: Cognitive aging occurs within a framework of
gains, declines, and stability. This tenet highlights findings
that have shown cognition in later life is multidimensional
and multidirectional rather than a universal and linear decline
across all cognitive processes. The implication of this tenet is
that some cognitive processes improve with age, some change
compared with younger adults, and other processes remain
stable throughout the life span.
Tenet 3: Cognitive aging is influenced by and incorporates
a wide range of inter- and intraindividual differences, includ-
ing but not limited to lifestyle factors such as diet, exercise,
health habits, and education. Interindividual differences reflect
variation among groups, whereas intraindividual differences
reflect variation within an individual. These influences are
important for distinguishing between-group differences and
within-group differences across the life span.
Methodological Considerations
One of the challenges when studying cognitive aging is the
selection of the appropriate research design and the result-
ing implications of study findings. For example, cross-
sectional research designs—those that study several groups
at a particular point in time—tend to exaggerate group dif-
ferences between younger and older adults, implying a
rather steep decrease in cognitive processes. Other, more
sophisticated research designs (e.g., sequential research de-
signs that study participants over time) show less extreme
differences between younger and older adults, indicating
more stability across the life span in many cognitive
processes. A more detailed discussion of research design
and the implications for understanding cognitive aging can
be found in the online ancillaries.
4605_Ch07_091-108 31/10/17 11:55 AM Page 95
Foundations of Cognition Aging: Basic
and Higher Order Cognitive Processes
Using a developmental life span approach, this section dis-
cusses how cognitive processes are affected over an individ-
ual’s life. Cognitive processes are categorized as basic and
higher order. Basic cognitive processes serve as the founda-
tion or building blocks for higher-order cognitive processes
and include sensory and perceptual processes, attention,
short-term memory, working memory, and long-term mem-
ory systems. Higher order processes typically require addi-
tional cognitive resources and are conceptualized as more
complex processes. Examples include reasoning, decision-
making, problem-solving, judgment, abstract thought and
logic, and language production and comprehension processes.
Higher order cognitive processes also include everyday problem-
solving, everyday cognition, wisdom, and expertise. Two
additional concepts that are discussed are implicit and explicit
processing and overall intellectual abilities.
Basic Cognitive Processes
Sensory Processes
Sensation is a biological process that is responsible for transmit-
ting incoming stimuli (or information) from the environment
to the appropriate neural structures in the brain. Increased age
is associated with decreasing auditory and visually based pro-
cessing (Fozard, 1990; Schieber & Baldwin, 1996). Auditory
decline is evidenced by difficulties hearing low- and high-level
thresholds, aging of the cochlea, and decreased processing of
auditory information. Visual decline is evidenced by decreases
in the amount of light entering and hitting the retina, increased
susceptibility to glare, decreased peripheral processing, and pres-
byopia (i.e., farsightedness due to the aging process) (Schieber
& Baldwin, 1996). Age-related declines in auditory and visual
processing begin in middle age and continue throughout old age.
Research has found that auditory and visual processing de-
clines are associated with a decrease in fluid abilities, one of the
main components of intellectual ability (Baltes & Lindenberg,
1997; Salthouse, 1990). These findings imply that certain cog-
nitive abilities and biological aspects may age together. An-
other key issue is the impact sensory processes may have on
cognitive abilities. If visually or auditory based information is
processed through a less optimal system, subsequent cognitive
processing of information may result in errors or take addi-
tional time. For example, an older adult experiencing moder-
ate hearing loss may need to listen to a voicemail message
multiple times to fully process and understand the message.
The extra time needed is due to degraded information received
from the auditory system and not to lack of language compre-
hension or memory. It is important to understand how sen-
sory processing is inextricably linked to basic and higher order
cognitive processing and, more important, the real-world and
clinical implications of this. Sensory processes are described
in greater detail in Chapter 9.
CHAPTER 7 ■ Cognitive Function 95
Perception
Perceptual processing describes the process of assigning mean-
ing to incoming sensory stimuli. For example, when shown a
picture of a dog, recognizing and correctly naming the object
“dog” is the process of perception. Perception is considered
an automatic and extremely fast cognitive process that occurs
without awareness or intention most times. Overall, older
adults have been found to successfully use situational context
and their vast experience to maintain the perceptual abilities
necessary for everyday functioning (Billino, Bremmer, &
Gegenfurtner, 2008; Costello, Madden, Shepler, Mitroff, &
Leber, 2010; Pichora-Fuller, 2008).
Attention
As conceptualized by Kahnaman (1973), attention is a
resource-limited cognitive process that is necessary for support-
ing proper functioning of all other cognitive abilities, especially
higher order cognitive processes. The ability to successfully
make decisions, problem-solve, or think through an issue re-
quires attentional resources. For example, reading this book
chapter becomes increasingly more difficult when your atten-
tional resources are taxed because of other interfering stimuli
(e.g., loud music, people talking). In a clinical setting, four
types of attention are described; these include the following,
in order from simplest to most complex: sustained (or focused)
attention, selective attention, alternating attention, and divided
attention. Throughout the day, individuals continuously shift
between these different types of attentional processes depend-
ing on the needs of a given task. Cognitive aging researchers
use a variety of neuropsychological measures to examine how
these types of attention are affected throughout the life span.
Sustained (or focused) attention is the ability to direct at-
tentional resources to a single task or activity, such as reading a
book. When comparing younger and older adults’ performance
on measures of sustained attention, no statistically significant
differences are found (Berardi, Parasuraman, & Haxby, 2001;
Carriere, Cheyne, Solman, & Smilek, 2010; Filley & Cullum,
1994; Rogers, 2000). Selective attention is the ability to direct
attentional resources to a task or activity while simultaneously
directing attentional resources to ignore distracting information.
As an example, watching a favorite television program while
trying to ignore friends talking in the other room would involve
directing attentional resources to watching the television show
while also directing attentional resources to not paying attention
to the chatter from the other room. In other words, attentional
resources are needed to ignore distracting information, stimuli,
or tasks.
Overall, mixed results have been found when comparing the
performance between younger and older adults on measures of
selective attention, ranging from no age-related findings to re-
duced inhibitory control during selective attention tasks. On
standard neuropsychological assessments, age-related differ-
ences have been found (Barr & Giambra, 2000; Haring et al.,
2013; Plude & Doussard-Roosevelt, 1989; Uttl & Pikenton-
Taylor, 2001), but these results are not consistent across all
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96 PART II ■ Aging: Body Structures and Body Functions
studies. For example, in a meta-analysis reviewing multiple
studies, Verhaeghen and Cerella (2002) found no age-related
differences in selective attention. Additionally, these age-related
differences in selective attention are reduced in tasks where the
individual has had prior experience or practice (Rogers, 2000).
Alternating attention is the ability to direct or switch at-
tentional resources between two or more tasks or activities.
It is conceptually distinct from divided attention because
tasks are performed one at a time with attentional resources
flexibly switching back and forth between tasks. For example,
switching between numbers and letters of the alphabet (i.e.,
1, A, 2, B, 3, C, 4, D, 5, E, etc.) is an example of a task that
requires alternating attention. Research has found significant
age-related differences between younger and older adults in
alternating attention tasks, with older adults having more dif-
ficulty alternating among tasks (Tombaugh, 2004).
Divided attention is the ability to allocate attentional re-
sources to two or more tasks or activities at the same time.
Driving while listening to music and carrying on a conversa-
tion is an example of using divided attention. Similar to the
other types of attentional resources, divided attention is lim-
ited, and, once exhausted, accuracy declines and reaction time
increases. Researchers typically use a dual-task paradigm to
investigate divided attention in which participants are in-
structed to complete two tasks at the same time. Participants’
dual-task performance is compared with their performance
when completing either task separately. Overall, research has
found age-related differences in divided attention, with
younger adults performing significantly better than older
adults. These findings are especially evident when completing
complex tasks like preparing income tax returns Rogers, 2000;
Tombaugh, 2004). Similar to the findings for selective atten-
tion, these age-related differences in alternating and divided
attention can be minimized when simpler tasks are used or
participants are given time to practice (Pellecchia, 2005;
Rogers, 2000; Silsupadol et al., 2009). For example, researchers
found improved walking speed under divided attention con-
ditions after 12 weeks of practice in older adults with difficul-
ties maintaining balance (Silsupadol et al., 2009).
Clinically, these findings are relevant, especially when at-
tention is needed to support other cognitive processes. For ex-
ample, carrying on a casual conversation with a patient who
is learning how to use a walker may negatively affect the ther-
apeutic process because attentional resources are being used
for walking, talking, and the new learning required to use the
assistive device. Removing distractions and allowing the pa-
tient to focus attention on a single task may improve perform-
ance. Once the structured task is being performed at a desired
level, the clinician may then introduce distractions to chal-
lenge the older adult to facilitate greater translation into a real-
world environment, such as a busy home or shopping center.
Several key factors also can affect performance, including
motivation and fatigue. This is of particular relevance for allied
health professionals (e.g., occupational therapists, speech-
language pathologists, physical therapists) who are developing
and implementing treatment goals for patients. To increase
engagement and treatment adherence, it is important to in-
clude patients in the process of developing realistic and mean-
ingful goals that they are invested in practicing and achieving.
INTERPROFESSIONAL PRACTICE
Promoting Optimal Function in Older Adults
With Normal Age-Related Cognitive Changes
Physical therapists, occupational therapists, and speech-
language pathologists have a unique opportunity to
facilitate optimal cognitive functioning in older adults. In a
monograph discussing cognitive enrichment of older adults,
Hertzog and colleagues (2008) outline several considerations
that should be made regarding individuals’ behaviors and
environmental contexts. One area in which rehabilitation
professionals must be sensitive is attitudes and beliefs
toward aging because one’s perception about aging can
influence the trajectory of the aging process. For example, if
an older adult believes aging is predominantly a negative
process, this can affect her performance on cognitive tasks. It
is important that therapists discuss aging within a life-span
developmental framework, highlighting the gains, losses,
and stability.
✺ PROMOTING BEST PRACTICE
Attentional Resources
Attentional resources can be affected significantly by
motivation and interest. Imagine being at a theater watching
a movie you are not particularly interested in. During the
movie, you are distracted by various things (the gentleman
loudly eating his popcorn behind you; the teenager talking
on her phone). The distractions make you even less
interested in watching the movie, and you end up falling
asleep. Now imagine going to see a movie that you are
extremely interested in. Even with the same environmental
distracters present, you direct all of your attentional
resources to the movie while ignoring the irrelevant sensory
input. After the lights come on you think, “I can’t believe the
movie is already over.” This latter scenario illustrates how
motivation and fatigue can influence how attentional
resources are used and how performance (in this case,
watching the movie versus falling asleep in the theater)
can be affected. During a therapy session, you should always
ask yourself which movie is your patient viewing? Is your
patient actively involved in his plan of care, including goal
development and goal setting? If not, your patient is less
likely to actively engage in the therapeutic process, become
easily distracted and less motivated to practice.
Memory
The term “memory” can be used to describe various types
of memory, including sensory memory, short-term memory,
working memory, and several long-term memory systems,
4605_Ch07_091-108 31/10/17 11:55 AM Page 97
including declarative and procedural long-term memory.
Extensive research has been conducted on the effects of age
and one’s memory (e.g., Hess, 1996; Smith & Earles, 1996)
that reflect gains, declines, and stability. The following sec-
tions discuss each of the aforementioned memory systems
in more detail.
Sensory Memory
Sensory memory is described as a preattentive memory
system that stores incoming sensory information for a very
short duration (less than 250 milliseconds) before transferring
the information to short-term memory or dropping the in-
formation from the system. It is referred to as “preattentive”
because we are not consciously aware of the information. By
the time you are aware of any given stimuli (e.g., a loud noise,
seeing the word “cat”) the information has already been trans-
ferred to short-term memory. Overall, research has found
minimal to no age-related differences in sensory memory
(Smith & Earles, 1996).
Short-Term Memory
Short-term memory stores information. Seven (± two)
stimuli can be stored for approximately 15 to 20 seconds
without rehearsal (Miller, 1956). “Without rehearsal” is an
important distinction because a true measure of short-term
memory does not enable participants to use any strategies,
such as repetition, for remembering information. To assess
short-term memory, participants are typically given a simple
memory task where they hear a list of stimuli (e.g., words or
numbers) and must recall as many stimuli as possible imme-
diately or after a short amount of time has elapsed. For ex-
ample, an individual is verbally presented a list of words at a
rate of one word per second (e.g., dog, squirrel, fish, rabbit,
elephant, ant, giraffe) and asked to immediately recall as
many words as possible. Mixed evidence has been found in
terms of age-related difference in short-term memory, with
some studies finding minimal to nonsignificant age-related
differences (Grady & Craik, 2000), whereas others identified
significant age-related differences in short-term memory
(Chen & Naveh-Benjamin, 2012; Fandakova, Sander,
Werkle-Bergner, & Shing, 2014).
Working Memory
Working memory is conceptually distinct from short-term
memory because it stores, maintains, and actively manipulates
information. For example, when you perform the following
math problem in your head, 2 + 3 – 1 × 4, you are using work-
ing memory. Another example is using the preceding list of
animals and mentally rearranging them in size from smallest
to largest. Working memory serves an important role in fa-
cilitating higher order cognitive processes such as language
production and comprehension (Kemper & Mitzner, 2001),
decision-making, problem-solving, and learning (Kausler,
1994; Tulving & Craik 2000). Originally conceptualized by
Baddeley and Hitch (1974), working memory consists of three
interrelated components: the central executive, the phonological
CHAPTER 7 ■ Cognitive Function 97
(or verbal) loop, and the visual-spatial sketchpad. More
recently a fourth component, the episodic buffer, was added.
The central executive processes and manipulates information
from the two lower systems, the phonological loop and the
visual-spatial sketchpad temporarily store and maintain ver-
bal and visual information, respectively. The episodic buffer
has not received extensive investigation but is hypothesized
to provide bidirectional linkage from each of the two sub-
systems within working memory to the corresponding long-
term memory representations. Working memory enables
individuals to save new information into long-term memory
while concurrently being able to store, maintain, and
process information from both visual and verbal outputs.
For example, when you give someone directions how to
drive from one location to another (e.g., school to the mall),
you are using working memory.
✺ PROMOTING BEST PRACTICE
Working Memory
A large body of research has investigated the overall construct
of working memory and has found significant age-related
differences, with younger adults performing better than older
adults (e.g., Baddeley & Hitch, 1994; Hess, 2005; Raz, Briggs,
Marks, & Acker, 1999; Schneider-Garces et al., 2010; Vogel,
Woodman, & Luck, 2001). Findings from a meta-analysis
indicated that as the task complexity or cognitive load
increases, age effects increase as well, with working memory
span tasks (e.g., counting backward by seven) resulting in the
largest age-related effects (Bopp & Verhaeghen, 2005). The
specific underlying mechanisms for these changes are not well
understood; for example, it is not known whether the central
executive, the storage systems (i.e., phonological loop and
visuospatial sketchpad), or both are responsible for these
age-related differences.
From a clinical perspective, therapists must consider how
working memory may facilitate or hinder progress. For ex-
ample, much of our communication with patients, such as a
family or plan of care meeting, relies on spoken communica-
tion. As the volume and complexity of information increases,
it may be more difficult for patients to maintain, organize,
and process all of the relevant information. To minimize this
difficulty, therapists can break up sessions to reduce the
volume of information or use written reminders. Patients and
family members can implement these strategies as well. For
example, using daily reminders may be helpful (i.e., shopping
list, daily tasks, medication adherence checklist), and elimi-
nating background noise and distractions can assist in spoken
communication.
Long-Term Memory
Rather than a single system, long-term memory actually
comprises several types of memory systems that differ on the
basis of the type of information contained and how each sys-
tem is affected during the aging process.
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98 PART II ■ Aging: Body Structures and Body Functions
Declarative Memory
Declarative memory is a verbal-based memory system and
is further divided into semantic and episodic long-term mem-
ory systems. Examples of information stored in episodic
long-term memory are personal, autobiographical memories
such as your first kiss or your 16th birthday party. Episodic
memory also contains information from more recent learning
events. To illustrate, consider the following example. Imagine
you participate in a two-part experiment. For Part 1 of the
experiment, you are given a list of 30 words to remember.
Part 2 of the experiment occurs 1 week later when you are
shown a list of words: 30 from the original list of words (from
Part 1) and 30 new words. Your task is to indicate which
words are from the original list and which are new words. To
successfully complete this task, you will need to remember
the specific learning event from the prior week (i.e., did I
learn this word last week or is it a new word?). Episodic
memory relies on effortful and conscious processing of a par-
ticular memory (or learning episode).
Semantic memory stores general world knowledge that is
not linked to a specific learning episode. Examples include
factual information (e.g., who was the first president of the
United States?), vocabulary (e.g., what does the word “justice”
mean?), linguistic rules (e.g., which sentence is correct: He
ran down the street or He runned down the street?), and so-
cial graces and customs (e.g., waving good-bye, saying hello).
It is hypothesized that memories are initially stored in
episodic memory and then, with additional use, are trans-
ferred and stored in semantic long-term memory once the
specific learning event is lost. For example, you probably do
not remember when you learned the state capital of Ohio was
Columbus. However, children who recently learned this
information would be able to recall this information, in
addition to remembering the specific learning event (e.g., in
Mrs. Strohscher’s class last month during social studies).
Eventually, these students will not retain the specific learning
event and only retain the information (e.g., Columbus is the
capital of Ohio) in semantic memory.
Aging appears to affect episodic and semantic long-term
memory differently. Age-related differences are consistently
found for episodic memory, with younger adults performing
significantly better than older adults (Spaniol, Madden, &
Voss, 2006). These differences are especially evident with
memory tasks that require effortful cognitive processing,
such as recall or fill-in-the-blank tasks compared with tasks
such as recognition, which provides context or cues (Danckert
& Craik, 2013; Hoyer & Verhaeghen, 2006; Nyberg &
Backman, 2011).
The pattern of age-related differences for semantic memory
is quite different compared with that of episodic memory, with
older and younger adults performing similarly or, depending
on the type of task, older adults performing significantly better
than younger adults. For example, on tests of vocabulary ability,
older adults readily outperform younger adults (Verhaeghen,
2003). This gain within semantic memory has been attributed
to the accumulation of knowledge and experience over the life
span. Overall, these data suggest a range of age-related trends
in declarative memory that vary from declines (i.e., episodic
memory) to maintenance and gains (i.e., semantic memory)
across the life span.
Procedural or Nondeclarative Memory
Procedural or nondeclarative memory is a nonverbal-based
memory system that stores information for motor-based skills
and behaviors (i.e., muscle memory), habits, emotional asso-
ciations, priming, and classical conditioning. Retrieval of
nondeclarative memories can occur with little effort or even
conscious awareness. Examples of procedural memory in-
clude playing a musical instrument, riding a bike, or perform-
ing a habitual task, such as brushing your teeth.
Research indicates that nondeclarative memory is fairly
well preserved, with minimal to no age-related declines being
noted (Grady & Craik, 2000; Voelcker-Rehage, 2008; Ward,
Barry, & Shanks, 2013). Age-related differences are more
likely to be found when the complexity of the priming or
motor task increases (Grady & Craik, 2000; Voelcker-
Rehage, 2008). A clear trend from these findings is the role
of task complexity and the subsequent need to use additional
cognitive resources. Compared with older adults, younger
adults seem to more effectively use cognitive resources when
completing difficult tasks compare. For example, driving in
an unfamiliar environment under less than ideal circum-
stances (e.g., night, poor weather, high traffic) could be more
difficult for an older adult due to task complexity and greater
than usual cognitive resources.
Prospective Memory
Prospective memory enables individuals to remember future-
oriented or scheduled tasks without the use of external mem-
ory aids (e.g., written note or list). Examples of prospective
memory include remembering to take medications twice a
day, wearing a brace to bed, stopping at the grocery store,
picking up your dry cleaning, or buying a birthday card for a
friend. Many researchers have hypothesized that prospective
memory should be significantly affected by normal aging
processes due to the cognitive effort required; however, re-
search has found mixed findings depending on the type of
prospective memory task, strategic or automatic (McDaniel
& Einstein, 2011; Mullet et al., 2013; Rose et al., 2010).
Strategic prospective memory requires effortful and con-
scious monitoring of the environment to remember, whereas
automatic or spontaneous prospective memory is usually trig-
gered by an external environmental cue. Studies that have used
prospective memory tasks requiring complex or high levels of
strategic processing result in dramatic age-related differences
(McDaniel & Einstein, 2011; Mullet et al., 2013; Rose et al.,
2010). On the other hand, prospective memory tasks that use
automatic or spontaneous retrieval processes and require less
cognitive resources result in minimal to no significant age-
related differences (McDaniel & Einstein, 2011). For exam-
ple, if an individual needs to stop at the store on the way home
from work, it is more likely that that individual will remember
4605_Ch07_091-108 31/10/17 11:55 AM Page 99
to do so if the store is actually on the route home because this
provides a cue enhancing recall. Evidence suggests tasks rely-
ing on spontaneous retrieval are preserved in older adults;
therefore, providing cues to rely on these automatic processes
could aid older adults with prospective memory tasks (Mullet
et al., 2013).
The clinical implications of prospective memory processes
are far ranging and imperative. Adherence with any health
behavior relies heavily on remembering to complete a future-
scheduled activity. Prospective memory can be supported by
facilitating automatic processing. For example, if a patient
needs to wear a brace to bed, automatic processing can be
facilitated by visual cues, such as laying the brace on the pa-
tient’s pillow to decrease the need for strategic processing.
Higher Order Cognitive Processes
Executive Functioning
Executive functioning is a global term referring to higher
order cognitive processes, such as reasoning, decision-
making, problem-solving, judgment, abstract thought, and
logic. Overall, research findings have found significant
differences between younger and older adults across a wide
range of executive functioning tasks (Goh, Yang, & Resnick,
2012; Neider et al., 2011; Voelcker-Rehage, 2008). For ex-
ample, significant differences between younger and older
adults have been found on reasoning and judgment tasks,
with older adults utilizing less efficient strategies than
younger adults (Neider et al., 2011). Older adults have been
found to be slower in estimation and judgment tasks while
being less likely to revise judgment strategies as new infor-
mation becomes available (Chasseigne et al., 1997; Mutter
& Pliske, 1996).
In general, age-related differences seem to be greater and
more pronounced as task complexity increases and/or as ad-
ditional cognitive resources are needed to successfully com-
plete the task (Voelcker-Rehage, 2008). For example, when
using a dual-task methodology (in which participants com-
plete two cognitive tasks at the same), older adults perform
less well than younger adults (Neider et al., 2011). This dif-
ference is most likely due to the increased cognitive effort
needed to complete two tasks at the same time compared
with the cognitive resources required to complete either task
alone.
Research also has found that various aspects of executive
function may change differentially with age. Goh and col-
leagues (2012) examined different aspects of executive func-
tion in a sample of 148 healthy older adults from the
Baltimore Longitudinal Study over approximately 14 years
with testing every 1 to 2 years. Results found an interesting
pattern of age-related differences and stability across a vari-
ety of executive functioning related–processes. Specifically,
age-related longitudinal declines were found for four types
of executive function related processes (i.e., inhibition, ma-
nipulation, semantic and phonological retrieval, and task
switching), whereas five executive functioning–related
CHAPTER 7 ■ Cognitive Function 99
processes (i.e., abstraction, capacity, chunking, discrimina-
tion, and short-term memory) were maintained or showed
improvements with age.
Although significant differences have been found on lab-
based tasks of executive functioning, little is known about
how these findings translate to the real world for older
adults. The following sections on everyday problem-solving
and everyday cognition explore this important yet under-
studied area.
Problem-Solving and Everyday Problem-Solving
An interesting line of research within the executive function-
ing literature is the research examining problem-solving and
everyday problem-solving. Studies of problem-solving typi-
cally use nonfamiliar, lab-based tasks that lack external va-
lidity, whereas studies of everyday problem-solving use tasks
that resemble real-world activities that have high external va-
lidity. Significant and consistent age-related differences have
been found between younger and older adults for problem-
solving (Hayslip & Sterns, 1974; Reese & Rodeheaver,
1985). Specifically, research has found older adults tend to
use less efficient strategies, persist longer in using erroneous
solutions, and produce more errors than younger adults when
using problem-solving processes during lab-based tasks
(Reese & Rodeheaver, 1985). However, these findings are
based on lab-based tasks that do not necessarily reflect
problem-solving needed for real-world situations (e.g., man-
aging finances, driving, medication adherence). Subsequently,
researchers hypothesized that older adults may not perform
as well on lab-based tasks because these tasks lack meaning
and relevance to older adults and thus potentially reduce older
adults’ motivation. For this reason, researchers have advo-
cated using tasks that resemble real-world situations to assess
problem-solving. One of the advantages of this approach is
the high degree of external validity, as evidenced by the use
of real-world situations and tasks, rather than lab-based tasks
that older adults may not be familiar with or motivated to
participate.
Research findings to date, however, have been mixed
when examining everyday problem-solving tasks (e.g.,
Blanchard-Fields, 2007; Denney, 1989; West,Crook, &
Barron, 1992). Willis (1996) suggests that everyday problem-
solving comprises cognitive and noncognitive factors
(e.g., health status, fatigue levels) and sociohistorical factors
(e.g., occupation, education level) that, taken together, fa-
cilitate older adults’ motivation, engagement, and perform-
ance. A reason for varied findings may be that current
studies have yet to conceptualize everyday problem-solving
within this framework as some continue to use hypothetical
problem scenarios instead of actual real-world scenarios
(Blanchard-Fields, 2007; Diehl et al., 2005). Additionally,
complexity of a problem-solving task (e.g., a single well-
defined answer versus ambiguous problem with multiple
possible solutions) may lead to differing outcomes (Allaire
& Marsiske, 2002). Thus, additional research is needed to
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100 PART II ■ Aging: Body Structures and Body Functions
tease out alternative operational definitions of everyday
problem-solving to best understand the trajectory across the
life span.
Everyday Cognition
Everyday cognition is an important yet relatively new re-
search area that examines how the role of cognition is used
in everyday or usual activities (Allaire & Marsiske, 2002). Al-
though statistically significant findings have been found on a
range of executive functioning lab-based tasks, everyday cog-
nition explores how individuals use cognitive processes in
real-world contexts. For example, the differences found be-
tween younger and older adults on a variety of lab-based tasks
are operationalized and quantified in milliseconds. Addition-
ally, tasks used in cognitive aging research are designed to
overload and tax participant’s cognitive resources, resulting
in decreased accuracy and increased reaction time. Although
theoretically informative and interesting, these results do not
provide information regarding how older adults use cognitive
resources on a daily basis.
In most cases, older adults successfully engage with and
complete everyday activities and tasks because their required
cognitive resources are not overly taxed or exhausted (Park &
Gutchess, 2000; Salthouse and Maurer, 1996; see Fig. 7-1).
Additionally, research has found that older adults compen-
sate for age-related differences in memory and attention
when completing decision-making tasks by relying on their
accrued knowledge and experience with decisions (Li, Baldassi,
Johnson, & Weber, 2013).
Older adults’ ability to successfully use everyday cognition
can be illustrated with research findings pertaining to work
performance. Generally, significant age-related differences
have not been found between younger and older adults in
job performance (Park & Gutchess, 2000; Salthouse &
Maurer, 1996). Park (2000) attributes this to older adults’
ability to effectively use their prior experience and knowledge
FIGURE 71 Balancing a checkbook requires what is called everyday
cognition. Comstock/iStock/Thinkstock
and specific strategies such as teamwork. This ability not only
reflects a gain for elders but also provides support for every-
day cognition as an important area that warrants further re-
search. Sterns and Dawson (2012) outline the importance
of resilience in overcoming changes in basic cognitive and
physical processes to allow for continued success in the
workplace. Additional strategies that facilitate effective job
performance include job sharing, effective workstation de-
sign, and training or retraining (Kanfer, 2009). Further in-
formation about older adults’ work performance can be
found in Chapter 20. These findings also highlight the con-
cept of cognitive reserve, which is discussed later in the chapter
(see “Optimizing Cognitive Aging and Health”), that has
been identified as a key moderating variable in cognitive
aging (Drag & Bieliauskas, 2010).
Conversely as with other domains of cognition, certain
everyday tasks may be more difficult for older adults especially
as task complexity increases. For example, novel activities that
heavily use executive functioning processes may be more chal-
lenging for older adults. A common example can be seen with
driving. Although much of driving is automatic or implicit,
other parts, such as merging onto a busy freeway or finding a
restaurant in a new city at night, require considerable cogni-
tive resources and faster reactions. Specifically, changes in
older adults’ executive functioning and speed of processing
may come into play in these types of real-world situations.
Additional examples of real-world situations that may be
more challenging for older adults include maintaining a com-
plicated medication regime or remembering complex instruc-
tions from one’s physician (Fisk, Rogers, Charness, Czaja, &
Sharit, 2012). Key factors to consider when determining
whether older adults’ everyday cognition and resulting per-
formance may be affected include (1) cognitive processes re-
quired, (2) novelty of the task, (3) complexity of the task, and
(4) amount of prior experience or practice afforded.
Language Production and Speech Comprehension
The higher order cognitive process of language comprises pro-
duction and comprehension processes. Production processes
enable individuals to generate and verbalize language, while
comprehension processes enable individuals to perceive and
understand spoken language. Production and comprehen-
sion processes work in tandem to provide effortless and
automatic processing and understanding of language. Similar
to other cognitive processes, research has found a pattern
of age-related gains, declines, and stability within language
production and speech comprehension. With respect to
comprehension processes, the underlying semantic long-
term memory system required to assist in the understanding
of words and phrases used in everyday language remains
intact, whereas age-related differences can be found for cer-
tain aspects of production. Examples include increased
word-finding difficulty and increased tip-of-the-tongue ex-
periences (in which the individual can almost, but not quite,
recall the desired word). Additionally, significant age-related
differences are more readily found when working memory
4605_Ch07_091-108 31/10/17 11:55 AM Page 101
processes are taxed, resulting in greater cognitive resources
required (Stine, Soderberg, & Morrow, 1996). Older adults
have been found to outperform younger adults in certain
areas of message production and discourse, such as story-
telling, while performing less well in tangential conversation
(e.g., discussing irrelevant family dynamics or past history),
giving directions, or verbosity (Kemper & Kemtes, 2000).
Overall, older adults maintain exceptionally high language
processing skills by relying on contextual features (or top-
down processing), using their well-developed semantic and
linguistic knowledge and listening to the prosody of speech
(Pichora-Fuller, 2008; Stine et al., 1996; Wingfield, 2000;
Wingfield & Stine-Morrow, 2000).
Wisdom
Many of us believe that as we age and gain life experiences,
we develop a deeper knowledge and understanding of our
world, resulting in wisdom. Definitions of wisdom typically
reflect knowledge gained through experience, ability to
understand what others may not, and good sense or judg-
ment (Merriam-Webster, http://www.merriam-webster.com/
dictionary/wisdom). However, operationally defining the
construct wisdom as well as developing reliable and valid
methods for studying wisdom is actually quite difficult, which
has resulted in mixed research findings (Smith & Baltes,
1990). A review study by Sternberg (2005) highlights these
mixed findings with views ranging from wisdom decreasing
with age, to increasing with age, to remaining stable after a
certain threshold (e.g., early 20s). Grossman and colleagues
(2010) found that despite declines in some fluid measures of
intelligence, such as speed of processing and working mem-
ory, older adults performed better than younger and middle-
aged adults on assessments of wisdom. On the other hand,
the Berlin Wisdom model (Baltes & Staudinger, 2000;
Mickler & Staudinger, 2008) posits that wisdom appears to
plateau around age 20 and remains fairly stable until declining
at age 75. Future research should focus on developing a stan-
dard definition of wisdom in addition to valid measures be-
cause this would provide a better understanding of how
wisdom changes across the life span.
Expertise
Expertise is defined as having a high level of skill or knowl-
edge in a particular area and reflects problem solving, rea-
soning, and memory (Masunaga & Horn, 2001). Overall,
research investigating the role of experience and expertise
on older adult performance has found a pattern of mainte-
nance. Several studies have shown the buffering effects of ex-
pertise in areas such as typing (Salthouse, 1984), playing the
piano (Ericsson, Krampe & Römer, 1993), and playing chess
(Charness & Bosman, 1994). These studies demonstrate the
concept of plasticity in cognitive processing and warrant fur-
ther research addressing “how” and “what” components of
skill and knowledge acquisition are responsible for developing
expertise. Research is also needed to further understand how
CHAPTER 7 ■ Cognitive Function 101
expertise functions as a potential buffer or moderator of
age-related differences.
Additional Cognitive Processes
Implicit and Explicit Processing
Implicit and explicit processing are two types of cognitive
processes used to learn (or transfer) information from short-
term to long-term memory and to retrieve information from
long-term to short-term memory. Implicit processing is un-
intentional, occurs without awareness, and is effortless, re-
quiring minimal cognitive resources. Explicit processing is
intentional, occurs with awareness, and is effortful, requiring
moderate to substantial cognitive resources. To illustrate both
processes, imagine learning the lyrics to a song. You could
learn the words to a song implicitly by listening to a song on
the radio multiple times. Over time you would, without
awareness, have learned the lyrics to the song. Or you could
use explicit processing by deliberately practicing the song
lyrics every night for 30 minutes. Other examples of tasks
that use implicit processing include driving a familiar route,
playing an instrument, or reciting the alphabet. Driving in
an unfamiliar location, learning to play an instrument, or
reciting the alphabet backward would require effortful and
explicit processing. In general, novel tasks require explicit
processing, and tasks that have been learned or practiced
repeatedly switch to implicit processing.
Overall, research has found age-related differences in tasks
and activities that require explicit processing and little to
no age-related differences for tasks and activities that require
implicit processing (Kessels, Boekhorst, & Postma, 2005;
Rieckmann & Backman, 2009; Verneau, van der Kamp,
Savelsbergh, & de Looze, 2014). Focusing on familiar tasks
during rehabilitative interventions may improve outcomes as
they rely more on implicit versus explicit processing. For ex-
ample, practicing the individual’s actual dressing and groom-
ing routine may be more beneficial than manufacturing novel
tasks or activities that only simulate these tasks.
Intellectual Abilities
Conceptually, intelligence comprises two types of abilities:
fluid intelligence and crystallized intelligence. Fluid intelli-
gence is the ability to use abstract reasoning, flexibly shift
one’s mental set, and initiate and complete purposeful action.
It includes the creative and flexible thinking required in novel
situations and can be directly affected by physiological struc-
ture changes (Horn & Cattell, 1967). Crystallized intelli-
gence is the accumulation of knowledge, experience, and
acculturation that is highly representative of individual differ-
ences (Horn & Cattell, 1967).
Research findings suggest several trends with regard to in-
telligence over the life course. Intellectual ability, taken as a
whole, remains relatively stable and constant throughout the
life span. However, the components of intelligence, fluid and
crystallized, change with age. Specifically, fluid intelligence
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102 PART II ■ Aging: Body Structures and Body Functions
exhibits an interesting pattern in which ability increases until
age 40 to 50, is maintained until one’s 60s and 70s and then
begins to decline (Hayslip & Sterns, 1979). This pattern of
change is of interest because it does not reflect a general linear
decline across cognitive abilities that is reflected in earlier
studies of cognitive aging that used cross-sectional research
designs. For example, across the following cognitive processes
(fluid and crystalized), numeric facility and perceptual speed
tend to decline first, followed by inductive reasoning, spatial
orientation, and verbal memory around age 67. Crystallized
intelligence, on the other hand, increases throughout the life
span and is relatively well maintained in old age. For example,
verbal ability is well preserved across the life span and begins
to demonstrate age-related declines around age 81 (Hayslip
& Sterns 1979; Schaie, 2005). Overall intellectual abilities
remain relatively stable across the life span as the declines
evident with fluid abilities are balanced by the gains found in
crystallized abilities.
It is important to briefly mention what researchers have
termed terminal decline, which is a significant decline in cog-
nitive functioning that occurs several years prior to death for
some individuals. Terminal decline can be due to neurological
difficulties and also broader physiological changes that occur
as one approaches death (MacDonald, Hultsch, & Dixon,
2011). More research is needed to better understand the un-
derlying mechanisms and how terminal decline may affect
older adults’ functioning.
Theories Of Cognitive Aging
Several theories have emerged attempting to explain why and
how certain cognitive processes change and decline across the
life span. We elaborate here on four theories of cognitive
aging that have received the most investigation: (1) speed of
processing (Salthouse, 1996), (2) working memory (Craik &
Jennings, 1992), (3) inhibition (Hasher & Zacks, 1988), and
(4) sensory functioning known as the “common cause” hy-
pothesis (Baltes & Linderberger, 1997).
Speed of Processing Theory
The speed of processing theory (Salthouse, 1996) identifies
generalized slowing as an explanation for age effects on cog-
nition over the life span. This theory suggests that age-related
differences between younger and older adults on cognitive
tasks can be attributed to a generalized slowing or decreased
speed at which individuals are able to process information. It
is theorized that this decrease in processing speed has an
impact on performance across a wide range of cognitive
processes and tasks, such as attention, working memory, and
decision-making.
Initially, researchers theorized generalized slowing ac-
counted for decline across all cognitive processes and that all
cognitive processes declined at the same rate (e.g., Birren,
1965; Salthouse, 1990, 1996). Furthermore, older adult per-
formance could be predicted by knowing how younger adults
perform because the difference was only quantitative (not
qualitative) in nature, with older adults performing x times
slower than younger adults. The implications of generalized
slowing are tremendous for researchers, clinicians, and indi-
viduals. If one assumes this “strong version” of generalized
slowing is correct, the implication is that cognitive aging oc-
curs within a biological-based model, and associated declines
are inevitable; thus, the role of individual differences, inter-
vention, and plasticity would not be applicable.
✺ PROMOTING BEST PRACTICE
Speed of Processing
The extent to which speed of processing accounts for
age-related differences has been investigated extensively.
Support has been found by Salthouse (1996), with 70 percent
of age-related variance on cognitive task performance
explained by speed of processing. However, other researchers
have identified different results when analyzing this data,
resulting in only 7 to 29 percent of variance explained (Sliwinski
& Buschke, 1999). Additionally, several studies have found that
speed of processing alone is not sufficient to explain all of the
age-related differences in task performance (Allen et al., 2001;
Haarmann, Ashling, Davelaar, & Usher, 2005; Hartley et al., 2013;
Wasylyshyn, Verhaeghen, & Sliwinski, 2011). Wasylyshyn and
colleagues controlled for processing speed at baseline but
still found significant age-related differences in higher level
cognitive functioning; therefore, speed of processing alone did
not fully explain the age-related differences between younger
and older adults.
On the basis of these findings, proponents of this view
advocate for a modified version of generalized slowing that
is either task-specific or process-specific (Lustig, Shah,
Seidler, & Rueter-Lorenz, 2009). The implications of a
modified theory of generalized slowing are quite different
from the original conceptualization and allow for differen-
tial rates of change within and across cognitive processes.
Additionally, this modified version of generalized slowing
takes into account the role of individual differences, inter-
vention, and plasticity.
Working Memory
Another domain that has been identified as being responsible
for age-related cognitive decline is working memory (Craik
& Jennings, 1992). As discussed earlier, working memory is
the online processing or active manipulation of information
required during mental tasks. For example, adding up the
total cost of groceries requires both storing and maintaining
information while simultaneously calculating the total cost.
It is hypothesized that working memory declines are in
part responsible for explaining age-related changes in cog-
nitive processing between younger and older adults (Craik
& Jennings, 1992; Hartley et al., 2013; Schneider-Garces,
2010). Hartley and colleagues (2013) found that working
4605_Ch07_091-108 31/10/17 11:55 AM Page 103
memory independently explained age-related changes in
cognitive task performance. Other researchers report a near
perfect association between working memory and executive
functioning while also noting that almost all of the age ef-
fects on episodic memory are removed when accounting for
working memory (McCabe, Roediger, McDaniel, Balota,
& Hambrick, 2010). Additional support for this theory has
been found with neuroimaging studies attributing age dif-
ferences in brain activation during a cognitive task to indi-
vidual variations in working memory span (Schneider-Garces
et al., 2010).
Inhibition
Another theory of cognitive aging is inhibition (Hasher &
Zacks, 1988). According to Hasher and Zacks, when pro-
cessing information, difficulties filtering or actively ignoring
irrelevant information become problematic with age. Ineffi-
cient filtering can overwhelm the cognitive system and make
it difficult to prioritize and process information. It is hypoth-
esized that older adults, compared with younger adults, have
greater difficulty inhibiting distracting or irrelevant informa-
tion, resulting in older adults performing less well than
younger adults.
Researchers supporting the work of Hasher and Zacks have
identified evidence that age-related effects on inhibitory con-
trol are responsible for cognitive aging (Darowski, Helder,
Zacks, Hasher, & Hambrick, 2008; Healey, Campbell, &
Hasher, 2008). For example, in a reading with distraction ac-
tivity, inhibitory control was the significant predictor of per-
formance on cognitive tasks (Darowski et al., 2008). Compared
with other theories of cognitive aging, the effect of age on in-
hibition has been found to be independent from declines in
working memory or processing speed (Pettigrew & Martin,
2014). Lustig, Hasher, and Tonev (2006) found that improve-
ments can be made in older adults’ performance on processing
speed tests when the number of distractions is reduced. In ad-
dition to the behavioral evidence found using assessment tools
(e.g., interference tasks such as the Stroop task), neuroimaging
evidence has supported the difficulty older adults have with in-
hibition during different memory tasks (Reuter-Lorenz &
Park, 2010).
Interestingly, Healey, Campbell, and Hasher (2008)
identified a potential benefit for older adults not engaging
in inhibition processing. Specifically, if information is not
filtered or actively ignored, it is available for later process-
ing. For example, in a negative priming task, an individual
is first asked to ignore an object (or word) and then later is
asked to pay attention to the object (or word). According
to inhibition theory, responding to the object (or word) the
second time should take longer. However, older adults’ re-
action time would not increase because they would not ini-
tially have inhibited the object (or word) (Verhaeghen &
DeMeersman, 1998). Thus, compared with younger adults,
older adults would experience less difficulty in completing
this task.
CHAPTER 7 ■ Cognitive Function 103
Common Cause Hypothesis
(Sensory Functioning)
Finally, Baltes and Lindenberger (1997) suggest a “common
cause” that is responsible for cognitive differences between
younger and older adults. Sensory functioning, primarily meas-
ures of visual and auditory processing, have been proposed to
explain age-related cognitive declines. Research has documented
the visual and auditory sensory declines associated with aging
(Fozard, 1990; Scheiber & Baldwin, 1996). These declines in
sensory functioning result in degraded (or poorer quality) infor-
mation and are proposed to explain why older adults perform
less well than younger adults on cognitive tasks. According to
the common cause hypothesis, older adults’ cognitive processing
(i.e., decision-making, working memory, abstract thinking) take
longer and/or result in less accurate responses due to degraded
information they have to use. For example, imagine listening to
a presenter at a conference. You are sitting in the back of the
room, and there seems to be a problem with the microphone.
As a result, you only understand 60 percent of what the speaker
is saying. This obviously is not due to your comprehension
(or other cognitive processes) but to the degraded auditory
information you are receiving.
Several studies have found that sensory functioning, in-
cluding visual and auditory acuity, accounted for nearly all
of the age-related variance in cognitive performance
(Kramer, Fabiani, & Colcombe, 2006; Park & Gutchess,
2000). Lin and colleagues (2011) also found that greater lev-
els of hearing loss were significantly associated with multiple
measures of cognition including global mental status, exec-
utive function, and memory. When sensory conditions were
controlled, older adults and younger adults performed
equally across several cognitive tasks, which further strength-
ens the idea that sensory functioning is integral in cognitive
processing (Naveh-Benjamin & Kilb, 2014).
Empirical support for each of these cognitive aging theo-
ries has been found. However, exclusive support for one the-
ory over others has not been found because these theories may
be complementary rather than mutually exclusive (Drag &
Bieliauskas, 2010). Further research is needed to understand
how these four theories independently and inter-dependently
explain age-related differences across cognitive processes. It
also is important to understand why and how certain cogni-
tive processes exhibit maintenance or gains across the life
span. To date, explanatory theories have not been proposed.
Optimizing Cognitive Aging and Health
Positive aging literature points to three specific areas to max-
imize one’s intellectual and cognitive abilities throughout the
life span: physical activity (e.g., aerobic activity, strengthen-
ing, balance, and flexibility activity), mentally stimulating ac-
tivities, and social engagement (Hertzog, Kramer, Wilson,
& Lindenberger, 2008; Kramer et al., 2006; see Fig. 7-2).
Cardiovascular fitness and training, which describes how the
body consumes and moves oxygen throughout the body, has
4605_Ch07_091-108 31/10/17 11:55 AM Page 104
104 PART II ■ Aging: Body Structures and Body Functions
FIGURE 72 Social engagement and physical activity can help
maintain cognitive ability in later life. kzenon/iStock/Thinkstock
been associated with optimizing cognitive health by improv-
ing overall health (e.g., reducing cardiovascular disease) and
potentially delaying or slowing cognitive changes (Hertzog
et al., 2008; Kramer et al., 2006). Several neural protective
physiological changes are associated with cardiovascular training
including increased cerebral flow, which will provide better sup-
ply of oxygen and nutrients to brain tissue; increased level of
brain-derived neurotropic factor, which is an important neural
growth hormone; increased levels of insulin-resistant growth
factor-1, which is another important growth factor in adults;
and increased brain volume (especially white matter or cortical
tissue) in frontal, temporal, and parietal lobes (Hertzog et al.,
2008; Kramer et al., 2006). Research has found individuals who
have a greater level of fitness at baseline are found to demon-
strate lower levels of cognitive decline into older age (Kramer
et al., 2006). Additionally, aerobic training programs have been
identified as effective in improving levels of executive function
and inhibition on a decision-making test (Hertzog et al., 2008).
Through regular interactions during the rehabilitation
process, therapists can integrate these types of activities into
the plan of care as well as educate the patient on continuing
these aspects of cognitive enrichment following formal reha-
bilitation. Participating in mentally stimulating and novel ac-
tivities can include increasing the difficulty of cognitive tasks
during therapy and educating patients to challenge themselves
at home with new and unfamiliar tasks, such as learning a new
language or activity. To be considered mentally stimulating,
tasks should be novel and mentally challenging, as new learn-
ing facilitates neural growth, development, and plasticity
(Draganski & May, 2008). For example, if an individual com-
pleted the newspaper’s crossword puzzle every day for 15 years,
crossword puzzles would not be considered a mentally stim-
ulating activity because it is familiar and well practiced.
Maintaining an active lifestyle that includes regular exer-
cise promotes healthy cognitive functioning and serves as a
neuroprotective buffer (Nussbaum, 2003). Finally, promoting
social engagement can be achieved simply by conducting
therapy interventions in a gym setting rather than individually
in a private room (as appropriate) as well as suggesting differ-
ent activities for the patient throughout the day. Discussing
the importance of social engagement once a patient returns
is also important. Understanding an individual’s daily routine
and social support may highlight areas in which additional
social engagement is needed. Including these additional prin-
ciples routinely into regular rehabilitation sessions as well as
providing comprehensive education for the patient may
greatly facilitate healthy cognitive aging.
Cognitive reserve is the amount of resources left over and
available after an individual engages in a task, which uses up
some of the capacity. Many physiological functions have a
residual or reserve capacity. For example, heart rate reserve
is the difference between one’s maximum heart rate and cur-
rent heart rate, whereas physical reserve capacity is the dif-
ference between one’s maximal ability and current level of
functioning. Individuals can improve and build these reserves.
Just like lifting weights can improve strength, mentally stim-
ulating activities can protect one’s cognitive abilities by build-
ing a cognitive reserve. If an individual can build a large
cognitive reserve, there is less chance that activities of daily
living will surpass available resources. More information
about cognitive reserve is located in Chapter 25.
Individuals who are engaged in regular social activities have
a tendency to have lower rate of cognitive decline over the life
span (Hertzog et al., 2008). Social engagement can range from
regular contact with friends and family through visits at home
to regularly scheduled lunches, to participation in hobbies and
leisure activities with others, such as fitness classes at the com-
munity recreation center or a swimming club. Additionally, it
has been identified that social isolation and lack of perceived
social support can have detrimental effects on psychological
well-being, including development of depressive symptoms, as
well as a more rapid cognitive decline with age (Fiori, Smith,
& Antonucci, 2007; Hertzog et al., 2008; Uchino, 2009).
✺ PROMOTING BEST PRACTICE
Civic Engagement and Cognition
Civic engagement (e.g., volunteerism) and lifelong learning
can be used to assist older adults in maintaining high levels
of social engagement and quality interaction. Wilson (2001)
identifies several motivations for support of lifelong learning:
updating of knowledge, skills, and abilities needed to keep
pace with changes in the workplace and societal upgrades;
allowing older adults to maintain purpose after retirement;
facilitating successful aging through education of disease
prevention and good self-care and health practices.
Volunteering is an avenue used for many purposes depending
on the individual and can be defined as “an activity undertaken
by an individual that is uncoerced, unpaid, structured by an
organization and directed toward a community concern”
(Morrow-Howell, 2010, p. 461).
4605_Ch07_091-108 31/10/17 11:55 AM Page 105
Although it is clear that maintaining a physically active
and mentally stimulating lifestyle with regular social inter-
action assists in facilitating healthy cognitive aging, further
research is needed in each of these areas to better understand
the direct impact and underlying mechanisms responsible.
Additionally, it would be beneficial to identify potential
barriers or facilitators, such as personality traits, demographic
characteristics, or external resources (e.g., social support,
financial resources) for participating and adopting physically,
mentally, and socially engaging health behaviors through-
out the life span.
SUMMARY
Collectively examining the cognitive aging literature, several
interesting patterns emerge that reflect a framework of gains,
declines, and stability. Two intertwined factors for under-
standing these different trajectories include the cognitive re-
sources required and the complexity of the task, which can
range from novel to familiar. These results also highlight the
multidirectionality and multidimensionality found within
cognitive aging. However, there are many unanswered ques-
tions in understanding why and how certain cognitive processes
decline while other processes remain stable or improve through-
out the life span.
One of the more difficult challenges faced by researchers,
clinicians, and policy makers is how best to interpret and
translate research findings to real-world situations, clinical
protocols, and policies. As discussed earlier, lab-based findings
are informative for understanding cognitive aging and testing
specific theories. However, an important question is how
relevant are these results for older adults in their day-to-day
lives. Does it make a difference whether it takes older adults
3 to 5 seconds longer to answer the phone? What about 3 to
5 seconds while driving and needing to stop quickly? These
two examples highlight the complexities in translating basic
research findings to real-world situations and clinical practice.
Understanding the complex pattern of cognitive aging can
facilitate the development and implementation of training
programs and interventions. Organizations and individuals
in management positions could use this information to de-
velop appropriate training programs that facilitate older
adult learning, selection procedures that do not discriminate
against older adults, and promotion systems that are fair
(Sterns & Dawson, 2012). Policy makers are in a unique po-
sition to use cognitive aging research findings to promote
funding for additional research and enact legislation that sup-
ports and accommodates individuals as they age. Mental
health, medical, and rehabilitation professionals can greatly
benefit from this information as it applies to treating and
providing services to older adults. In the rehabilitative setting,
clinicians can use this information to either simplify or pro-
vide more challenging tasks for patients.
The population of aging adults is unique and requires a
thorough understanding of the life span including healthy
cognitive aging. Additionally, we must understand the
CHAPTER 7 ■ Cognitive Function 105
intricate relationships between cognition and everyday func-
tion as well as being able to interpret relevant findings from
the current literature to best translate this information from
the laboratory to real-world and or clinical settings.
CASE STUDY
Mrs. Elaine Thomas is a 65-year-old who lives alone in a
single-story condominium located in a suburban region.
She has two adult children, one of whom lives within
15 minutes; the other lives out of state. Mrs. Thomas
recently retired from her job as a second-grade teacher.
She is very independent and does not have any serious
chronic health conditions. Although she has prepared
financially for her retirement, she doesn’t know exactly
how she should spend her time. She wants to remain
physically and mentally active and engaged. She does
crossword puzzles, swims 3 times a week, and socializes
with friends and family at least once a month.
Questions
1. Do Mrs. Thomas’s children have cause for concern?
2. Please provide rationale for your answer.
3. On the basis of her presentation, what recommend-
ations would you have for Mrs. Thomas and her family?
Critical Thinking Questions
1. What are the methodological concerns facing
researchers in adult development and aging? What
are the strengths and limitations of cross-sectional
and longitudinal research designs?
2. Discuss the importance of using the four tenets to
study and understand cognitive aging.
3. Describe the normal effects of age on memory. How
might these changes affect the treatment approach in
a rehabilitative setting?
4. Discuss how older adults remain functionally inde-
pendent in a community-dwelling environment.
5. How would you describe the process of healthy
cognitive aging to someone who is not familiar with
the research literature?
6. Discuss two basic theories or mechanisms that have
been proposed to account for age-related cognitive
decline. Are these theories (or mechanisms) mutually
exclusive? Why or why not?
7. What advice would you give to a middle-aged
individual (or anyone for that matter) wanting to
maintain an optimal level of cognitive functioning as
he or she ages?
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106 PART II ■ Aging: Body Structures and Body Functions
8. Considering the discussion of cognitive aging, what
are some possible strategies to implement in the
design of a home exercise program to facilitate
positive outcomes?
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Cardiopulmonary and Cardiovascular Function
“We don’t stop playing because we grow —George
old; we grow old because we stop playing.
LEARNING OUTCOMES
By the end of this chapter, readers will be able to:
1. Describe the age-related changes that are expected
in cardiopulmonary and cardiovascular function.
2. Describe the factors that should be considered in prioritizing
the goals of an intervention for cardiopulmonary and
cardiovascular conditioning and provide the rationale.
3. Outline the focus of the assessment and the measures that
would be most relevant to record based on the older adult’s
needs and wants.
4. Outline an intervention plan vis-à-vis prescribing training for
cardiovascular and pulmonary function as these relate to activ-
ities of daily living and other areas of activity and participation.
5. Describe the precautions that are necessary when assess-
ing and prescribing activities to enhance cardiopulmonary
function.
6. Provide the rationale for deciding whether a maximal test
or submaximal test is indicated.
7. On the basis of the findings of a maximal test or
submaximal test: (a) outline the short-term and long-
term responses expected for the intervention plan and
(b) describe adverse responses the older adult could
exhibit in response to the plan.
Clinical Vignette
Mr. Miciej Kasper, aged 69 years, is a retired college professor.
He was born in Poland and immigrated to the United States
when he was 27 years old. His father died of heart disease.
His mother lived to 88 years and had a history of high blood
pressure. Other than having smoked a pack of cigarettes daily
since he was 16 years old, Mr. Kasper reports good general
health and that he has “never been sick a day in his life.”
1. Although Mr. Kasper currently reports good health,
what are the implications of his history on your assess-
ment and decision-making?
2. Like many people, Mr. Kasper may have long-
established beliefs and practices about health and
well-being. How will you identify and consider these
in your short- and long-term intervention plan?
CHAPTER 8
Elizabeth Dean
Bernard Shaw (1856–1950)
”
T his chapter focuses on the health of older people with
special reference to the cardiopulmonary and cardio-
vascular systems. In contemporary rehabilitation practice,
occupational and physical therapists appreciate the need to
consider context, given that the lungs and heart do not func-
tion independently of the person in whom they reside. This
topic is discussed in relation to the World Health Organi-
zation (WHO; 2001) definition of health and the Interna-
tional Classification of Functioning, Disability and Health
(ICF), which frames the importance of physical activity with
respect to what an individual needs or wants to do, and his
or her capacity for activity and participation. Physical activity
and exercise are key to offsetting age-related changes and
maximizing function and health-related quality of life of
older people. Physical activity and exercise reduce illness and
disability, and their impact and may mitigate side effects of
medical treatment. Considering the needs of older adults,
the exercise-based means of assessing cardiopulmonary and
cardiovascular status are described across the spectrum of
meeting minimal requirements for performing daily activi-
ties, to having superior reserve capacity for increased physical
capacity and functional independence, and potentially ath-
letics. Irrespective of age, people have exercise conditioning
potential that can be maximized, even in the presence of
most chronic health conditions. Because exercise capacity is
influenced by environment, ways in which an older person’s
environment might be modified to increase physical activity
and reduce hazards—that is, by paying attention to contex-
tual factors (environmental and personal in the ICF)—are
outlined. The focus in this chapter is on changes associated
with normal aging and on assessment and intervention de-
signed to assist older adults in maintaining and enhancing
cardiopulmonary function that supports function.
Increasingly, physical and occupational therapists work
with well older adults—that is, those who, even if they have
one or more chronic medical conditions, live in the commu-
nity and engage in a range of daily activities that are impor-
tant to them. To maximize the function of such individuals,
therapists need to understand the impact of the older person’s
health behaviors, including nutrition, physical activity, and
smoking, on the older adult’s presentation, on the natural
109
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110 PART II ■ Aging: Body Structures and Body Functions
history of the condition(s), responses to intervention, and
long-term functional prognoses. A baseline of these health
behaviors provides the backdrop for the functional conse-
quences of other conditions for which the older adult may be
seeing the rehabilitation professional.
AROUND THE GLOBE: The Pandemic of Lifestyle-Related
Noncommunicable Diseases
Unhealthy Western lifestyles (e.g., sedentary, diets high in processed
foods) that are common in high-income countries are being
adopted by people in low- and middle-income countries, such that
lifestyle-related noncommunicable conditions are now appearing
in the top 10 contributors to premature death (WHO, 2012).
Interrelationships Among Structure
and Function, Activity, and Social
Participation: Cardiovascular and
Pulmonary Function
On the basis of the WHO’s definition of health, the ICF
(WHO, 2001) has become an important framework and basis
for assessment and defining goals and outcomes of intervention
for occupational and physical therapists (Chapter 2). Each in-
dividual is viewed as a whole such that his or her participation
and quality of life are viewed distinctly, as well as interdepend-
ently with the capacity to perform activities and the integrity
of anatomic structure and physiologic function. Specifically,
activity includes activities of daily living (ADL) and those ac-
tivities associated with participation and engagement in living.
The ICF framework has particular relevance in health care
today. First, this framework is consistent with a model of
health versus illness care. Second, it is consistent with contem-
porary health-care priorities—namely, noncommunicable dis-
eases (NCDs) that are lifestyle-related (i.e., ischemic heart
disease, cancer, smoking-related conditions, hypertension and
stroke, diabetes, and osteoporosis). The WHO has decreed
that these conditions and their associated social and economic
burdens are largely preventable (WHO, 2012). These condi-
tions have achieved epidemic proportions. Furthermore, peo-
ple are developing comorbidities earlier in their lives than in
the past century because of unhealthy lifestyles. Because the
biomedical model can maintain people’s lives when threatened,
people today experience long periods of morbidity, and partic-
ularly end-of-life morbidity, unless they pay attention to their
lifestyle practices (specifically, nutrition, physical activity and
exercise, smoking, sleep, and stress). Prolonged morbidity pro-
gressively limits a person’s participation or quality of life.
With the increased predominance of lifestyle-related
NCDs in high-income countries and the increasing predom-
inance in low- and middle-income countries, and the
chronicity of these diseases, there has been growing interest
in quality-of-life issues.
Age-Related Changes in the
Cardiopulmonary System
and Its Function
Aging has a direct effect on each component of the car-
diopulmonary system which includes the airways, lung
parenchyma and its interface with the circulation (the alve-
olar capillary membrane), chest wall, and respiratory mus-
cles. Ventilation of the alveoli and oxygenation of venous
blood depends on the anatomic and physiologic integrity
of these components (Koeppen & Stanton, 2010; West,
2012).
Airways
Aging is associated with a decrease in elastic tissue and an
increase in fibrous tissue throughout the body’s systems in-
cluding the cardiopulmonary system. Because the large air-
ways are predominantly rigid connective tissue, few changes
with aging are reported. Because the medium and small
airways are composed of less connective tissue and more
smooth muscle, a decrease in the elasticity of these structures
occurs with aging, resulting in reduced structural integrity of
the tissue and increased compliance (compliance = ⌬ volume/
⌬ pressure; increased compliance = increased stiffness).
Lung Parenchyma
The lung parenchyma is composed of spongy alveolar tissue
that is designed to be ventilated and provide an interface with
the pulmonary blood through the alveolar capillary mem-
brane, which has a large surface area to promote the oxygena-
tion of blood. Age-related increases in connective tissue and
elastin disintegration reduce elastic recoil, the principal
mechanism of normal expiration. The loss of normal recoil
contributes to uneven distribution of ventilation, airway clo-
sure, air trapping, and impaired gas exchange. The net result
of these changes is a decrease in alveolar surface area, hence
reduced efficient gas exchange.
Alveolar Capillary Membrane
The alveolar capillary membrane is uniquely designed to op-
timize the diffusion of gases between the alveolar air and the
pulmonary circulation. The diffusing capacity, the ability of
oxygen (O2) to diffuse from the alveolar airspaces into the
pulmonary capillary, progressively declines with age and has
been attributed to reduced alveolar surface area, alveolar
volume, and pulmonary capillary bed.
Chest Wall
The chest wall is composed of the structures separating the tho-
rax from the head and neck, the diaphragm separating the tho-
rax from the abdomen, the rib cage, the intercostal muscles,
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CHAPTER 8 ■ Cardiopulmonary and Cardiovascular Function 111

and the spinal column. With age, the joints of the thorax
become more rigid, and cartilage becomes calcified; hence, the TABLE 81 ■ Age-Related Changes in the Cardiopulmonary
chest wall becomes less compliant. The chest wall becomes bar- System and Its Function
rel shaped, the anteroposterior diameter increases, and the nor- MORPHOLOGICAL AND
mal three-dimensional motion of the chest wall during the STRUCTURAL CHANGES FUNCTIONAL SIGNIFICANCE
respiratory cycle is diminished.
Thorax
Calcification of bronchial ↑ Resistance to deformation of
Respiratory Muscles and costal cartilage chest wall
↑ Stiffness of costovertebral joints ↑ Effective use of accessory
The diaphragm, the principal muscle of respiration, tends to respiratory muscles
flatten with age-related hyperinflation of the chest wall, re- ↑ Anteroposterior diameter ↓ Tidal volume
↑ Wasting of respiratory muscles ↑ Exercise-induced hyperpnea
duced lung compliance and air trapping in the lungs, and is
↓ Maximal voluntary ventilation
possibly secondary to reduced muscle mass. Loss of respiratory ↓ Force of cough
muscle mass parallels the age-related reduction in skeletal ↑ Risk of aspiration or choking
muscle mass in general. Loss of abdominal muscle strength Lung
reduces the force of coughing, which can contribute to im- ↑ Size of alveolar ducts ↓ Surface area for gas exchange
paired airway mucociliary clearance and aspiration. ↓ Supporting duct framework ↑ Physiologic dead space
↑ Size of alveoli ↓ Elastic recoil
↑ Mucous glands ↓ Vital capacity
Net Effect of Age-Related ↑ Alveolar compliance ↓ Inspiratory reserve volume
Cardiopulmonary Changes ↑ Expiratory reserve volume
↑ Functional residual volume
These anatomic changes give rise to predictable physiologic and residual volume
or functional changes in pulmonary function after the car- ↓ Ventilatory flow rates
↓ Distribution of ventilation
diopulmonary system has matured (see Table 8-1). Respira-
↑ Closure of dependent airways
tory mechanics that largely reflect the resistance to airflow ↑ Arterial desaturation
and the compliance of the chest wall and lung parenchyma ↑ Resistance to airflow in small
are altered with aging. Specifically, both airflow resistance airways
and lung compliance increase. With respect to cardiopul- ↓ Pulmonary capillary network
↓ Distribution of perfusion
monary function, forced expiratory volumes and flows and
↑ Impaired diffusion capacity
inspiratory and expiratory pressures are reduced. Functional ↑ Fibrosis of pulmonary
residual capacity and residual volume are increased. These capillary intima
effects are further accentuated in recumbent positions. Arte- ↓ Ventilation to perfusion
rial oxygen tension and saturation are also reduced linearly matching
with age. Thus, progressively over the life cycle, the lung be-
Data from Koeppen & Stanton (2010) and West (2012).
comes a less efficient gas exchanger.

Age-Related Changes in the Heart

Cardiovascular System and Its Function
The cardiovascular system is composed of the heart and vas-
culature. The left side of the heart is responsible for pumping
blood that has been oxygenated in the lungs throughout the
body to all the cells of the organ systems via the arterial vas-
culature. The venous vasculature is responsible for returning
blood that has been partially deoxygenated and contains
metabolic waste products, including carbon dioxide, to the
right side of the heart when it is pumped through the lungs
to be reoxygenated. Other metabolic waste products are
cleared as the blood flows through the kidneys, gut, and
liver. Clearance of such wastes and cellular debris is also fa-
cilitated by the lymphatic drainage system. Although loss of
efficiency of the cardiovascular and lymphatic systems may
occur with age, high levels of functioning of these systems
can be maintained throughout the life cycle when lifestyles
are optimized.
Electrical Behavior
Age-related fibrotic changes in the heart’s specialized nerve
conduction system may result in abnormal cardiac impulses.
Electrocardiographic irregularities such as premature ven-
tricular contractions, atrial fibrillation, and heart blocks are
common in people over 65 years of age (Fleg & Lakata,
2008). Medications can often help stabilize or regulate the
heart’s electrical activity; however, artificial pacemakers may
be implanted when medications do not work.
Mechanical Behavior
The heart pumps less effectively with age due to changes in the
mechanical properties of the cardiac muscle, which alter its
length–tension and force–velocity relationships. Additionally,
changes with age in both the integrity of the valves—the atri-
oventricular valves, the pulmonic valve, and the aortic valve—
and variations in the aging cardiopulmonary and cardiovascular
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112 PART II ■ Aging: Body Structures and Body Functions

systemic circulations can result in less efficient pumping action

of the heart (Strait & Lakatta, 2012). Histologically, the heart TABLE 82 ■ Age-Related Changes in the Cardiovascular
tissue becomes fattier, and both heart mass and volume in- System and Its Function
crease. Amyloidosis, a histologic feature of aging observed in MORPHOLOGICAL AND
many organs including the heart and vasculature, is character- STRUCTURAL CHANGES FUNCTIONAL SIGNIFICANCE
ized by the progressive deposition of amyloid protein. This
waxy protein infiltrates tissue, rendering it dysfunctional. In Heart
↑ Fat constituents ↓ Excitability
general, the walls of the heart become more compliant with ↑ Fibrous constituents ↓ Cardiac output
age. The myocardial fibers no longer contract at optimal points ↑ Mass and volume ↓ Venous return
on the length–tension or force–velocity curves, which reduces ↑ Lipofuscin (by-product of glycogen ↑ Cardiac dysrhythmias
the efficiency of myocardial contraction, in turn, the capacity metabolism)
for effective cardiac output. ↑ Amyloid content
↓ Specialized nerve conduction tissue
↓ Intrinsic and extrinsic innervation
↑ Connective tissue and elastin
Blood Vessels ↑ Calcification
Blood vessels require varying degrees of distensibility or com- Blood Vessels
pliance depending on their specific function. The forward ↑ Loss of normal proportion of smooth ↓ Blood flow to oxygenate
motion of blood on the arterial side of the circulation is a muscle to connective tissue and tissues
elastin constituents ↓ Blood flow and risk of
function of the elastic recoil of the vessel walls and the pro-
clots in venous
gressive loss of pressure energy down the vascular tree. The circulation
decrease in elasticity of the arterial vessels with aging may ↑ Rigidity of large arteries ↓ Cardiac output
result in chronic or residual increases in vessel diameter and ↑ Atheroma arterial circulation ↓ Venous return
vessel wall rigidity, which impair the function of the vessel. ↑ Calcification
↑ Dilation and tortuosity of veins
The reservoir function of the venous circulation is dependent
on its being highly compliant to accommodate the greatest Data from Campbell, Caird, & Jackson (1974); Davis (1992); Strait & Lakatta (2012).
proportion of the blood volume at rest. Although the me-
chanical characteristics of venous smooth muscle have been
less well studied compared with arterial smooth muscle, the and in the absence of clinical heart disease (Fleg & Lakatta,
efficiency of its contractile behavior can be expected to be re- 2008), which has major implications for the mechanical be-
duced with aging. Furthermore, its electrical excitability and havior of the heart and the regulation of cardiac output, par-
responsiveness to neurohumoral transmitters tend to be less ticularly when stressed during activity and exercise.
rapid and less pronounced.
Functional Consequences
Blood of Age-Related Cardiopulmonary
The ability of the vasculature to move blood through the vas- and Cardiovascular Changes
cular system and shift volumes of blood between vascular beds
depending on need is diminished with aging; the rapidity Exercise is fundamental to activities that require some degree
with which these changes can be effected is correspondingly of endurance, demanding the maintenance of increased oxy-
reduced. The ability to effect these vascular adjustments in gen transport and tissue oxygenation. Although some types
response to gravity and exercise are tantamount to effective of activity, such as card playing or watching television, require
physical functioning. a greater metabolic demand than is required when one is
strictly at rest, the increased metabolic demand is typically
minimal and not usually sustained.
Net Effects of Age-Related
Cardiovascular Changes
The Functional Performance Threshold
The age-related anatomical and physiological changes of the
heart and blood vessels result in reduced capacity for oxygen The ability to perform ADL to meet the minimum criterion
transport at rest and, in particular, in response to situations im- compatible with personal care and independent living can be
posing an increase in oxygen demand of metabolically active thought of as a functional performance threshold (Young,
tissue (particularly skeletal muscle) for oxygen (see Table 8-2). 1986). Young people have considerable physiological capacity
Therefore, activities associated with a relatively low metabolic and reserve that enable them to perform activities and exercise
demand are perceived by older persons as physically demand- well in excess of the metabolic and physical demands required
ing. Certain activities may no longer be able to be performed, by routine daily activities. With aging, however, changes in
whereas others may require rest periods in between. Many the various organ systems—that is, lungs, heart, nervous sys-
older people have electrical conduction abnormalities at rest tem, endocrine system, and musculoskeletal systems—reduce
4605_Ch08_109-128 31/10/17 5:29 PM Page 113
CHAPTER 8
physiological capacity and reserve. If physical decline results
in a functional capacity below the functional performance
threshold, the minimum criteria for self-care and independent
living cannot be met. Falling below this threshold can be a re-
sult of progressive age-related changes, restricted mobility, or
health condition(s) sufficient to lower an individual’s already
minimal reserves.
The rate of decline in functional capacity with age and the
decline in functional performance are qualitatively different.
Although functional capacity deteriorates linearly with ad-
vancing age, the decrease in functional performance declines
in a curvilinear manner. Thus, an older adult can lose signifi-
cant capacity yet retain considerable function over the years.
Metabolic Demand of Activities
of Daily Living and Exercise
The metabolic demand of an activity can be defined by the
unit called the metabolic equivalent (MET). One MET is
equal to 3.5 mL O2/kg of body weight per minute, the nor-
mal basal metabolic demand for oxygen (American College
of Sports Medicine [ACSM], 2013, 2014). By convention,
the metabolic demands of various activities are expressed as
multiples of the basal metabolic rate. A list of typical activities
with their associated METs can be found in the online an-
cillary materials. Although scarce, research conducted over
the past decade has found that metabolic costs of daily activ-
ities and walking are substantially different in older adults
(Jones, Waters, & Legge, 2009; Knaggs, Larkin, & Manini,
2011) and that having mobility impairments increases meta-
bolic cost (Knaggs et al., 2011). It is thought that poor
efficiency of movement, exacerbated by co-activation of an-
tagonistic muscle groups, is partially responsible for elevated
costs (Mian, Thom, Ardigo, Narici, & Minetti, 2006). These
differences are important for rehabilitation professionals to
consider when prescribing activities and exercise for healthy
and mobility impaired older adults.
It can be somewhat difficult to know the metabolic cost
of some activities that are important to older adults. For ex-
ample, the metabolic costs of sexual activity and the capacity
to work have been relatively neglected in the literature, par-
ticularly with respect to older people. Metabolic cost of sexual
activity in young people depends on the body position and
other factors and is relatively low. Sexual activity is equivalent
to 3 to 5 METs (climbing two flights of stairs or walking
briskly for a short duration). Considering an older person’s
capacity for physical activity (Levine et al., 2012) and the
variations in hemodynamic status that occur during sexual
activity, it can be well tolerated for many older people
(Steinke, 2014). If aerobically conditioned, an older person
can perform sexual activity, such as intercourse, without ex-
cessive heart rate, blood pressure, and overall exertion re-
sponses (Palmeri et al., 2007). However, sexual activity may
be less well tolerated in older adults with cardiovascular con-
ditions leading to heart palpitations, shortness of breath, and
fatigue (Thorson, 2003). To minimize the metabolic demand
■ Cardiopulmonary and Cardiovascular Function 113
and exercise stress, sexual encounters can be timed with med-
ications and with energy peaks during the day, and body po-
sitions can be modified. For example, upright positions may
be better tolerated than recumbency.
Increased longevity and the elimination of mandatory re-
tirement have increased interest in vocational assessment for
older people. The American Thoracic Society (1986) guide-
lines suggest that if a given occupation exceeds 40 percent of
an individual’s peak O2 consumption in an exercise test, an
individual would not be able to tolerate working at that oc-
cupation for prolonged periods. Research is needed to refine
and extend these guidelines for older persons who are con-
sidering changing occupations or reentering the labor force,
both for vocational capacity and safety.
Progressive changes in the cardiopulmonary and cardio-
vascular systems, in conjunction with changes in the capacity
for oxygen and substrate utilization in the musculature, result
in less efficient oxygen transport in the older adult. With ac-
tivity and exercise, the increased metabolic demand for oxy-
gen and substrate requires a commensurate increase in
ventilation and cardiac output. Both maximal ventilation and
cardiac output decline linearly with age, and maximal oxygen
consumption is correspondingly reduced. The extraction of
oxygen at the tissue level, however, which is measured by the
arteriovenous oxygen difference, does not change significantly
with age. The degree of endurance needed to perform ADL
varies depending on the task. Those ADL that are primarily
skill based, such as dressing, toileting, grooming, shaving,
bathing, and feeding, are associated with low metabolic de-
mand and generally require little endurance. Functional lim-
itation in skill-based ADL in older persons tends to reflect
musculoskeletal or neuromuscular deficits rather than diffi-
culties with oxygen transport or gas exchange. However,
ambulation, climbing stairs and hills, yard work, housework,
shopping, gardening, sexual activity, volunteer work, gainful
employment, managing transportation, and social activities
outside the home are associated with higher metabolic de-
mand, require greater endurance and tend to reflect the status
of the cardiopulmonary and cardiovascular systems.
Whether an active lifestyle contributes to or results from
cardiopulmonary and cardiovascular conditioning warrants
discussion. The question can best be addressed by examining
the elements of aerobic conditioning. To elicit an aerobic
training response, the stimulus must be of sufficient intensity,
frequency, and duration and be carried out over a prolonged
period. The critical parameters of the prescription needed to
effect an aerobic training response are the performance of aer-
obic exercise for 20 to 30 minutes at 60 to 70 percent of the
maximum oxygen consumption that is associated with a heart
rate between 70 and 80 percent of the maximum heart rate
for a minimum of 3 days a week for 3 to 6 months (ACSM,
2013). The physiological adaptations that result from aerobic
conditioning reflect an increased ability to transport oxygen
and to use oxygen and metabolic substrates at the tissue level.
Depending on an individual’s age, most typical activities are
not performed at a sufficient intensity, duration, or frequency
4605_Ch08_109-128 31/10/17 5:29 PM Page 114
114 PART II ■ Aging: Body Structures and Body Functions
or over a sufficient time period to effect long-term aerobic
adaptations. However, habitual activity does maintain suffi-
cient physiological adaptation to perform tasks associated with
low metabolic demand. Given that maximal heart rate and
aerobic capacity diminish with age, even skill-based ADL can
become aerobically demanding. For example, routine walks
down hospital corridors can be associated with an intensity of
exercise that exceeds acceptable limits in some older adults
using walkers (Baruch & Mossberg, 1983). This scenario is one
in which older individuals are frequently not monitored.
Routine tasks and activities not considered to be metabolically
demanding must be analyzed at two levels: their relative phys-
iological demand on a given individual and the individual’s
capacity to meet that metabolic demand such that the adapta-
tion that is elicited is both therapeutic and safe.
Cognitive decline has been associated with aging and re-
duced functional performance and independence. Such de-
cline can be associated with reduced midlife activity and may
be offset with regular physical activity and exercise (Behrman
& Ebmeier, 2014). Because of the interdependence of cog-
nitive function and physical performance in older people,
baseline and serial assessments of cognitive capacity (see
Chapter 7) can be informative, particularly when activity and
exercise programs are being prescribed. Keep in mind, too,
that exercise is associated with musculoskeletal factors and
with maintaining gait and balance (Chapters 10 and 11).
Assessing Functional Performance
The objective of the assessment of functional performance is
to determine the older adult’s ability to perform daily activi-
ties. Functional performance reflects the capacity to perform
work. Nutritional status and body weight are important com-
ponents of the assessment of a person’s capacity to perform
work. When nutritional status is optimal, an individual will
be better able to engage in regular physical activity and struc-
tured exercise programs (see Fig. 8-1).
Numerous performance tests have been described in the
literature (Carey & Posavic, 1982; Katz, Ford, Moskowitz,
Jackson, & Jaffe, 1963; Kruiansky & Gurland, 1976; Linn &
Linn, 1982; MacKenzie, Charlson, DiGioia, & Kelley, 1986;
Mahoney & Barthel, 1965). Additional information about
evaluation of performance can be found in Chapter 27 and in
the online ancillary materials. Such tests must be performed
according to standardized criteria to ensure their validity and
reliability. A major liability of these tests is that monitoring is
seldom considered an integral component; however, appropri-
ate monitoring is vital to avoid underestimating the physiolog-
ical demand placed on the older adult. Although fundamental
to normal function, movement constitutes a physiological
stressor and thus is inherently risky, particularly in older per-
sons. Adverse effects may include abnormal heart rate, blood
pressure, and breathing frequency; cardiac dysrhythmias; al-
tered intraabdominal and thoracic pressures; reduced venous
return, stroke volume, and cardiac output; orthostatic intoler-
ance; and blood glucose swings. In turn, the work of breathing
and of the heart may be excessive, which adds further to the
overall metabolic cost of the activity.
Assessing the person’s ability to perform an activity should
be viewed as a unique form of exercise test. Although motor
control and performance may be the focus of ADL reeduca-
tion, important cardiovascular and pulmonary responses
should be monitored at least initially. Baseline measures in-
cluding heart rate and rhythm, breathing frequency, systolic
and diastolic blood pressure, rate pressure product (the prod-
uct of heart rate and systolic blood pressure, which is highly
correlated with myocardial oxygen consumption and the
work of the heart), and perceived exertion provide valuable
information about an older adult’s ability to perform an ac-
tivity. One of the most commonly used scales for rating per-
ceived exertion is the Borg’s scale, and this has been adapted
to other symptoms such as pain and fatigue (Table 8-3).
Occupational and physical therapists need a thorough un-
derstanding of the physiological demands of the activity or
exercise that the older adult is performing, so that the exercise
response can be anticipated and is appropriate. For example,
aerobic activities with incremental work rates, preferably in-
volving the legs, will result in a commensurate increase in
heart rate, blood pressure, breathing depth and rate, and in-
creased perceived exertion. Activities involving primarily the
arms, such as hair combing or snow shoveling (an activity
often associated with myocardial infarction), result in a dis-
proportionate increase in blood pressure and work of the
heart compared with dynamic leg exercise. Arm exercise may
be a justifiable alternative for people with leg limitations
(Fig. 8-2); however, these activities need to be monitored
closely in the older person because of changes in ability to re-
cover from exertion and the potential for longer-term recov-
ery from any injury.
Many ADL require a change in body position, such as get-
ting out of bed, the tub, or a chair or picking up an item from
the floor. Although these activities may not be metabolically
demanding, they lead to significant fluid shifts secondary to the
effect of gravity and have profound hemodynamic conse-
quences. Because the fluid-volume-regulating mechanisms in
older persons may be blunted, dizziness, blackouts, or fainting
can result. Thus, the hemodynamic status of these individuals
needs to be monitored until the therapist is sure that these
activities can be safely performed. Activities such as getting
out of bed, the tub, or a chair, or getting off the toilet may
appear comparable; however, the mechanisms of orthostatic
intolerance—that is, postural hypotension—associated with
each activity can differ. Getting out of bed in the morning may
be accompanied by morning stiffness, imbalance, slowed vital
signs, slowed autonomic responsiveness, and reduced muscle
pump activity in the legs. Getting out of the tub is associated
with significant peripheral vasodilation from having been in
warm water for a period of time. Thus, adaptation of the normal
fluid shifts will be poorer on assuming the standing position.
In addition, there is enormous drag in lifting oneself out of
water either in the tub or a swimming pool, and increased car-
diac work is required secondary to the postural stabilization.
4605_Ch08_109-128 31/10/17 5:29 PM Page 115
CHAPTER 8
Modfied MyPyramid for Older Adults
FIGURE 81 The modified MyPlate for older adults.
Getting off the toilet may follow a period of autonomic changes
and physical straining and hence may result in reduced venous
return. Orthostatic intolerance associated with getting out of a
chair may reflect fluid shifts and pooling of blood in the ab-
domen and legs during sitting. Finally, orthostatic intolerance
associated with picking an item off the floor may reflect reduced
cerebral blood flow secondary to the sudden movement to the
erect position and the lack of the normal rapid compensatory
response. Observing and monitoring the objective and subjec-
tive responses to changes in body position enables the occupa-
tional and physical therapist to make specific recommendations
aimed at reducing the risk of blackouts, fainting, and dizziness.
■ Cardiopulmonary and Cardiovascular Function 115
Another critical factor that may have significant effects
on an older person’s ability to perform an activity or exercise
is impaired thermoregulation. Older people have a reduced
capacity to thermoregulate and report being hypothermic
(Kemp, Després, Pebayle, & Dufour, 2014), and potentially
have an impaired ability to lose exercise-induced body heat.
The increase in peripheral blood flow to dissipate heat during
activity, especially in a warm ambient environment, may com-
promise cardiac output and blood flow to the working mus-
cles. Failure of blood pressure regulating mechanisms may be
responsible. Activity in warm environments taxes the older
adult to an even greater extent and may exacerbate congestive
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116 PART II ■ Aging: Body Structures and Body Functions

TABLE 83 ■ Subjective Scales of Exercise Responses

PERCEIVED EXERTION BREATHLESSNESS DISCOMFORT/PAIN FATIGUE

0 Nothing at all Nothing at all Nothing at all Nothing at all
0.5 Very, very weak Very, very light Very, very weak Very, very light
1 Very weak Very light Very weak Very light
2 Weak Light Weak Light
3 Moderate Moderate Moderate Moderate
4 Somewhat strong Somewhat strong Somewhat strong Somewhat strong
5 Strong Hard Strong Hard
6
7 Very strong Very heavy Very strong Very strong
8
9
10 Very, very strong/maximal Very, very strong/maximal Very, very strong/maximal Very, very strong/maximal

Note. Based on the Borg Rating of Perceived Exertion scale (Borg, 1982).

Mathias, Nayak, & Isaacs, 1986; Podsiadlo & Richardson,

1991), and the 6- and 12-minute walk test (6- and 12-MWT;
McGavin, Artvinli, Naoe, & McHardy, 1978; McGavin,
Gupta, & McHardy, 1976).

Functional Capacity
Functional capacity refers to the capacity to respond to an ex-
ercise stimulus, maintain the physiological adjustments nec-
essary to sustain aerobic exercise for a period of time (work),
and then recover appropriately from that stimulus on cessation
of exercise. Although this capacity declines with increasing
age, individual differences among older people are consider-
ably greater than among young people. The nutrition and
physical activity and exercise icon illustrates the general prin-
ciples for various levels of physical activity for optimal health
irrespective of age (see Fig. 8-1).

Assessing Functional Capacity

FIGURE 82 Although this man has difficulty walking, he is able to
work toward enhancing his functional capacity, using an arm
ergometer to exercise. (Courtesy of the Geriatric Day Hospital,
Specialized Geriatric Services, Saskatoon Health Region, Saskatoon,
Saskatchewan, with permission).
heart failure and dehydration. The older adult may have signs
and symptoms of lightheadedness, disorientation, instability,
fainting, and heart irregularities. Some common submaximal
tests of functional performance, the validity, reliability, and
safety of which have been established in older subjects, can be
found in the online ancillary materials. These include the self-
paced walking test (SPWT; Bassey, Fentem, MacDonald,
& Scriven, 1976; Cunningham, Rechnitzer, Pearce, &
Donner, 1982), modified shuttle walking test (MSWT;
Singh, Morgan, Hardman, Rowe, & Bardsley, 1994; Singh,
Morgan, Scott, Walters, & Hardman, 1992), bag-and-carry
test (BCT; Posner et al., 1995), timed up and go test (TUGT;
Assessing functional capacity involves determining an indi-
vidual’s peak aerobic power or ability to sustain aerobic ex-
ercise over time. These assessments are typically based on the
results of a peak exercise test or endurance test. Although
exercise testing is a well-established practice for individuals
with cardiopulmonary and cardiovascular dysfunction, as
well as for healthy people, exercise testing and training in
older age-groups is not as advanced. This may reflect the
inherent challenges of dealing with older age-groups related
to the prevalence of multisystem complications such as
arthritis, cardiopulmonary and cardiovascular dysfunction,
hypertension, obesity, diabetes, thyroid problems, depres-
sion, and cognitive impairment. Although peak aerobic
power may be of physiological interest in older people, en-
durance is likely to have greater practical value with respect
to functional capacity overall.
To assess functional capacity in young people, maximum
exercise testing is considered the gold standard. The results of
a maximum exercise test provide a profile of the individual’s
4605_Ch08_109-128 31/10/17 5:29 PM Page 117
CHAPTER 8
capacity to transport oxygen during progressive increments
in work rates and the upper limit of oxygen consumption for
that individual. Although maximum tests have a role in as-
sessing older athletes, they are of less value in assessing older
people in general. Maximum exercise tests are neither feasible
nor necessarily safe for many nonathletic older people, and
the criterion for defining the test as a true maximum test is
unlikely to be achieved in this population. Instead, peak or
submaximal exercise tests are used in older people because
they provide practical information regarding an individual’s
functional capacity and endurance. In a maximum exercise
BOX 81 Principles for Selecting and Administering Submaximal Exercise Tests
PRE-SESSION CHECKLIST
Appropriateness of time of day for activity or exercise for individual
Quality of night’s sleep
Activity before the session (e.g., visitors, tests, agitation, or irritations)
Discomfort or pain
Competing demands
Timing with respect to medications
Types of changes in medications
Lability of vital signs or hemodynamic instability
General well-being
Interest and motivation
ESTIMATE FUNCTIONAL CAPACITY
Estimate based on history and assessment
Possible outcomes: high, intermediate, or low
IF THE ESTIMATED FUNCTIONAL CAPACITY IS HIGH*
Test Options
Peak exercise test
Continuous incremental protocol on treadmill or ergometer
Maximal Exercise Test
Continuous incremental protocol on treadmill or ergometer (Note:
Depending on the individual’s age, history, and assessment, either
type of test may require a physician present.)
ADL
High metabolic demand
Test End Points
Based on the history and assessment, determine relative and absolute
end points that indicate the discontinuation of ADL or exercise
IF THE ESTIMATED FUNCTIONAL CAPACITY IS INTERMEDIATE
Test Options
Submaximal exercise test
Continuous incremental or steady-state protocol on modality
or 6- or 12-min walk test
ADL
Intermediate metabolic demand
Test End Points
As above
IF THE ESTIMATED FUNCTIONAL CAPACITY IS LOW
Test Options
Submaximal exercise test
Interrupted protocol on modality or 3- or 6-min walk test
■ Cardiopulmonary and Cardiovascular Function 117
test, the individual undergoes an incremental protocol until
the maximum oxygen consumption is reached. Submaximal
testing is associated with less risk, is more pleasant to per-
form, and can be readily administered by a knowledgeable
rehabilitation professional.
Principles for selecting and administering submaximal
exercise tests have been described in detail in the literature
(Noonan & Dean, 2000); the clinical decision-making
process is summarized in Box 8-1. The goal of the test needs
to be determined and a decision made as to whether a symp-
tom or sign limited test, or both, or a steady-state exercise
ADLs
Low metabolic demand either interrupted or uninterrupted
Test End Points
As above
MONITORING
Level of monitoring before, during, and after testing determined by
history and assessment
Basic
Heart rate
Systolic and diastolic blood pressure
Rate pressure product (product of heart rate and systolic blood
pressure provides an index of myocardial oxygen consumption and
work of the heart)
Breathing frequency
Chest or breathing discomfort
Perceived exertion
Breathlessness
Fatigue
General discomfort or pain
Other parameters: color, perspiration, orientation, coordination,
stability, facial expression, comfort, and ability to talk
Advanced
EKG
Arterial saturation (noninvasive pulse oximeter)
Respiratory gas analysis† (i.e., oxygen uptake, minute ventilation,
tidal volume, etc.)
Cardiac output (can be determined noninvasively)
Serum enzymes and lactate (require blood work)
ADL = activities of daily living.
*Estimated high functional work capacity: approximately equal to or
greater than that of a healthy normal sedentary person.
†Oxygen consumption studies can provide detailed profile of respiratory,
hemodynamic, and metabolic responses to incremental or steady-state
exercise; this information is used to aid diagnosis of the mechanisms
of exercise limitation and define the parameters of the exercise
prescription.
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118 PART II ■ Aging: Body Structures and Body Functions
test is indicated. Submaximal tests can be used to predict
maximal oxygen uptake of older people with predictions most
often using measures of heart rate and perceived exertion
(Evans, Ferrar, Smith, Parfitt, & Eston, 2015; Smith, Eston,
Norton, & Parfitt, 2015).
Endurance can be tested with either a continuous steady-
state test or a test involving an interrupted protocol for
individuals with very low functional work capacity. To max-
imize exercise test validity and reliability pretest conditions
need to be standardized. The findings of the test can then
be used confidently as the basis for assessment and evalua-
tion, and for comparing the findings of subsequent tests.
Because it may be difficult to standardize pretest conditions,
it is important to record them to clarify what has differed
from one administration to the next. A sample checklist
is provided in the online ancillaries. Differences in one or
more pretest conditions could explain a performance dif-
ference between tests that is independent of a change in
the older adult’s status or response to an exercise interven-
tion. Such differences include change in body mass, differ-
ent medication regime, time of day of exercise test, food
and beverage intake close to exercise time, and quality of
the previous night’s sleep. The recording of the exercise
test is best done systematically on a data sheet. Samples of
these sheets can be found in the ancillary materials online.
Data sheets can record such assessment as a treadmill or
ergometer test or as a self-paced walking test or circuit type
of test. The tester needs to establish what objective mea-
sures and subjective measures will be recorded before the
test. Several baseline measures are recorded every minute,
with the individual standing or sitting quietly and not talk-
ing. These conditions ensure that true resting measures are
obtained. A decision is also made beforehand regarding
what measures will be taken during the test, if any. Mini-
mally, pre- and posttest measures are recorded. Postmea-
sures include those taken during the cool-down period if
a cool down is needed. The older adult remains sitting
quietly at the end of the recovery period or at end of the
active part of the test, so that valid and reliable recovery
measures are obtained. The end of the test is denoted by
when the vital signs and the subjective measures return to
baseline or stabilize at near baseline values. Finally, indica-
tions for terminating an exercise test need to be established
beforehand. Should the test be terminated prematurely, the
reason is recorded on the data sheet—that is, was the test
terminated as expected, and if not, what was the precise
reason?
Considerable research is needed to maximize the validity
and reliability of submaximal exercise testing procedures and
thereby to increase the diagnostic and clinical value of per-
forming these tests in populations in which maximum testing
has fewer indications. Despite their limitations, if carefully
administered and the procedures appropriately documented,
submaximal exercise testing can provide a basis for prescrib-
ing activity and exercise that is both therapeutic and safe for
older people (ACSM, 2013, 2014).
Functional Consequences
of Fitness in Older People
Deconditioning
People tend to become less active as they age. The effects of
deconditioning with inactivity have been well documented
over the past 60 years and are multisystemic (Mackinnon,
2000; Mascitelli & Pezzetta, 2004). Other than reduced res-
piratory muscle strength and endurance, most of the effects
of restricted mobility on the cardiopulmonary system have
been those associated with recumbency and bedrest (see
Fortney, Schneider, & Greenleaf, 2011, for a summary of
decades of research) including the following:
■ reduced lung volumes and capacities, with the exception of
closing volume of the airways, which increases;
■ reduced alveolar-arterial oxygen difference and arterial
oxygen tension;
■ increased resting and submaximal heart rates and blood
pressure;
■ reduced maximal oxygen consumption;
■ reduced total blood volume and plasma volume; and
■ increased blood viscosity, which increases the risk of
thromboembolism (Fortney et al., 2011; Kortebein, et al.,
2008).
The rate of deconditioning has been reported to exceed
that of conditioning (Kortebein et al., 2008), which has par-
ticular consequences in the older individual with less physi-
ological reserve. The effects of deconditioning are accentuated
in older people. Older men and women may decondition dif-
ferently. Men and women residing in a long-term facility
have been reported to differ in terms of physical fitness com-
ponents and functional performance (Singh, Chin, Paw,
Bosscher, & van Mechelen, 2006). Although functional per-
formance was not different between the two sexes, peripheral
muscle strength and eye–hand coordination were reported to
be better preserved in deconditioned men in the facility,
whereas women were more flexible and had superior motor
coordination. These findings have implications for rehabili-
tation assessments and potential interventions indicated.
Conditioning
Training elicits the same physiological benefits with respect to
oxygen transport and oxygen and substrate use and comparable
magnitudes of change in aerobic power and strength in older
persons as those seen in younger people (e.g., Coetsee &
Terblanche, 2015; Mendelsohn, Overend, Connelly, &
Petrella, 2008; Puggaard, 2003; Vaitkevicius et al., 2002), and
these effects are still apparent in individuals with chronic dis-
eases. Submaximal heart rates, blood pressure, and ventilatory
rates are reduced. Stroke volume increases, and oxygen extrac-
tion at the tissue level is also increased. Comparable to young
people, exercise can augment peripheral vasodilatation in older
adults, which supports the preservation of vascular plasticity in
4605_Ch08_109-128 31/10/17 5:29 PM Page 119
CHAPTER 8
this population (Wray, Uberoi, Lawrenson, & Richardson,
2006). Further, aerobic fitness can improve the plasticity of the
brain and, thus, may reduce cognitive as well as physical age-
related changes (Colcombe et al., 2004). These improve-
ments translate into increasing functional capacity over and
above the critical functional performance threshold (Coetsee
& Terblanche, 2015; Mendelsohn, Overend, Connelly, &
Petrella, 2008). Older people, however, may increase their
maximal cardiac output and stroke volume in response to
training, in favor of peripheral adaptation (Spina, Rashid,
Davila-Roman, & Ehsani, 2000).
Even though the absolute metabolic cost is theoretically
constant, older people experience a given activity as more
physiologically demanding than younger people because of
the reduced capacity of their oxygen transport systems and
their musculature to respond to the physical demand. Decline
in the economy of movement in older adults may also con-
tribute (Thomas et al., 2011). Thus, even fit older people
report that activities such as walking, climbing stairs, and car-
rying objects are demanding. With increasing age, these seem-
ingly innocuous activities can be the equivalent of a maximal
effort and may increase an older individual’s heart rate, blood
pressure, and oxygen consumption to maximal values.
The prescription parameters of an exercise program are
based on the results of an exercise test. The clinical decision-
making process involved in defining the parameters of an ex-
ercise program has been described in detail in the literature
previously (Dean & Butcher, 2012a, 2012b) and is summa-
rized in Box 8-2. However, there are two additional principles
of exercise physiology that have particular relevance in pre-
scribing therapeutic activity and exercise for older people—
namely, the principles of training specificity and reversibility.
The human body is extremely efficient in that physiological
adaptation to exercise stress is unique to a specific activity or
exercise. Thus, to improve an individual’s ability to perform
BOX 82 Principles for Prescribing Activities of Daily Living (ADL) and an Exercise Program
PRESCRIPTION OF DAILY ACTIVITIES TO ENHANCE CARDIOPUL-
MONARY CAPACITY
Object
To maximize functional performance by promoting the appropriate
physiological adaptation and task endurance, with maximum
movement economy, comfort, and least risk
Parameters
Type
Based on individual’s needs; prioritize
Intensity
Activity Phases: If feasible, tailor a specific ADL or sequential ADL into:
■ Warm-up (up to 75 percent of the intensity for the steady state)
■ Steady state (performed within target range based on predeter-
mined levels of physiologic or subjective variables)
■ Cardiopulmonary and Cardiovascular Function 119
an activity, that activity should be the primary object of train-
ing. The lower the initial functional capacity, the more sig-
nificant is the principle of specificity. Also, once training has
been discontinued, the training effect does not carry over, and
deconditioning begins immediately. Thus, to maintain a given
level of activity or exercise, the training stimulus must be pre-
sented at the required intensity, duration, and frequency and
over the requisite period of time that is consistent with elicit-
ing physiological adaptation (ACSM, 2013, 2014).
Implications for the Management
of the Care of Older People
The primary outcome of rehabilitation for older people is
maximizing function and occupational performance, of which
physiologic (cardiopulmonary and cardiovascular) capacity
and reserve are significant determinants.
Goals
Two principal goals to maintain cardiopulmonary function
for older people are to:
1. maximize the cardiopulmonary and cardiovascular re-
serve capacity such that this capacity exceeds an indi-
vidual’s critical functional performance threshold with
consideration of physical activity and exercise stimuli
and nutritional status and
2. maximize an individual’s ability to perform ADLs. The
ability to perform ADLs largely requires the physio-
logical capacity to adapt to the upright position and to
move against gravity; these are both central compo-
nents of functional performance.
The basis for these goals is fourfold. First, the older
adult will be able to perform self-care and be functionally
■ Warm-down
■ Recovery (monitored until within 10 percent of baseline values,
and individual appears to have returned to baseline)
■ Lower target limit: None other than pathologically low values
for physiological variables (e.g., consistent with a hypotensive
episode)
■ Upper target limit: Physiological variables not to exceed a
predetermined level of physiological variable (e.g., heart rate,
blood pressure, exertion level, or subjective experience of
exertion, breathlessness, discomfort or pain, fatigue, chest
pain)
Duration
If recovery is less than 30 min, patient can likely tolerate an increase
in duration
Continued
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120 PART II ■ Aging: Body Structures and Body Functions
BOX 82 Principles for Prescribing Activities of Daily Living (ADL) and an Exercise Program—cont’d
If recovery is between 30 min and 3 h, duration is probably optimal.
If recovery is longer than 3 h, duration is likely too long. (This recov-
ery excludes the anticipated cumulative fatigue over the course of
the day.)
Frequency
If recovery is within 30 min, likely too infrequent
If recovery is between 30 min to 3 h, optimal frequency
If recovery is longer than 3 h, likely too frequent
Time Course
Based on adaptation to performance criterion, optimal movement
economy, sufficient cardiopulmonary—cardiovascular conditioning,
velocity, and safety
Progression
Reduce demands of activity if individual is consistently in the upper
limit of the target range; individual can tolerate higher demand
activities if the physiological responses are not consistently reaching
the target therapeutic range.
If low functional work capacity, performance and adaptation are
enhanced with lighter-intensity, shorter, more frequent sessions.
IF ESTIMATED FUNCTIONAL CAPACITY IS HIGH
Object
To maximize functional capacity by promoting physiological
adaptation to an exercise stimulus, with maximum movement
economy, comfort, and safety, and thereby increase functional
capacity reserve above the functional performance threshold
commensurate with the individual’s needs if the estimated func-
tional capacity is high
Parameters
Type
Based on goals and results of the exercise test
Intensity
If normal exercise response and adaptation can be expected, then
steady-state exercise at 70 to 85 percent of peak physiological
parameters on peak test (e.g., heart rate, blood pressure, perceived
exertion)
If abnormal aerobic responses and adaptation to exercise are
expected (e.g., chronic airflow limitation, restrictive lung disease or
heart disease), define target training range on the basis of breath-
lessness scale, exertion, or chest pain provided that physiological
parameters remain within acceptable limits
Duration
20 to 40 min per session
Frequency
3 to 5 times per week
Time Course
In health, 3 to 6 months; but in sedentary persons, change can be
observed in 4 to 8 weeks
Progression
With adaptation, target range is no longer maintained (i.e., heart
rate, blood pressure, and exertion levels consistently below selected
range based on initial exercise test); progression based on a
repeated exercise test to redefine exercise prescription parameters
IF ESTIMATED FUNCTIONAL CAPACITY IS INTERMEDIATE
Parameters
Set between those for high and low
Type
For example, treadmill, ergometer, walking, swimming, water exercises
Intensity
60 to 75 percent of peak work rate achieved on exercise test
Duration
20 min or less
Frequency
One or two times per day
Time Course
With pathology, can expect prolonged course
Progression
Maintain exercise parameters: if exceeding values, cut back; if
consistently below, can increase the duration or frequency
IF ESTIMATED FUNCTIONAL CAPACITY IS LOW
Parameters
Type
For example, walking, water exercise, and general light activity or
exercise
Intensity
Based on heart rate: lower limit = resting heart rate + 0.60 (peak
heart rate from the exercise test resting heart rate)
Upper limit = resting heart rate + 0.80 (peak heart rate from the
exercise test—resting heart rate)
If heart rate inappropriate or invalid measure of exercise intensity,
blood pressure, perceived exertion, or the talk test
Can be used to define the target training range
Duration
Maximize tolerance by maintaining power output constant and
velocity changes to maintain perceived exertion constant
Emphasis on prolonging duration by using an interrupted regimen
of alternating higher and lower demand work, or low-demand work
with rest
Frequency
Several times daily guided by pre-exercise-session check
Time Course
If reduced functional capacity due to deconditioning, adaptation
will be observed daily and weekly
If reduced functional capacity due to physical limitations, it is weeks
to months for central or peripheral adaptation, or both, to occur
Progression
Exercise progressed as soon as the target training parameters are
no longer consistently reached in the exercise session
MONITORING
Refer to guidelines in online ancillary materials
Essential to guide exercise prescription, training, and for general
safety
Note. Supplemental oxygen may be a component of the ADL or exercise
training session.
4605_Ch08_109-128 31/10/17 5:29 PM Page 121
CHAPTER 8
independent. Second, this level of physical performance
will avoid the negative consequences of restricted mobility
and is consistent with health promotion. Third, should the
older adult be exposed to a period of relative inactivity or
become ill, a greater initial functional capacity provides a
greater margin of safety. Detraining effects will be mini-
mized and recovery hastened. Fourth, irrespective of
whether the older adult has a health condition, health-
related quality of life can increase proportionally with num-
ber of healthy living practices adhered to, including regular
physical activity and exercise (Blanchard, Courneya, &
Stein, 2008). Research is needed to elucidate the clinical
reasoning process for determining the level of functional
performance that is needed by a given older person to min-
imize morbidity and mortality, maximize health-related
quality of life, and to elucidate the parameters of an exercise
prescription that would best achieve these outcomes in the
short and long term.
Whether the focus is directed toward functional per-
formance, functional capacity, or both, rehabilitation is
based on a detailed analysis of the factors that contribute to
functional impairment of the older adult, which may reflect
nutritional deficits. A nutritionist may need to be consulted;
however, the occupational and physical therapist need to be
familiar with basic nutritional requirements across the life
span and assess nutritional adequacy at a basic level, making
general recommendations related to nutrition, weight loss,
or both.
The rationale for improving an older adult’s ability to per-
form ADLs and functional capacity appears inherently rea-
sonable. However, the goal of enhancing functional capacity
in an older adult with cardiopulmonary or cardiovascular dys-
function may appear paradoxical and warrants some discus-
sion. Given that the purposes of the cardiopulmonary and
cardiovascular systems are oxygen transport and gas ex-
change, and that these functions are effected through an in-
tegrated system of steps along the oxygen transport pathway,
it becomes clear that augmenting the function and efficiency
of the steps in the pathway can enhance oxygen transport
overall. The net result of improved efficiency of various steps
in the pathway is improved maximum functional capacity.
Individuals with severe cardiopulmonary and cardiovas-
cular dysfunction who cannot achieve an intensity of exercise
that is sufficient to stimulate improved aerobic capacity can
improve their functional capacity through other mechanisms,
including desensitization to shortness of breath, increased
motivation, and improved movement efficiency. Endurance
is a primary objective with respect to optimizing function in
the older person. Although muscle strength, balance, and
coordination are also central to function, these features can
frequently be optimized commensurate with endurance ac-
tivities and exercise. The principle of exercise specificity in-
dicates that optimal adaptation results if the target activity
serves as the training stimulus. Keep in mind that assessment
and intervention should take into account both cardiopul-
monary and musculoskeletal factors (Chapters 10 and 11).
■ Cardiopulmonary and Cardiovascular Function 121
When the desired outcome is the client’s ability to maintain
important daily activities, these capacities are linked, and
often intervention can address them simultaneously.
Assessment
To prescribe ADL or exercises for older people to maintain
or enhance cardiopulmonary function, the mechanisms con-
tributing to impaired function must be analyzed in detail.
Prescribing activity and exercise for older people is as exacting
as drug prescription, in that exercise is inherently risky, par-
ticularly in older age-groups, and needs to be prescribed based
on clear indications. Exercise can be associated with side ef-
fects and has some contraindications. Maximizing therapeu-
tic gain and minimizing risk is the objective and may be
achieved with the application of a five-point system of analy-
sis of function. Collectively, the contribution of these six
factors is established so that the mechanisms of functional
impairment are understood and ADL and exercise can be
prescribed appropriately by directing the intervention at spe-
cific causes of functional impairment and within an individ-
ual’s capacity thereby maximizing oxygen transport required
for daily activities.
The object of the assessment is to determine the individ-
ual’s ability to meet the metabolic demands of the activities
or exercise of interest. Common parameters that are meas-
ured during exercise include heart rate, systolic and diastolic
blood pressure, rate pressure product, and breathing fre-
quency. Oxygen consumption can be measured using a meta-
bolic measurement cart; however, this measure is not
routinely performed. Rather, oxygen consumption is esti-
mated based on tables, provided that the work rate or work
performed can be accurately determined. Other responses
that need to be monitored will depend on the specific indi-
vidual and the particular factors such as deconditioning that
contribute to functional deficit. Although the availability and
sophistication of monitoring equipment has increased, the
rehabilitation professional needs to determine what measures
are of particular interest, clinically relevant, and meet the re-
quirements of being valid and reliable. Because exercise test-
ing is an exacting procedure and must be methodically
executed to be meaningful, the rehabilitation professional
must standardize and appropriately record the pretest, test-
ing, and posttest conditions of the exercise test. The details
of the specific protocol must be established and the times of
work rate changes and measurement recording clearly noted
so that the test can be performed in precisely the same way
on another occasion or by another person, if necessary. There
is greater potential for variability in performing tests of daily
activities than standardized exercise tests; thus, such tests
need to be strictly standardized to maintain quality control,
validity, and reproducibility. At the same time, relatively sim-
ple screening mechanisms may provide guidance in identify-
ing subsequent assessment needs. A pedometer can be useful
in objectively assessing an individual’s activity level. Ten
thousand steps a day is consistent with an active lifestyle
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122 PART II ■ Aging: Body Structures and Body Functions
(Tudor-Locke & Bassett, 2004), and fewer than 5,000 steps
a day is consistent with a sedentary lifestyle (Tudor-Locke,
Craig, Thyfault, & Spence, 2013).
Prescription of Activities of Daily Living and Exercise
Occupational and physical therapists must consider several
factors when prescribing daily activities or exercise for a given
individual. First, the object of the prescription needs to be
defined to enhance functional performance, functional capac-
ity, or both. If the object is to enhance functional perform-
ance of an ADL, then activity is the focus of training. The
activity must be analyzed in terms of its cardiopulmonary and
cardiovascular demands, in addition to whether the individual
is capable of performing the activity from a neuromuscular
and movement function perspective (see Chapters 10 and 11).
The body position assumed in performing an activity and the
use of any assistive device can alter the metabolic demand.
Although some degree of aerobic fitness is desirable in the
older adult, maximal aerobic fitness is not needed to perform
many daily activities and live independently. Rather, activity
performance and safety are the primary considerations. As-
sessment of an older adult’s functional capacity should be
based on the demands expected in the individual’s living en-
vironment. For example, distance and speed requirements in
the community environment vary widely. Distances to walk
at community sites frequented by older adults ranged from
16 to 677 meters on average, and the average speed required
to cross the street in the time of a walk signal varied from
0.44 to 1.32 meters per second (Salbach et al., 2014). An
older adult’s ability to perform an ADL or exercise will also
depend on such factors as the time of day, whether the indi-
vidual has eaten recently, what medications the individual
may be receiving, and general well-being on a given day.
Also, how rested and energetic the individual feels will influ-
ence the ability to perform the activity or exercise. A low-
demand activity that needs to be performed once is less
demanding overall than the same or more demanding activity
that has to be performed multiple times. High-demand ac-
tivities can be effectively interspersed with rest periods. Even
in healthy young people, this type of interval training can sig-
nificantly increase the overall amount of work performed.
Two concepts applied nonspecifically in the clinic are en-
ergy conservation and pacing. Although conserving energy
may be a goal, energy sparing needs to be balanced with en-
ergy expenditure to avoid the deleterious effects of inactivity
and deconditioning. The pace of an activity or exercise affects
the overall metabolic cost. Performing an activity too slowly,
as well as too fast, can increase metabolic cost; therefore, the
pace at which optimal efficiency is achieved needs to be in-
cluded as a component of the prescription. Research is
needed to examine the concepts of energy conservation and
activity pacing so that these concepts can be prescribed on a
rational basis and exploited therapeutically.
The assessment identifies ADL deficits and the type of
exercise program that will improve function. The capacity of
the older adult to meet the metabolic demand, however, must
also be evaluated. An exercise stimulus, whether prescribed
to promote adaptation to ADL or exercise, should involve no
more than 60 to 70 percent of peak effort and be tolerated
without undue fatigue or distress. Metabolism for daily ac-
tivities requires the interplay of anaerobic and aerobic meta-
bolic processes. Sprint-type activities demand rapid release
from sources of oxygen; thus, the anaerobic system of metab-
olism is stimulated. Light activities and activities demanding
more prolonged submaximal endurance require aerobic me-
tabolism. A physiological steady state is achieved during aer-
obic exercise and is more functional than anaerobic training.
Aerobic adaptation can be achieved with a maximum training
intensity of 40 percent of the heart rate reserve [heart rate
reserve = resting heart rate + (maximum heart rate ⫺ resting
heart rate)] in older persons, whereas in young people, a min-
imum training intensity of 60 percent of the maximum heart
rate is required. Anaerobic activities or exercise are seldom
indicated for older people because these can be excessively
demanding physiologically and are associated with greater
risk. In addition, high levels of anaerobic capacity are not as
essential in daily living compared with aerobic capacity. The
recommendations for exercise for older adults by the American
College of Sports Medicine are comparable to those for
adults, with some important distinctions. These are outlined
in Box 8-3 and are expanded on in relevant sections of this
chapter and Chapter 13.
The parameters of activity or exercise prescription include
a warm-up, a steady state, a warm-down, and a recovery
period (ACSM, 2013). Even in prescribing daily activities,
these components are essential if maximal benefit is to be de-
rived with the least risk. The warm-up and warm-down are
critical in priming the cardiopulmonary, cardiovascular, and
musculoskeletal systems for work and recovery, respectively.
An appropriate warm-up will improve the efficiency during
the steady-state portion of the prescription. Monitoring is
BOX 83 Recommendations for Physical Activity
and Public Health in Older Adults
Recommendations for older adults are similar for younger adults
in general with the following distinctions:
■ The recommended intensity of aerobic activity considers the
person’s aerobic fitness
■ Flexibility activities should be included
■ Neuromotor fitness is a particular focus on exercise prescription
■ Balance exercises should be included with a view to minimize
fall risk
■ Physical activity promotion should be part of a comprehensive
program including muscle strengthening, reduced sedentary
activity, risk management as well as moderately intensive
aerobic activity
Source: Garber et al., 2007.
4605_Ch08_109-128 31/10/17 5:29 PM Page 123
CHAPTER 8
important during all portions of the prescription, including
during the warm-down and recovery. These components are
needed to ensure that the physiological adjustments needed
to perform work have returned to baseline conditions (e.g.,
the degradation of lactate and circulating catecholamines).
Also, adequate warm-down and recovery reduce late-onset
fatigue and soreness.
Older people, particularly those with low functional ca-
pacities, can perform large amounts of work in an interval ex-
ercise program. Interval training involves alternating either
relatively high and low metabolically demanding activity or
low metabolically demanding activity and rest periods. Cu-
mulatively, an individual can perform an overall amount of
work that would not be achievable if it was attempted all at
once. In addition, such a schedule is considerably safer and
subjectively tolerated better. Rehabilitation professionals need
to exploit interval-training regimens in a systematic manner
in therapeutic programs for older people.
A balance of activity and rest can also be incorporated
over the course of a day to maximize function. Theoretically,
judicious rest periods contribute to physiological restoration,
enabling the individual to perform more work and activity
over time. The prescription of rest periods warrants as much
attention as the prescription of exercise, given that the neg-
ative effects of excessive rest, as well as exercise, are particu-
larly hazardous in the older person. Rest needs to be viewed
as a therapeutic intervention, and similarly, the appropriate
parameters need to be selected to optimize function. Con-
siderable research is needed to improve the prescription of
rest in conjunction with activity and exercise so that its in-
clusion will maximize work output and minimize the delete-
rious effects of inactivity.
The overall success of the prescription of ADL and exer-
cise reflects not only knowledge of exercise physiology, but
also consideration of psychosocial factors. The attitudes, val-
ues, and beliefs of older persons and those of their families
and peers toward them and their physical status also have a
significant impact on the outcomes of the program.
Physical activity is essential to life. Physical decline related
to aging has been associated with deconditioning. However,
studies related to motivating older adults to be physically ac-
tive are limited. One study examined this relationship in older
Australians and found that primary motivating factors to be
physically active included keeping healthy, liking the activity,
improving physical fitness, and maintaining joint mobility
(Kolt, Driver, & Giles, 2004). Research suggests that brief
advice provided by a health-care professional is an effective
motivator. For example, a single motivational session and
15 booster telephone calls or contacts, delivered by phone or
computer, significantly increased physical activity in adults
aged 55 and older over the course of 1 year and led to a higher
percentage of intervention participants meeting recom-
mended levels of physical activity compared with controls
(King et al., 2007). Brief advice followed by telephone calls
from a trained motivational counselor was found to be ef-
fective in increasing self-efficacy for exercise, an important
■ Cardiopulmonary and Cardiovascular Function 123
element for increasing physical activity (Bennett, Young, Nail,
Winters-Stone, & Hanson, 2008). Similarly, a single session
with a person trained in motivational interviewing, followed
by telephone calls increased exercise in previously inactive
adult cancer survivors (Bennett, Lyons, Winters-Stone, Nail,
& Scherer, 2007).
Special mention needs to be made of walking and strength
training. Walking capacity and a certain level of strength are
fundamental to many daily activities. Although walking may
not be essential, it can often facilitate the performance of a
variety of occupations. Exercise can improve many domains
of functional fitness even among very old, previously seden-
tary individuals, which may in turn facilitate the performance
of desired activities (Simons & Andel, 2006).
Greater attention is being placed on the affective dimen-
sion of exercise. The pleasure or sheer enjoyment factor may
sustain ongoing physical activity more than the goal of being
healthy or fit. Dancing is little prescribed for its therapeutic
benefits, yet has many established benefits. These include im-
proved strength, endurance, balance, and cognition. The role
of listening to music alone can be stimulating and lead to a
sense of overall well-being, which in turn may lead to an in-
dividual increasing his or her activity level.
Smoking is the major cause of preventable death in adults
(Mokdad, Marks, Stroup, & Gerberding, 2004). Thus, smok-
ers need to be identified, smoking cessation resources and
programs need to be made available, and smoking cessation
needs to be a component of management in rehabilitation
programs for older people to maximize functional and long-
term health outcomes. Other common health concerns that
are less often addressed but warrant attention by rehabilita-
tion professionals include sleep quality and quantity, anxiety,
stress and depression (see Chapter 12). Poor sleep and mental
health issues can independently affect functional capacity.
Optimizing sleep or improving an older adult’s mental health
and resilience alone may improve functional outcomes.
INTERPROFESSIONAL PRACTICE
Toward Shared Core Competencies
Although occupational therapists and physical therapists
have unique competencies, health assessment and health
promotion interventions including regular physical activity and
exercise are core shared competencies of the two disciplines
(World Federation of Occupational Therapists, 2014, 2016).
These need to be practiced interprofessionally, as well as
taught interprofessionally to students in their entry-level
programs.
Monitoring
Although they may appear to be performing activities asso-
ciated with low metabolic demand, many older adults will be
working at loads that would be unacceptable in young people
or that alternatively are not within the therapeutic threshold
to elicit the maximal benefit. Given that exercise constitutes
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124 PART II ■ Aging: Body Structures and Body Functions
a risk and that to be therapeutic its intensity needs to be
gauged, objective as well as subjective monitoring should be
a standard component of assessment and therapeutic inter-
ventions. All too often, however, stringent monitoring is neg-
lected in well older adults, or those who have health issues
but are medically stable older people. The inherent risk of ex-
ercise is accentuated in older people for several reasons that
add further to the need to monitor these individuals. Some
older adults with no cardiac history may report ischemic leg
pain at rest or during exercise. These individuals have a high
probability of having cardiac involvement and require cardiac
and blood pressure monitoring. Older people are prone to
high blood pressure and, in general, are more apt to experi-
ence blood pressure irregularities during exercise than young
people. Alternatively, some older people are prone to hy-
potensive episodes. Thus, judicious blood pressure monitoring
is essential. Although many individuals are taking medications
for heart disease and hypertension, monitoring hemodynamic
status is still essential. Some medications, including those to
manage blood pressure, interfere with normal hemodynamic
responses to exercise, in which case other parameters need to
be used. Special provision needs to be made for older adults
with diabetes, and a sugar source must be available in the
event of a hypoglycemic episode associated with increased
activity or exercise.
Safety
Safety issues are a foremost concern when testing and pre-
scribing ADL and exercise. An activity or exercise is pre-
scribed within the anticipated upper limit of an older adult’s
physiological capacity, yet above the lower limit of the ther-
apeutic threshold range, and appropriate monitoring is con-
ducted to verify this. A thorough knowledge of signs and
symptoms of distress during exercise is essential, and these
signs need to be anticipated and taught to an older person
when self-monitoring is appropriate. In addition, older peo-
ple are at risk of falls and fractures; thus, risks need to be
identified and addressed to maximize the older adult’s safety
during exercise (Gillespie et al., 2012). Occupational and
physical therapists involved with prescribing activity or formal
exercise for any population must have current certification in
cardiopulmonary resuscitation. Settings in which well older
adults are provided with fitness interventions should have a
procedure outlined in the event of emergencies, and appro-
priate equipment and facilities in the case of a respiratory or
cardiac arrest. All members of the department need to be
reacquainted with emergency procedures on a regular basis.
Customizing the Environment
to Maximize Function
An astronaut living and working in space is not considered dis-
abled. Modifications with respect to bathing, toileting, wash-
ing, exercising, and working have been made to enable the
astronaut to survive and to be functionally independent in
space. For older people, too, the physical environment can
be optimized to promote function and independence as the
individual continues to age and to maximize safety. Adaptive
equipment, mobility aids, and assistive devices within and out-
side the home need to be reevaluated. In this way, independent
living is promoted, the amount of time the individual is upright
and moving is maximized, and the risk of morbidity, falls, and
injury is reduced. Cultural considerations are also important in
that they provide the basis for each individual’s lifestyle, nutri-
tion, physical activity, and preferences related to these. The
principles underlying the nutrition and physical activity and
exercise icon can be qualitatively modified to meet an individ-
ual’s cultural preferences. Such sensitivity and attention to
cultural issues will enable each individual to adhere to the re-
habilitation specialist’s recommendations related to health and
function. Engagement of the individual’s family and social sup-
port network, and possibly community, is central to consider
when designing exercise programs for older people, given a
supportive environment, socially as well as physically, may be
all that is required to support an active lifestyle.
SUMMARY
The principal goals of intervention to address issues of
normal-aging older adults are to maximize health, improve
the ability to perform daily activities, optimize functional per-
formance, and enhance functional capacity, the reserve of the
cardiopulmonary and cardiovascular systems, and the effi-
ciency of oxygen transport overall. These goals are central to
augmenting an older person’s health-related quality of life
through maximizing functional capacity and independence.
Such an approach raises the older adult’s functional capacity
above the critical functional performance threshold so that
with progressive aging and in the event of illness or restricted
mobility, there is sufficient reserve to minimize functional
deterioration and dependency. Most of what has been asso-
ciated with age-related function loss can be attributed sig-
nificantly to inactivity, disuse, and deconditioning.
Occupational and physical therapists must have a high level
of expertise in the assessment and prescription of activity-
based conditioning and exercise. Such expertise is based on
knowledge of the following:
■ An understanding of the determinants of health, including
optimal nutrition and physical activity, abstinence from
smoking, quality sleep and rest, and managing stress
■ An understanding of the ICF, including contextual factors
and their impact on health and well-being (personal and
environment factors)
■ Healthy age-related changes in the cardiopulmonary and
cardiovascular systems in addition to multiple other systems
that work in an integrated manner to effect functional per-
formance and enhance functional capacity with training
■ Effects of nutritional status and weight on health and
functional capacity
4605_Ch08_109-128 31/10/17 5:30 PM Page 125
CHAPTER 8
■ Exercise physiology in health, the principles of adaptation
to activity and exercise in older people, and the basis for
activity or exercise prescription in this population
■ Environmental factors that can be modified to augment
functional capacity and quality of life
Occupational and physical therapists are in a unique po-
sition to maximize functional performance and functional
capacity in the older adult based on evidence and to identify
areas that warrant additional study. Moreover, on the basis
of a thorough knowledge of exercise physiology in health and
health conditions, rehabilitation professionals have a respon-
sibility to advise other health-care professionals in the pro-
motion of activity and exercise in the older population from
both a therapeutic and a lifestyle perspective.
CASE STUDY
James Hampton is an African American man who is
72 years of age. He has worked in construction most of
his life and now works part time as an office cleaner. Since
he retired from construction, he has been generally inac-
tive and socially disengaged other than attending church
a couple of times a month. He lives with his wife and has
no medical conditions.
Questions
1. Describe the impact of age-related changes in
cardiopulmonary and cardiovascular function on
Mr. Hampton’s health status. Might his race/culture
affect his health risks?
2. Prioritize the goals of an exercise prescription and
provide the rationale, including how you would
engage Mr. Hampton in the goal setting.
3. What are some important precautions to help
Mr. Hampton avoid injury as he increases his
physical activity.
Critical Thinking Questions
1. Describe the interrelationships among structure and
function, activity, and participation for older adults
with respect to the cardiopulmonary and cardiovascu-
lar systems (World Health Organization International
Classification of Function).
2. Explain why the relationships among structure and
function, activity, and participation with respect to
the cardiopulmonary and cardiovascular systems are
often limited in older adults.
3. Compare and contrast changes in cardiopulmonary
and cardiovascular function that you would expect to
see in older adults.
■ Cardiopulmonary and Cardiovascular Function 125
4. Describe changes in cardiopulmonary and cardio-
vascular function secondary to an older adult’s
personal factors, such as age, sex, culture, lifestyle,
nutritional status, leisure, physical activity, and
long-term occupation.
5. Describe the comprehensive skill set related to health
behavior change needed by contemporary rehabilita-
tion professionals working with older adults.
REFERENCES
American College of Sports Medicine. (2013). ACSM’s guidelines for exercise
testing and prescription (9th ed.). Baltimore: Lippincott: Williams &
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Sensory Function and Function
Related to the Skin
Linda A. Hunt
“—Helen
The most pathetic person in the world is someone who has sight but no vision.
Keller, American author, political activist, and lecturer (1880–1968)
LEARNING OUTCOMES
By the end of this chapter, readers will be able to:
1. Explain the relationship between sensory changes that
occur in older adults with resultant physical and behavioral
compensation.
2. Discuss the age-related changes of the eye and its support
structures and of the visual pathway.
3. Describe the auditory system changes associated with
aging, particularly as they relate to the reception of speech
sounds.
4. Identify common age-related changes that occur in taste,
smell, touch, temperature, and pain perception.
5. Relate sensory deficits common in older adults to functional
performance and lifestyle issues.
6. Identify how interprofessional teamwork may help older
adults improve functional performance and address
lifestyle issues.
Clinical Vignette
Shirley Rosen is 75 years old. She retired at age 62 from her
position as a receptionist at an office within walking distance
from her home. When her husband died 5 years ago, she re-
turned to part-time work at her previous place of employ-
ment and shares a position with another woman who works
part-time. When the weather permits, Mrs. Rosen walks the
two blocks to work; otherwise, she drives herself to work.
Mrs. Rosen’s coworkers notice that she frequently asks people
to repeat themselves when on the telephone and that she is
often squinting when looking at the computer. Sometimes
Mrs. Rosen wears a wool jacket during the summer months
because she finds the office too cold with the air conditioning.
Judy Johnson, a long-time friend, has noted that when they
go out to lunch Mrs. Rosen takes small bites of her food, does
not eat all her meal, and seems to have lost pleasure in eating.
Often, when Judy makes a comment to Mrs. Rosen, she will
smile and nod her head, but this response does not match
CHAPTER 9
■ Amanda Stead ■ Bobby Nijjar
”
Judy’s comment. Judy wonders if Mrs. Rosen is developing
dementia.
1. How does the social and physical environment of an
older adult (such as Mrs. Rosen) support or hinder
function in the context of pain or sensory changes due
to aging?
2. What is the role of context (cultural, personal, tempo-
ral, virtual), occupational justice (American Occupa-
tional Therapy Association, 2014), and health and
wellness and how are these affected by sensory changes
due to aging?
3. How might a hearing impairment influence how
others perceive an older adult’s (such as Mrs. Rosen)
cognitive and psychological health?
4. How might impaired sensory conditions affect dietary
choices and, consequently, overall health?
O ur bodies receive sensory information about the phys-
ical world through generalized and specialized sensory
receptors. These receptors begin functioning in utero in most
cases, and, beginning in early adulthood, start a slow and pro-
gressive decline (Cech & Martin, 2002). The “senses” (vision,
hearing, touch, taste, smell) or systems of sensation send in-
formation via a sensory modality in the peripheral nervous
system (PNS) to the central nervous system (CNS), where
the information is comprehended. Perception, a higher sen-
sory function and a middle ground between sensation and
comprehension, enables the organism to receive and perceive
that a stimulus has occurred, process the information, and at-
tach meaning to it.
Our perceptions change with experience as we learn the
likely meaning of signals, and it is these learned perceptions
that may aid us as our sensory receptors begin to decline. The
parietotemporal and parietooccipital areas of the cerebral cor-
tex, important sensory areas, are responsible for the integration,
or association, of information regarding sensory modalities.
129
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130 PART II ■ Aging: Body Structures and Body Functions
Sensory information does not travel through a direct route of
monosynaptic connections from receptor cells to the CNS.
Rather, somatosensory input and sensory fiber tracts travel
through several relay stations, or integrating centers, in the
brain-stem reticular system and the thalamus (Lynch, 2006).
Any neuronal degeneration in these integrative and relay
structures reduces the quality of information received at the
CNS level.
The information contained in this chapter should be
viewed in the context of the many typical changes that take
place in the aging nervous system, as sensory and sensory
integrative changes are a reflection of these systemic changes.
Age-related changes in the sensory systems (summarized in
Table 9-1) can have a major impact on the social, psycholog-
ical, and physical function of the older person. This chapter
describes common changes found in older adults that affect
the senses, specifically:
■ vision and hearing,
■ taste and smell, and
■ the somatic senses—touch, pain, and temperature.
Vision System and Functional
Performance
Due to various structural and function changes in the eye, all
older adults experience a decrease in visual ability as they age.
Even though the older adult may not be acutely aware of the
changes because they occur gradually and people can often
adapt to them, visual problems are of great significance for
TABLE 91 ■ Summary of Effects of Age-Related Sensory Changes on Functional Activities
SENSORY SYSTEM PRIMARY CHANGES RELATED TO AGING
Vision Loss of subcutaneous fat around the eye
Decreased tissue elasticity and tone
Decreased strength of the eye muscles
Decreased corneal transparency
Degeneration of sclera, pupil, and iris
Increase in density and rigidity of lens
Increased frequency of disease processes
Slowing of CNS information processing
Hearing Loss or damage to sensory hair cells of cochlea and
the lower basal turn of the inner ear
Nerve cell diminution of cochlear ganglia
Degeneration in central auditory pathways
Loss of neurotransmitters
Taste Decrease in taste buds
Varicose enlargement
Smell Degeneration of sensory cells of nasal mucosa
Superficial Slower nerve conduction velocities
sensation
Note. CNS = central nervous system.
many older adults. The relationship between vision impair-
ments and activity limitations and participation restrictions,
as well as depression, psychological distress, and decreased
quality of life, has been well documented (Alma et al., 2011;
Brody et al., 2001; Brown & Barret, 2011; DiNuzzo, Black,
Lichtenstein, & Markides, 2001; Horowitz, Reinhardt, &
Kennedy, 2005; Ramrattan et al., 2001; West et al., 2002).
Refer to Chapter 14 for the leading causes of blindness and
low vision in older adults.
Normal Age-Related Vision System
and Vision Changes
Age-related changes occur in the support structures of the
eye, and the visual pathway. See Figure 9-1 for an illustration
of a healthy eye. Changes in the support structures include
loss of subcutaneous fat and decreased tissue elasticity and
tone, all of which may make the eyes appear sunken or result
in redundancy of the skin of the eyelids and eyelid malposi-
tions. Tear production may decrease, causing symptoms of
foreign body sensation and burning and, for some, corneal
ulceration (Esenwah, Azuamah, Okorie, & Ikoro, 2014). In-
creased use of over-the-counter topical ophthalmic solutions
by older adults may mask symptoms of “dry eye” and cause
additional problems in those who have concomitant cardiac,
respiratory, or neurological system pathology. Additionally,
the levator palpebrae superioris eye muscle becomes weak,
causing problems with upward gaze and convergence, which
in turn results in poor eye coordination and difficulty focusing
(Esenwah et al., 2014).
FUNCTIONAL RESULTS
Decreased near vision
Poor eye coordination
Distortion of images
Blurred vision
Compromised night vision
Loss of color sensitivity, especially green, blue, and violet shades
Difficulty with recognition of moving objects, items with a
complex figure, or items that appear in and out of light quickly
Difficulty in hearing higher frequencies, tinnitus
Diminished ability for pitch discrimination
Reduced speech recognition and reception
Loss of speech discrimination
Higher thresholds for identification of substances
Decline in suprathreshold sensitivity for odors
Decreased response to tactile stimuli
Alterations in perception of pain
Adversely affected by thermal extremes
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CHAPTER 9
Lens
Conjunctiva
Cornea
Iris
Pupil
Anterior cavity
FIGURE 91 Internal anatomy of the eyeball.
Canal of Schlemm
(From V. C. Scanlon & T. Sanders. (2007).
Essentials of anatomy and physiology, 5th ed. Ciliary body (muscle)
Philadelphia: F.A. Davis, p. 205, with Suspensory ligament
permission.)
Changes in the eye begin with the cornea, where light first
enters. The cornea thickens, flattens, and becomes less
smooth and more rigid after age 60 to 65 years, causing or
increasing astigmatism, which is a defect caused by a devia-
tion from the spherical curvature, resulting in distorted or
blurred images as light rays are prevented from meeting at a
common focus. These changes also affect the way in which
light is reflected. A ring of opaqueness forms in the cornea
of some individuals and a deposit of pigment occurs in most
corneas (Esenwah et al., 2014). These changes result in a re-
duced corneal transparency that limits the amount of light
reaching the retina and may reduce the visual field. In addi-
tion, decreased corneal sensitivity may cause older adults to
be less aware of injury or infection.
The sclera, pupil, and iris undergo degenerative changes.
The scleral tissue loses water and fatty deposits increase, caus-
ing a yellow cast and decreased opacity (Esenwah et al.,
2014). The pupil decreases in size and becomes more fixed
(senile miosis) due to muscle atrophy that controls dilation
of a pupil. This restricts the amount of light that falls on
retina. Senile miosis may also affect depth perception. Ob-
jects may appear further away in the distance than they really
are, thus senile miosis may affect driving ability when people
attempt to merge in traffic or make left turns. The iris de-
creases in dilation ability because of several processes, includ-
ing an increase of connective tissue, sclerosis of the blood
supply, and muscle weakness (Esenwah et al., 2014). Because
the maximum size of the pupil is decreased, the pupil cannot
dilate to the same extent in response to reduced light, and
thus less light gets to the retina. Thus, a gradual loss of visual
acuity occurs and older adults have more difficulty seeing
clearly in low light situations.
The lens also changes with age, resulting in a decrease in
the eye’s ability to transmit and focus light (Esenwah et al.,
■ Sensory Function and Function Related to the Skin 131
Vitreous chamber
Fovea in macula lutea
Retinal artery and vein
Optic nerve
Optic disc
Retina
Choroid
Sclera
Inferior rectus muscle
2014). Cellular changes cause an increase in density and
rigidity of the lens, which may compromise near and far
vision. These changes in the lens may also contribute to fil-
tering of the color spectrum, resulting in a loss of color sen-
sitivity across the total spectrum but especially for green, blue,
and violet shades. Loss of color sensitivity results in reduced
visual acuity for subtle differences in color shadings.
The central area of the retina, the macula, has a concen-
tration of cone cells that allow for color vision and fine-
detail discrimination, and rod cells that are extremely sen-
sitive to light are responsible for peripheral vision and night
vision. However, rod density has been found to decrease by
up to 30 percent with advancing age (Aggarwal, Nag, &
Wadhwa, 2007). As the retina ages, it gradually loses neu-
rons, and the retinal nerve fiber layer has been found to thin
by 20 to 30 percent with increased age (Lovasik, Kergoat,
Justino, & Kergoat, 2003).
Because of these changes, older adults experience a nar-
rower field of vision (deceased ability to see objects at the cor-
ner of their gaze), have problems with seeing clearly in low
light settings, have problems with light and dark adaptation,
and have increased sensitivity to glare. Older adults may need
three times more lighting than younger people to see clearly
(Hooyman & Kiyak, 2005). Because light and dark adaptation
is compromised, more time is needed for an older adult to ad-
just his or her eyes when entering or leaving a dark room. This
may predispose older adults to falls as they ambulate in rooms
with varying light levels and may cause problems with reading
signs at night. Glare from shiny objects, polished floors, head-
lights, and wet pavements is poorly tolerated for many people
as they age, and older adults need more time to recover from
glare situations. Avoidance of night driving is common due
to glare and light and dark adaptation problems, which in turn
affects participation in evening social activities.
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132 PART II ■ Aging: Body Structures and Body Functions
Between the ages of 40 and 45, the ability to focus on
near objectives is lost due to normal, age-related changes in
the lens, the structure responsible for properly focusing an
image on the retina. As the lens ages, elasticity decreases,
resulting in reduced ability of the lens to change shape (ac-
commodate) in response to the distance of the object being
viewed. Difficulty focusing on near objects, presbyopia,
makes it difficult to read print and perform close-vision
tasks. In addition, accommodation loss further reduces over-
all visual acuity in middle-aged and older adults. Bifocals,
progressive lenses, or reading glasses are often prescribed for
presbyopia.
Evidence suggests that age-related visual problems are
also due to nervous system changes (Elliott et al., 2009).
Older adults are slower at processing visual stimuli and need
to see stimuli longer before accurately identifying them.
Some of these visual perception changes may occur because
of degeneration along the optic pathway or in areas of the
cortex responsible for processing visual information; such
changes result in slowed information processing and in-
creased perceptual inflexibility that affects image judgment
(Guest, Howard, Brown, & Gleeson, 2015). This slowed
processing translates into more difficulty recognizing moving
objects, items with a complex figure or ground, and items
that appear in and out of light quickly. Personal care tasks,
as well as instrumental tasks, such as driving, housekeeping,
and meal preparation, depend on such recognition. Further-
more, changes in the nervous system affect contrast sensi-
tivity (Elliott et al., 2009). In its simplest terms, contrast
sensitivity refers to the ability of the visual system to distin-
guish between an object and its background. For example,
imagine a gray car on a cloudy day (low contrast) versus black
coffee served in a white coffee cup (high contrast). Pedula
and colleagues (2006) found poor visual acuity and contrast
sensitivity linked to accidents, falls, fractures, and mortality.
See Chapter 14 for assessments related to visual acuity, con-
trast sensitivity, depth perception, and field of view. A vari-
ety of communication and environmental strategies and
modifications can be implemented to assist the older adult
(Box 9-1).
BOX 91 Examples of Communication Strategies and Environmental Modifications for Older Persons With Low Vision
■ Use voice or touch to get attention
■ Face the older adult
■ Ensure adequate lighting in the room (note: high levels of
illumination my result in glare)
■ Direct the light source from behind the older adult or on the side
of the better seeing eye for reading or writing to reduce glare
■ Avoid fluorescent lighting
■ Remove clutter and limit number of objects in the environment
■ Avoid visual clutter in the environment (e.g., decrease number
of prints, posters, or pictures on the walls; use solid colors for
background surfaces)
Auditory System and Functional
Performance
More than 5 percent of the world’s population has a dis-
abling hearing loss (World Health Organization, 2015). The
number of adults with a hearing loss has doubled in recent
years, in part because of the aging population. Hearing loss
is the third most prevalent common condition in the United
States: 25 percent of those aged 65 to 74 and 50 percent of
those who are 75 and older have disabling hearing loss
(National Institute on Deafness and Other Communication
Disorders, 2016a). Vision and hearing, along with speech,
contribute to human communication. Like the visual system,
the auditory system likely undergoes many central and pe-
ripheral changes with age. This fact becomes critical when
we consider the importance of hearing for speech and older
adult functional living.
Normal Age-Related Auditory System
and Hearing Changes
Presbycusis, or age-related hearing loss, is a typical degrada-
tion of the hearing sensory system associated with age.
Unique to the hearing system, the classification of “normal”
(with aging) is often associated with some level of impair-
ment and deficit. For younger people, normal hearing is
reflected by a standard decibel level (loudness) at selected fre-
quencies (pitch) based on published normative data. Hearing
loss of older adults is typically reflected in an audiogram as
the bilateral loss of high-frequency sounds. Contextually, this
is manifested as difficulty with hearing very high-pitched
sounds, and if this loss extends to just slightly lower frequen-
cies, the ability to understand speech becomes impaired. This
type of sensory impairment is exacerbated by situational con-
texts such as loud and busy environments or poor positioning
of speakers (Sha, Chen, & Schacht, 2009). Audiologists, pro-
fessionals who test hearing and treat hearing loss, usually di-
vide hearing loss into conductive, sensorineural, and mixed
loss. Conductive hearing loss, or blockage of acoustic energy
■ Enlarge educational/reading materials using a photocopier
■ Provide written instructions on non-glossy paper; use high
contrast print and paper and at least 14-point font; may need
even greater font size for people with very poor visual acuity
■ Use a large black felt marker for written instructions
■ Enhance contrast:
■ Add strips of contrasting tape to the edge of steps
■ Mark light switches with contrasting fluorescent tape
4605_Ch09_129-144 31/10/17 5:28 PM Page 133
CHAPTER 9
that prevents the conduction of sound to the inner ear, may
occur because of problems in the external or middle ear
(Fig. 9-2). External ear infections or too much cerumen (wax)
buildup in the external canal may cause blockage of sound.
The middle ear may be filled with fluid from Eustachian tube
dysfunction or upper respiratory disease, preventing the three
bones of the middle ear from conducting sound efficiently
past the eardrum. Diseases of the middle ear that affect bone
movement, such as tumors, also can affect the mechanical
transmission of energy (Sha et al., 2009). Interestingly, peo-
ple with conductive hearing loss can hear better in noisy sur-
roundings (Kanagala & Berkower, 2003). Conductive-related
problems can often be corrected by ear cleaning, medication,
or surgery. Unfortunately, conduction loss is not the primary
cause of hearing loss in the older population.
Sensorineural hearing loss results from loss or damage to
the sensory hair cells of the cochlea, a pea-sized snail-shaped
organ of the inner ear (Fig. 9-3), or to the nerve cells of the
cochlear ganglion, brain stem tracts, or cortex, or a combi-
nation of any of these. Age-related changes (presbycusis),
medications, noise, acoustic neuroma, and Meniere’s disease
can all cause sensorineural hearing loss. This type of hearing
loss is characterized by better air conduction than bone con-
duction (Kanagala & Berkower, 2003). At the current time,
sensorineural loss due to age-related changes is not cor-
rectable, but compensation with a hearing aid is possible.
The hair cells of the cochlea are slowly lost and may be as-
sociated with the progressive high-frequency hearing loss of
old age (Sha et al., 2009). Damage to the hair cells and de-
generative changes in the organ of Corti, the band containing
hair cells, can occur from exposure to a variety of drugs or
noise. Although technically damage to the hair cells is not
Auricle
FIGURE 92 Outer, middle, and inner ear
structures. (From Scanlon, V. C., & Sanders, T.,
Essentials of anatomy and physiology, 5th ed.,
F.A. Davis, Philadelphia, 2007, p. 211, with permission.)
■ Sensory Function and Function Related to the Skin 133
age related, as a person ages, increased opportunity for expo-
sure to these noxious factors occurs. There are likely age-
related factors that may alter the stiffness of the cochlear basi-
lar membrane or changes in the fluid of the cochlea. These
changes can be considered mechanical cochlear changes that
affect older adult hearing (Sha et al., 2009).
A common but often unrecognized cause of hearing loss
in the older adult is central auditory processing disorder. The
typical pathology is either in the central neuronal connections
or auditory cortex; however, the peripheral mechanisms are
intact. This type of hearing loss is seen in people with neu-
rodegenerative disorders, such as dementia (Kanagala &
Berkower, 2003). An interesting and promising line of re-
search in neural auditory problems is related changes in neu-
rotransmitters with aging. Similar to other parts of the CNS
and PNS, the auditory nervous system appears to have synaptic
areas that suffer from loss of specific neurotransmitters. For
example, age-related changes of glutamate and glutamate-
related genes may be an important factor in presbycusis patho-
genesis (Tadros et al., 2007).
An ever-increasing common problem in older adults is
tinnitus, or the perception of sound in the absence of an
acoustic stimulus. Tinnitus is unilateral in about 50 percent
of cases and is perceived as buzzing, whistling, or ringing
in the ears. More than 35 million adults experience tinnitus,
and in 2 to 3 million, the problem is severe enough to affect
quality of life (Ahmad & Seidman, 2004). The prevalence
of tinnitus increases with age and is correlated with both
age-related hearing loss and noise-induced hearing loss.
There do not appear to be sex differences, although there
may be racial/ethnic differences (Tucker et al., 2005). Tin-
nitus is caused by several factors, including medications and
Temporal bone
Semicircular canals
Stapes Vestibular branch
Incus Acoustic or
Malleus 8th
cranial nerve
Cochlear branch
Cochlea
Tympanic
membrane
Vestibule
External auditory
meatus Eustachian tube
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134 PART II ■ Aging: Body Structures and Body Functions
Semicircular canals
Vestibular
Endolymph nerve
Cochlear nerve
Crista
Saccule
Scala tympani
Ampulla
Utricle
Scala vestibuli
Cochlea
Oval window
Round window
Oval window
metabolic and vascular diseases, and it is difficult to treat.
Management includes:
■ Cognitive behavioral therapy, counseling, and support
groups. Counseling and therapy are targeted at decreasing
the stress and distraction associated with the tinnitus; sup-
port groups offer emotional support through sharing of
experiences for dealing with the condition.
■ Diet and lifestyle interventions. Because nicotine use and
high salt and caffeine intake can increase tinnitus, education
and modifications may be beneficial. In addition, stress man-
agement and relaxation may assist in controlling tinnitus.
■ Auditory habituation. A noise is presented via a “noise gen-
erator” into the affected ear(s) at a soft enough level that
the brain perceives both the noise and the tinnitus.
■ Masking. The use of an external electronic device (a “masker”)
to produce sound that cover ups the tinnitus. (Canadian
Academy of Audiology, 2015; Langguth, Kreuzer, Kleinjung,
& De Ridder, 2013)
Effects of Normal Age-Related Auditory
System and Hearing Changes
Whether the hearing loss older adults experience is only age-
related (presbycusis) or from and in combination with other
causes, such as noise exposure (socioacusis), ototoxic drugs,
disease, or genetics is difficult to determine. Regardless, the
impact on function and occupation may be significant. As
noted previously, few older adults have conductive hearing loss
primarily or at all. Rather, a majority have sensorineural hearing
loss alone or in combination with conductive hearing loss
(mixed loss). The sensorineural component affects both hearing
sensitivity and speech understanding in complex ways. Hearing
sensitivity appears to change with age. For example, as age in-
creases, hearing level increases, with the most dramatic diffi-
culty is in hearing the higher frequencies, such as those greater
than 400 Hz. In addition to age-related changes in threshold
sensitivity, there appear to be changes in pitch discrimination
Vestibulocochlear
nerve
Cochlear duct
FIGURE 93 Inner ear structures. (From Scanlon, V. C.,
& Sanders, T., Essentials of anatomy and physiology,
5th ed., F.A. Davis, Philadelphia, 2007, p. 212, with
permission.)
and auditory reaction time. The older adult’s ability to detect
small changes in pitch, a skill important for the understanding
of both music and speech, may begin to diminish as early as
the fourth decade. Beyond the mid-50s, the ability to detect
small pitch changes decreases as a linear function of age and
becomes more problematic in the higher frequencies (Sha
et al., 2009). Like pitch discrimination, auditory reaction time
changes with age. Because older adults are more cautious in
responding to auditory stimuli, changes in both pitch discrim-
ination and auditory reaction time should be evaluated as part
of broader changes in perception and cognition that may affect
behavioral responses.
One of the most life-altering effects of hearing loss is on
speech perception. This complex skill is related to several abil-
ities: speech reception, speech discrimination, and speech un-
derstanding in stressful situations. A reduction or inability to
understand speech is the most common reported symptom
among older hearing-impaired individuals presenting to an
audiology clinic. Speech reception and recognition, typically
measured as the intensity level required to produce 50 percent
correct responses for a standard list of words, are reduced with
age, which typically correlates with a decreased in hearing sen-
sitivity (Berry, Mascia, & Steinman, 2004). Gaeth (1948) first
described this concept as phonemic regression—as a person ages,
he or she has less ability to understand phonemes, units of
sound that distinguish one word from another.
A closely related auditory skill is speech discrimination. A
common characteristic of age-related hearing loss is the de-
creased ability to hear high-frequency sounds—in particular, th
and f, resulting in poor speech recognition or discrimination
(Berry et al., 2004). Speech discrimination is measured clinically
by administering a test of phonetically balanced monosyllabic
words, with the loudness of the words increasing during the
test. This poor discrimination acuity can affect speech under-
standing of older adults and can restrict their speech intelligi-
bility input to a narrower range. This leads to the common
complaint described by Mascia (1994) as “I can hear you but I
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CHAPTER 9
can’t understand you” Speech may be difficult to understand or
may not sound clear, and similar words may be confused—pat
and bat or dinner and thinner (Berry et al., 2004).
Social Consequences of Hearing Loss
When working with older adults, it is important to be able
to recognize behaviors that may indicate a hearing loss and
the functional consequences that may occur because of the
loss. These behaviors include the following:
■ Making repeated requests for a person to speak louder or
to repeat what was said
■ Not responding to verbal questions or conversation
■ Giving nonpertinent or inappropriate responses to questions
■ Directing questions to spouse, family, or caregiver
■ Leaning forward, tilting head to one side
■ Showing distress or irritation; becoming disoriented or
confused during conversations
■ Withdrawing in social situations
Understanding speech during stressful listening conditions
is probably the most common and troublesome for the typical
older adult. Stressful listening conditions exist daily and
everywhere, such as in the car, a room with background noise,
or in a group-speaking situation. Although speech under-
standing in the older population is markedly decreased in the
presence of these stressful listening conditions, it should be
noted that variability exists among older adults. Each difficult
listening condition does not result in the same degree of per-
ceptual difficulty in every older person.
Untreated hearing loss can cause isolation, anxiety, de-
pression, and paranoia and can have a significant negative im-
pact on quality of life (Gopinath et al., 2012; National
Council on Aging, 2013). The embarrassment caused by mis-
understanding others may lead to social withdrawal, and poor
BOX 92 Examples of Communication Strategies and Environmental Modifications for Older Persons with Hearing Loss
■ Communication
■ Face the older adult directly
■ Get visual attention before speaking
■ Speak clearly using a low-tone voice and moderate rate
of speech
■ Approach the older adult from the front to avoid startling
■ Reduce glare and ensure adequate lighting to enhance
visual and nonverbal cues
■ Do not shout
■ Rephrase if the message is not understood
■ Television, radio, music
■ Have the older adult use closed captioning, assisted
listening devices, and remote controls to select
programming
■ Have the older adult avoid running the television or radio
constantly
■ Sensory Function and Function Related to the Skin 135
hearing may lead the older adult to think others are mum-
bling; family relationships may be strained, enjoyment of
daily activities and occupations may be limited, social inter-
actions may decrease, and the emotional and physical health
of the spouse can be affected; in some cases, it can even
lead to divorce (Genther, Frick, Chen, Betz, & Lin, 2013;
National Council on Aging, 2013; Wallhagen, Strawbridge,
Shema, Kurata, & Kaplan, 2001). In people with existing
mental health or behavioral problems, such as depression or
Alzheimer’s disease, a hearing loss may result in increased
disability (Wahl & Heyl, 2003). Investigators have noted that
poor understanding of speech may appear to others as related
to cognitive decline, when in fact it is more likely a conse-
quence of hearing loss (Schneider, Daneman, & Pichora-
Fuller, 2002; Wahl & Heyl, 2003). Safety may also be a
concern if the older adult cannot hear alarms or if someone
is moving toward them; this may increase feelings of vulner-
ability. At a basic level, older adults may no longer have access
to familiar sounds in the environment—for example, they
may not hear birds chirping or footsteps approaching—which
produces one more strain on a person already adjusting to
changes. Several attitude or perceptions scales exist for use
with older adults with hearing loss, and an audiologist typi-
cally administers these instruments. One example, the Hear-
ing Handicap Inventory for the Elderly, examines hearing
difficulties and their impact on activities of daily living, such
as time spent in conversation, reluctance to talk on the phone
or in face-to-face conversations, and self and others’ percep-
tions of the hearing loss (Ventry & Weinstein, 1982).
Treating the hearing loss can result in significant clinical
improvement in the older person’s functioning—in particular,
improved ability to attend to, understand, and respond to
speech. A variety of adaptation techniques, accommodations,
and devices are available that can make communication easier
(see Box 9-2).
■ Background noise
■ Have the older adult use carpeting on floors, acoustical tiles
on ceiling, drapes on windows, and upholstered furniture
(rather than wood and metal furniture and banners from
high ceilings) to absorb sound
■ Have the older adult sit away from distracting background
noises, windows, and plaster walls
■ Have the older adult avoid crowded areas
■ Safety
■ Have the older adult use alerting devices (e.g., flashing lights
or vibro-tactile devices) or lower pitched rings for smoke
detectors, doorbells, and telephones
■ Have the older adult use volume controls for telephones
■ Other
■ Have the older adult use amplified doorbells, voice
recognition, and telephone ringers
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136 PART II ■ Aging: Body Structures and Body Functions
Several kinds of hearing aids are available:
1. Behind-the-ear (BTE)—fits behind the ear and has a
small ear hook that extends over the top of the auricle
into the ear canal. A new kind of BTE aid is an open-
fit hearing aid, which is small and fits behind the ear
completely, with only a narrow tube inserted into the
ear canal, enabling the canal to remain open.
2. In-the-ear (ITE)—fits completely inside the outer ear
and is used for mild to severe hearing loss. Some ITE
aids may have a telecoil, a small magnetic coil that al-
lows sound to be received through the circuitry of the
hearing aid, rather than through its microphone, mak-
ing it easier to hear conversations over the telephone.
3. In-the-canal (ITC)—is nearly invisible because it is
so small, is inserted into the canal, and there are two
types. The ITC aid is made to fit the size and shape
of a person’s ear canal. A completely-in-canal aid is
nearly hidden in the ear canal. Both types are used for
mild to moderately severe hearing loss. Because they
are small, ITC-type aids may be difficult for an older
person to adjust and remove. (National Institute on
Deafness and Other Communication Disorders,
2016b)
Most hearing aids work best in a quiet environment be-
cause they amplify all sounds equally, thus communication
with a hearing aid can be frustrating because background
noise is picked up. Assistive listening devices (ALDs), which
consist of headphones, earphones, or earbuds, and a micro-
phone, amplify the primary signal and not the competing
noise (Fig. 9-4A, B). Thus, ALDs are more advantageous
FIGURE 94 An assistive listening device, consisting of (A) a
headphone and (B) a microphone, improves the ease of
communication. (Courtesy of the Rural and Remote Memory Clinic,
Saskatoon, Saskatchewan, Canada, with permission.)
when background noise exists (Watson & Maino, 2007).
Telephone amplification, personal communication devices,
and room amplification systems with individual receivers are
examples of technologies that may be of benefit for older
adults with hearing loss.
✺
PROMOTING BEST PRACTICE
Effects of Vision and Hearing Loss on Older Adults’
Ability to Interact With Others and the Environment
Research related to sensory impairments such as vision and
hearing losses confirms that these are associated with chronic
stress due to significant person–environment mismatch, which
may reduce the potential of autonomous and efficient day-to-
day functioning to elicit positive emotions (Wahl, Heyl, &
Schilling, 2012). Age-related vision impairment comes with
significantly lower competence in exerting basic activities
of daily living because visual capacity is a critical prerequisite
for safely accessing and using the physical environment
autonomously. The most dramatic impact of hearing
impairment is the undermining of social communication
in day-to-day life. Thus, it is important for health-care
professionals to explore if personality changes are due to
sensory loss.
Taste and Smell: Physical Changes
and Functional Performance
Although taste and smell together make up the chemosensory
system, they are quite different mechanisms anatomically.
They are considered together because of their functional link
to the flavor of food. Taste and smell change with age but are
also very sensitive to environmental effects such as smoking.
Both smell and taste complaints are common in older persons.
“Chemosensory impairments may be classified in several
categories: anosmia (lack of smell), hyposmia (decrease in
smell), dysosmia (distortion of smell), ageusia (absence of
taste), hypogeusia (decreased sensitivity of taste) and dysgeu-
sia (distortion of taste)” (Seiberling & Conley, 2004, p. 1209).
Malaty and Malaty (2013) have since added two additional
categories: phantosmia (smell hallucination) and phantogeu-
sia (taste hallucination).
Taste changes relatively little with age compared with
smell, which undergoes more significant change; thus,
chemosensory complaints and associated disturbances of
older adults are more likely due to olfactory changes rather
than alterations in taste (Heft & Robinson, 2014). One ex-
planation of the stronger decline in the olfaction (smell) than
gustation (taste) is the rapid turnover of the taste receptors.
In addition, several cranial nerves, with robust innervation of
taste receptors, are responsible for detecting taste:
■ cranial nerve V—trigeminal nerve, which mediates tem-
perature, stinging sensation, and sharpness;
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CHAPTER 9
■ cranial nerve VII—facial nerve, which innervates the
anterior two-thirds of the tongue;
■ cranial nerve IX—glossopharyngeal nerve, which inner-
vates the posterior one-third of the tongue; and
■ cranial nerve V—vagus nerve.
In comparison, olfaction is mediated by one cranial nerve
(cranial nerve I—olfactory nerve), and the receptors have
much slower turnover rate. Thus, disorders related to taste
are much less common than other sensory disorders (Heft &
Robinson, 2014). As well, changes in taste and smell have a
common factor: the neuronal degeneration of the lower part
of the postcentral gyrus where these sensations are “appreci-
ated” (Purves et al., 2004); thus, changes may not be a sensory
change per se but rather a change in sensory integration or
sensory comprehension. Interestingly, older men, on average,
have larger and earlier age-related declines in odor perception
than women (Doty & Cameron, 2009).
Common changes found in the mouth tissue of older
adults include decline in thickness and dryness of the oral
mucosa, decline and replacement of the acini (where secre-
tions are produced), components of the salivary glands with
fibrous adipose tissue, and decreased density of taste buds on
the tongue (Imoscopi, Inelmen, Sergi, Miotto, & Manzato,
2012). The ability to detect, identify, and discriminate among
sweet, sour, salty, bitter, and umami tastes also deteriorates
as one ages (Kaneda, Maeshima, & Goto, 2000; Methven,
Allen, Withers, & Gosney, 2013), with the biggest declines
in the ability to taste salt followed by sour, umami, and bitter.
The least decline is for sweetness (Methven et al., 2013).
These changes may result in poorer flavor discrimination and
a decreased ability to identify foods in the mouth. However,
because food flavor arises largely from olfactory stimulation,
it is possible these changes are more likely related to age-
related declines in smell.
✺ PROMOTING BEST PRACTICE
Food Activities and Identity Maintenance Among
Community-Living Older Adults
Semistructured interviews, conducted with 39 community-
dwelling older adults (aged 61–89) living in West London, were
analyzed using a grounded theory approach to explore the role
of food activities in identity. Three identities were evident: food
lover, non-foodie, and not bothered. Food lover and non-
foodie were lifelong identities, whereas not bothered was a
new identity that emerged through a cumulative change in
food activities in older adulthood. The authors found that
engaging in food activities was an important part of productive
aging for the food lovers; the most significant threat to
participants’ identity was a change in the social meaning of
food activities (e.g., eating alone at a table changed the social
meaning); and deteriorating health made food activities more
difficult and less pleasurable due to decreased mobility and
more restrictive and controlled food activities. The food lover
identity was an important identity that contributed to
■ Sensory Function and Function Related to the Skin 137
participants’ mental well-being, whereas both the non-foodie
and not-bothered identities were unimportant and did not
contribute to mental well-being. The authors suggest
assessment of feeding and eating performance should include
questions about the importance and meaning of food activities
to the older adult (Plastow, Atwal, & Gilhooly, 2015).
Olfaction also plays a major role in safety: It provides early
warning of dangers, such as fire, dangerous fumes, leaking
gas, spoiled foods, and polluted environments. Thus, not only
can smell dysfunction significantly diminish quality of life, it
can be life-threatening (Seiberling & Conley, 2004; Mattes,
2002). Various reasons for age-related decline in olfactory
function have been reported including higher detection
thresholds (lowest intensity where a stimuli can be detected),
a decline in suprathreshold (a stimulus above the specified
threshold) sensitivity for odors, impaired ability to identify
and discriminate odor, deficits in the ability to identify odors
and taste on the basis of taste and smell, and distorted taste
or smell (Larsson, Finkel, & Pedersen, 2000; Methven et al.,
2012; Schiffman & Graham, 2000; Schiffman & Zervakis,
2002). Changes in the olfactory tract and bulb are similar to
overall CNS changes, for example, generalized atrophy with
a loss of neurons. Degeneration of the nasal mucosa sensory
cells has been documented, such that by the ninth decade, the
olfactory threshold increases by about 50 percent, contributing
to poor smell recognition (Dharmarajan & Ugalino, 2000).
Smell identification is impaired with increased age, even in
generally healthy individuals. It appears that the ability
to identify odors correctly increasingly deteriorates with age,
especially in men (Malaty & Malaty, 2013; Seiberling &
Conley, 2004).
Taste and smell changes are functionally important for
older adults. Because of taste and flavor changes eating may
be less pleasurable, leading to alterations in food choices, de-
creased appetite, and decreased food intake (Solemdal,
Sandvik, Willumsen, Mowe, & Hummel, 2012). Older
adults who need specific dietary restrictions may not adhere
to those regimens, i.e., older adults who need to reduce salt
intake because of high blood pressure. As a result, subse-
quent exacerbation of disease risk, weight loss, and nutri-
tional and immune deficiencies can occur (Malaty & Malaty,
2013; Roberts & Rosenberg, 2006). In addition, older adults
with chemosensory decrements may be at greater risk for
food poisoning or overexposure to environmentally haz-
ardous chemicals that might otherwise be detected by taste
and smell (Mattes, 2006). For older individuals with
chemosensory loss, several interventions can be imple-
mented: (1) flavor amplification, which is adding concen-
trated essence of foods to meals; (2) providing various
flavors, textures, and temperatures in one setting to improve
intake; (3) ensuring good oral care before meals. Finally,
counseling should be considered as chemosensory disorders
significantly affect an individual’s overall well-being (Seiberling
& Conley, 2004).
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138 PART II ■ Aging: Body Structures and Body Functions
Somesthesis: Physical Changes
and Functional Performance
Somesthesis includes the sensations that arise from light and
deep touch of the skin and the viscera, vibration, pain, and
temperature, as well as kinesthesis, the sensation and aware-
ness of active or passive movement. Similar to other sensory
modalities, age-related somesthesis changes occur, but envi-
ronmental effects cannot be ruled out; for example, neu-
ropathies and structural changes in the skin (e.g., thinning)
make age-related changes almost impossible to detect in the
purest sense.
Skin Changes With Aging
The skin consists of three layers: the epidermis (outermost
layer), the dermis (middle layer), and hypodermis or sub-
cutaneous (innermost layer). The major functions of skin
include immunity, temperature regulation, nutrient stor-
age, sensory reception, communication, and excretion
(Benbow, 2009). The epidermis, the thinnest layer, gives
the skin its waterproofing barrier properties and protects
against ultraviolet light. Within the epidermal layer are
melanocytes, which provide skin color, and Langerhans
cells, which play an immune-surveillance role. The dermis
layer forms the bulk of the skin and is responsible for per-
ception of environment, thermoregulation via sweat glands,
immunological defense via mast and macrophage cells, and
water storage. This layer also contains the proteins collagen
and elastin, both which provide structural stability and re-
silience. The innermost layer, the hypodermis, stores lipids
to provide thermal insulation and a protective cushion
against trauma. Finally, dispersed throughout the skin are
the cutaneous appendages, which include eccrine glands
(sweat), apocrine glands (scent), sebaceous glands (oil),
and hair follicles (Thomas & Burkemper, 2013; Voegeli,
2012).
As adults age, atrophic changes occurs at each of the
three layers of the skin, which affects the sensations of touch
and pressure, pain and temperature, among other functions
of the skin. The epidermis becomes thinner, drier, and
stiffer. The overall thickness of the dermis also decreases,
and along with degeneration of pacinian and Meissner’s
corpuscles, impairs the sensation of light touch and pres-
sure. Further, the reduction of the number of and size of
sweat glands impedes proper thermoregulation. The de-
creased production of collagen and elastin, and weak and
decreased blood vessels makes the skin frail and prone to
bruises, damage, and wrinkles. Finally, the hypodermis layer
stores less subcutaneous fat, reducing cushioning and im-
pairing thermoregulation, both of which increase the risk
of skin breakdown and hypothermia (Bear-Lehman, Albert
& Burkhardt, 2006; Cowdell & Radley, 2012; McLafferty,
2010; Voegeli, 2012).
Touch and Pressure
The skin receptors responsible for the perception of pressure
and light touch, pacinian and Meissner’s corpuscles, undergo
structural changes and decline in number (Bear-Lehman et al.,
2006; Voegeli, 2012), such that by the ninth decade, they are
only one-third of their original density (Cech & Martin, 2002).
In addition, the sensory fibers innervating the peripheral
receptors undergo changes and decline, and the speed, quan-
tity, or quality of information processing may be affected
(Verdu, Ceballos, Vilches, & Navarro, 2000). Decreased re-
sponse to tactile stimuli, higher touch threshold (e.g., firmer
stimulation of the skin is required before the stimulus is de-
tected), and decreased ability to detect touch and pressure have
been reported in some older adults (Tremblay, Mireault,
Dessureault, Manning, & Sveistrup, 2005). Poorer hand sen-
sibility has been found to be associated with problems grasping
or handling, independent of grip strength. Similarly, decreased
foot sensation was related to balance problems, independent
of tandem stand performance (Bear-Lehman et al., 2006). It
is important to note that the degree of change is highly variable
in that the effects vary greatly in their magnitude across indi-
viduals. Donat, Özcan, Özdirenc, Aksakoglu, and Aydinoglu
(2005) reported that although touch/pressure was decreased
in individuals older than 60 years, statistically significant
differences were not found between age-groups (60–69,
70–79, over 80 years), suggesting that age-related changes in
touch/pressure may not be progressive in healthy older adults.
Interestingly, a study that had older subjects train two-point
discrimination tactile skills found tactile ability may be pre-
served and may be improved with therapeutic interventions
(Dinse et al., 2006).
Touch provides important information about one’s envi-
ronment, is an important prerequisite for adequate perform-
ance of manual tasks, and plays a role in communication
(Benbow, 2009; Carmeli, Patish, & Coleman, 2003; Francis
& Spirduso, 2000). Older adults who experience loss or a
decrease in tactile acuity or sensitivity will have difficulty
localizing and identifying stimuli. Response time may be de-
creased, as the speed and intensity in which the stimuli are
perceived are reduced. An older person must take special care
to avoid injury from prolonged pressure on the skin. Changes
in tactile sensitivity result in increased reliance on other sen-
sory systems for information, a problem for older adults with
vision loss.
Pain
The nociceptive pathways of older adults undergo numerous
and widespread changes in morphology, electrophysiology,
neurochemistry, and function with aging (Box 9-3).
Although some studies of experimental pain support the
view that pain thresholds (e.g., the older adult can tolerate a
more extreme stimulus without perceiving it to be painful) to
short-duration noxious stimuli are increased in older adults,
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CHAPTER 9
BOX 93 Structural and Biochemical Changes Affecting Pain Perception in Older Adults
■ Decreased density of unmyelinated fibers by age 60
■ Selective loss of unmyelinated fibers (1.2–1.6 μm in
diameter)
■ Decreased density of myelinated fibers
■ Decrease in large-diameter and finely myelinated afferent
fibers (0.1–5.0 μm)
■ Peripheral nerves
■ Decreased nerve conduction velocity
■ Wallerian degeneration
■ Marked reduction in substance P in aged human skin and in
the thoracic and lumbar dorsal root ganglion cells
■ Dorsal horn sensory neurons
■ Decrease in number and size of sensory neurons in dorsal
root ganglia
research has yielded inconsistent findings. Explanations for
these contradictory findings could be related to research
methodology, the tools used to assess pain or the hypothesis
that human endogenous pain-regulatory systems may be de-
generating for some older adults as they age. Older adults
with functioning endogenous pain-regulatory systems may
be able to produce a greater analgesic response similar to
younger adults, whereas older adults with a degenerating sys-
tem may exhibit higher pain ratings and reduced habituation
on repeated stimuli (Edwards & Fillingim, 2001a).
Sensory fibers A-delta and C are also responsible for pain
detection. The A-delta fibers are myelinated and sense short,
localized, sharp pain sensation, and the C-fibers are unmyeli-
nated and sense dull and burning pain that outlasts the stim-
ulus. The demyelination and reduced density of the A-delta
fibers suggests that some older individuals rely on the C-fiber
input to responding to noxious stimulation (Edwards &
Fillingim, 2001b; Shaffer & Harrison, 2007). Riley and
colleagues (2014) concluded that such sensory changes in
the skin of older adults increase the pain threshold and
decrease tolerance, which reduces the “purposeful reserve
between the onset of pain and the beginning of injury”
(p. 279). Riley and colleagues also found a race difference
in pain tolerance: Older (57–76 years) non-Hispanic black
subjects had a lower tolerance to pain and withdrew their
hand from a cold water bath significantly earlier compared
with non-Hispanic white subjects at both 12° and 8°
Celsius temperatures.
While pain perception, particularly deep pain perception,
may decrease in older adulthood (Lautenbacher, Kunz,
Strate, Nielsen, & Arendt-Nielsen, 2005), pain in older
adults is often underrecognized, with health-care profession-
als often viewing pain as an inherent part of aging, and un-
derreported, which in turn leads to undertreatment (Herr &
Garand, 2001). Chronic pain in later life can have a profound
impact on an older adult’s quality of life, social, physical, and
■ Sensory Function and Function Related to the Skin 139
■ Marked loss of myelin
■ Signs of damage including axonal involution especially in the
medial lemniscal pathways
■ Altered spinal neurochemistry specifically age-related loss of
serotonergic and noradrenergic neurons in the dorsal horn
■ Cortex, midbrain, brain stem
■ Decreased numbers of opiate and decreased efficacy of
opiate mediated antinociception
■ Neuronal death, loss of dendritic arborization, neurofibrillary
abnormalities
■ Decreased synthesis, axonal transport, uptake, and receptor
binding of neurotransmitters
Note. From Gagliese & Farrell (2005).
occupational function, and independence and emotional
well-being (Menz et al., 2013; Peat, Thomas, Handy, &
Croft, 2004; Thomas, Peat, Harris, Wilkie, & Croft, 2004).
Health professionals cannot ignore the nonphysiological
aspects of pain and need to consider the psychological,
sociological, cultural, and contextual factors that may all play
a role in pain perception and pain expression in older adults.
Chapter 17 describes some of the health conditions that
contribute to excess pain in older adults and strategies for
assessing and managing pain.
Temperature
It is unclear how much of the thermoregulatory impairments
seen in older adults are age-related. Skin structure changes
(e.g., thinning), decreased vascularization, chronic disease
processes, personal health habits, such as smoking, and a
sedentary lifestyle may all play a role.
There are three mechanisms through which the skin assists
in thermoregulation: blood vessel constriction or dilation, pro-
ducing sweat from eccrine glands, and contraction of the erec-
tor pili muscles that surround the hair follicles (Benbow,
2009). Thermoreceptors, which are sensitive to the surrounding
environment changes (external and internal), help to regulate
and maintain a constant body temperature. Cold and heat
receptors are found in the skin, spinal cord, and hypothala-
mus, and the skin receptors provide the hypothalamus with
important information about the need to generate, converse,
or dissipate heat (McLaferty, 2010). Part of the inability to
cope with environmental temperature extremes is related
to the decrease in perception of the thermal environment due
to changes in the skin with aging, including reduction in the
number of thermoreceptors and their function (McLaferty,
2010). Aging causes a decline in the number of sweat glands
and also decreases the functional efficiency of the remaining
sweat glands, therefore less sweat is produced, leading to
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140 PART II ■ Aging: Body Structures and Body Functions
impaired ability to dissipate heat. Older women, who sweat
less, are less likely to lose heat by sweating compared with
older men. To sweat adequately, optimal hydration is re-
quired, and older adults may have suboptimal hydration levels
due to decreased ability to concentrate urine, reduced thirst
sensation, and limiting fluid intake as a way to manage urine
incontinence (McLafferty, 2010). Furthermore, older adults
are not able to increase cutaneous blood flow as effectively as
younger adults to lose heat through radiation (McLafferty,
2010). In response to cold environments older adults have a
reduced ability to generate heat. The shivering response and
the cutaneous vasoconstrictor response are less effective. The
decreased amount of subcutaneous fat stored in the hypoder-
mis reduces the body’s insulation against heat loss. Finally, the
hair on the body becomes thin reducing the ability of the erect
hair caused by the erector pili muscles around the hair follicles
to trap air to support heat retention (Benbow, 2009; Voegeli,
2012). Research on thermal extremes of hot and cold indicates
that older adults have increased thresholds in the hand and
foot compared with younger adults (Riley et al., 2013). Inter-
estingly, central body regions lost sensitivity more slowly com-
pared with the extremities, which showed the greatest and
earliest change with age.
Age-related changes may make it more difficult for the
older adult to detect a difference between cool and cold or
warm and hot, and decreased temperature sensitivity in-
creases the risk of injuries, such as burns, frostbite, and hy-
pothermia. The physiologic deficits could be compensated for
by conscious behavioral responses, including wearing appro-
priate clothing layers, moving to a cooler or warmer environ-
ment as needed, and decreasing or increasing activity level
as needed. However, due to perception deficits, implemen-
tation of preventative measures may not be seen as necessary
(Dharmarajan & Bullecer, 2003). Because older adults are
more adversely affected by extremes of hot or cold, many so-
cial service agencies have special programs for the elderly
population during the very hot or cold times of the year.
INTERPROFESSIONAL PRACTICE
Collaboration
Addressing sensory changes associated with normal aging
requires communication and collaboration among health-care
professionals.
Loss of sensory abilities that are common among older adults
requires that occupational and physical therapists collaborate
with nurses, nutritionists, optometrists, nurse practitioners,
physicians, speech and language therapists, and others.
Collaboration with community service and government
agencies (e.g., Meals on Wheels) at all levels and with private-
sector organizations and charitable groups can assist with
organizing needed environmental changes that enhance safety
and function. Community- and faith-based agencies bring more
resources, such as transportation (which can, for example, help
older individuals participate in religious services), to clients.
SUMMARY
Although age-related changes in the sensory systems are nu-
merous and may cause activity limitations and participation
restrictions, many older adults can and do adapt to these
changes. Sensation and perception in the sensory systems
have some common themes:
1. Sensitivity may be decreased.
2. Perceptual changes may reflect general nervous system
changes rather than specific changes of the sensory
modality.
3. A reaction in an experimental condition may be con-
servative and more reflective of generally slower CNS
information processing, rather than a specific change
to the sensory modality.
4. Perception over a lifetime may become learned and
automatic, with maintenance of functional skills even
in the presence of sensory decline.
There are both positive and negative aspects to the
learned sensory and perceptual patterns one adopts over the
life span. On one hand, the older adult can “fill in” missing
information based on remembered events and learned con-
texts. On the other hand, life can be more challenging or
even dangerous if sounds, sights, smells, tastes, and other
sensory events are misperceived and erroneously interpreted—
questions may be answered incorrectly, the struggle to
communicate may result in withdrawal, unsafe situations
may go undetected, something harmful may be touched,
and enjoyment from previous pleasurable sensory events,
such as movies, religious events, conversations, and music
may be lost.
Changes in sensory and perceptual information are re-
flective of overall nervous system deterioration and, in par-
ticular, cognitive function. However, changes in cognition
may affect adaptation to the physical environment, and re-
search in age-related cognitive changes (Chapter 7) may
be biased by sensory and perceptual abilities of older sub-
jects. Of course, there is much more to cognition, but the
role of sensory sensitivity diminution must be taken into
account.
Two important facts about the sensory perceptual sys-
tems and their neural pathways need to be considered:
(1) They are integrated at a higher cortical level, the
“association cortex,” and (2) it is likely that sensory and
perceptual losses share a common component of degener-
ation, such as neurotransmitter changes or basic cell action
alterations. These common connections and associations
may have functional effects. Just as the older adult “can’t
hear without my glasses on,” he or she may find one sen-
sory pathway aiding another as sensitivity decreases. A
young adult may compensate well if one sensory system is
affected. However, older adults may be compensating or
adapting to sensory or perceptual losses with systems that
are likewise impaired.
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CHAPTER 9
CASE STUDY
Mr. Curtis Marshall is an 85-year-old man being seen in
an outpatient clinic for physical and occupational therapy.
Mr. Marshall’s family has noticed a decline in endurance,
strength, and willingness to participate in usual activities.
He worked as a laborer until age 68. He has high blood
pressure and osteoarthritis in his knees and hips.
The occupational therapist, Sam, and the physical
therapist, Mackensie, quietly listen as Mr. Marshall
discusses a most recent appointment with his physician.
Mr. Marshall states, “I swear that doctor is experiment-
ing on me.” Sam asked, “Why do you think this
Mr. Marshall?” Mr. Marshall responds, “The doctor said
something about not being able to give me medicine for
my arthritis because of my high blood pressure. I do not
understand what one has to do with the other. Do either
of you?” Sam and Mackensie explain the relationship be-
tween high blood pressure and ibuprofen, such as Advil.
They ask Mr. Marshall to explain the information back
to them, which he successfully does.
During the session, Mackensie asks if Mr. Marshall has
any questions about the handout of exercises and informa-
tion about arthritis that was provided to him last week.
Mr. Marshall acts disinterested in the handouts. With more
conversation, Mackensie discovers that Mr. Marshall had
difficulty reading the handout. Mr. Marshall notes that he
was too embarrassed to admit that he could not see the
material well enough to read it and that he also did not
clearly hear all the information and therefore really did not
remember in detail what was taught to him.
Mr. Marshall explained to Sam and Mackenzie that he
saw a commercial on TV about hearing devices. “Do you
think I need a hearing aid? My grandkids tell me I turn
the TV up too loud for their comfort.”
Mr. Marshall tells Sam and Mackenzie that since his
wife died 2 years ago, he typically eats cereal and canned
soup because “she did all the cooking.” Mr. Marshall’s
family has him over once a week for dinner. He goes to
church but does not enjoy attending because he cannot
hear the sermon that well and reading gives him a
headache. He is thinking about no longer attending serv-
ices. “What’s the point?” he asks. “My family is always in
such a hurry. They tell me I am a grumpy old man.”
Questions
1. What additional reasons might account for
Mr. Marshall’s self-imposed dietary changes?
2. How might self-imposed dietary changes affect
Mr. Marshall’s overall health, and how can this be
addressed?
3. What additional referrals and communication should
be made? Why?
■ Sensory Function and Function Related to the Skin 141
Critical Thinking Questions
1. What general changes occur with aging in all sensory
organs or systems?
2. How might changes in sensory systems affect the
older adult’s behavior? Are any changes generally
more devastating than others? Why or why not?
3. How might an older adult change his or her daily ac-
tivities because of visual changes? Auditory changes?
4. How might social function change for an older adult
who cannot understand speech sounds normally?
Who has tinnitus?
5. What dangers might an older adult face because of
changes in taste, smell, or superficial sensations? On
the basis of known physiological changes, are any of
these dangers more likely to occur than others in the
vast majority of older adults?
6. Imagine that you are designing a retirement or life-
care center or group home for well older adults.
Taking the research about sensory system and sen-
sory integrative changes into account, what are a
few important steps you would take to ensure that
sensory stimuli are received optimally by all residents
of your facility? Think beyond local and federal legis-
lation or regulations related to health and safety and
(a) design the facility taking into account financial
constraints and (b) design the ideal facility. Think
sensory systems and technology.
7. Identify adaptations, strategies, and interventions
commonly used for older adults to compensate for
sensory deficits in vision, hearing, taste, touch, and
smell. What suggestions might you, as an occupa-
tional or physical therapist, provide to an older adult
experiencing sensory changes?
8. Explain how normal changes in aging and the
sensory systems may impact a disease condition
and the client’s ability to manage medical care.
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Neuromuscular and Movement Function:
Muscle, Bone, and Joints
Vanina Dal Bello-Haas
“The life course is made up of change and transition at least as much as periods ofstability.
LEARNING OUTCOMES
By the end of this chapter, readers will be able to:
1. Describe the typical age-related muscular, skeletal, and
nervous system structural changes that may lead to
impairments and affect functional abilities.
2. Discuss the effects of aging on muscle strength, muscle
power, and joint range.
3. Explain assessment considerations for the older adult and
the specific procedures used for assessing range of motion,
flexibility, and strength.
4. Describe the types of exercise and activity programs that
may be used to increase range of motion, flexibility, and
strength in the older adult.
5. Discuss the relationship between older adult function
and muscle strength and power.
6. Identify interventions that may be used to prevent or
lessen age-related neuromusculoskeletal changes in
older adults.
Clinical Vignette
Mrs. Fran Smithson is a 78-year-old woman who lives with
her husband of 56 years in a two-story home. There are
five steps up into the house with a railing on both sides of
the steps. There are eight steps (no railing) from the main
floor to the second floor, where Mr. and Mrs. Smithson’s
bedroom is located.
Mrs. Smithson was diagnosed with osteoarthritis 10 years
ago. She has severe pain in her hands that causes problems
with dressing, primarily with the fine motor dexterity needed
for buttons and clasps. In addition, food preparation is difficult
(e.g., cutting food and opening containers). Mrs. Smithson
has identified pain in her right hip and has been having diffi-
culty negotiating stairs. She must climb one step at a time
and often has to hold onto her husband to negotiate the stairs,
CHAPTER 10
■ Norma J. MacIntyre ■ Sirirat Seng-Iad
relative
—J. R. Kelly (1987, p. 52)
”
especially since there is no railing. Mrs. Smithson was previ-
ously a very active woman. She volunteered at the local hospital
visiting with patients twice a week. However, she is now only
able to volunteer once every other week because her hip is too
sore to visit the hospital more frequently. She is unhappy she
can no longer knit, as she greatly enjoyed making socks, mit-
tens, and sweaters for her 13 grandchildren. Mrs. Smithson
loves to garden but, because of the pain in her hip and hands,
she minimizes the work by maintaining only the flower boxes
in the front of her house
1. What changes has Mrs. Smithson experienced that
would be considered “normal” age-related changes?
What changes would be considered “abnormal”?
2. How have meaningful daily activities been affected by
the diagnosis of osteoarthritis and the subsequent
symptoms?
3. On the basis of the information provided about
Mrs. Smithson, what would be the main focus of your
intervention(s)?
V arious tissues make up the neuromusculoskeletal
system, including muscle, tendon, ligament, bone,
cartilage, and nerves. Similar to the other body systems
described in several chapters in this book, age-related body
structure and function changes are also prevalent in the
neuromusculoskeletal system. Because of these changes,
older adults are at risk for common impairments, including
decreased strength, decreased range of motion (ROM),
and problems with mobility and function. Thus, older
adults may experience a gradual decline in abilities and
have difficulty with daily activities, functional performance,
and occupations as they age. As with other systems, the
aging process in musculoskeletal and neurological systems
varies greatly from one person to another. However, for
145
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146 PART II ■ Aging: Body Structures and Body Functions

some individuals, age-related changes may contribute to Health condition

the development of several chronic conditions typically (disorder or disease)
seen in older adults. In addition, changes secondary to dis-
use, other system pathologies, and personal factors, such as
lifestyle and nutrition, may contribute to or enhance the Body functions Activity Participation
effects of aging of the neuromusculoskeletal system. This and Structures (limitations) (restrictions)
(impairments)
chapter will:
■ describe the typical age-related changes in muscular, skele-
tal, and nervous systems that may lead to impairments and
affect functional abilities in the older adult.
■ discuss the effects of aging on muscle strength and power, Personal
Environmental factors
joint flexibility, posture, and the resultant impact on the (facilitators/barriers) factors
A
older adult’s function.
■ explain the procedures used for assessing range of motion, Health condition
Osteoarthritis
muscle strength, posture, and assessment considerations (disorder or disease)
for the older adult.
■ identify interventions and specific exercise programs that
may be used to prevent or lessen age-related neuromuscu- Body functions Activity Participation
loskeletal changes in older adults. and structures (limitations) (restrictions)
■ identify the impact on daily function. (impairments)

Typical age-related and abnormal biological alterations

Pain (hands and hip) Knitting Volunteering
in the neuromusculoskeletal system (impairments) can lead hip ROM Dressing at hospital
to activity restrictions and participation limitations for many L/E strength Cooking Square dancing
older adults. Figure 10-1 illustrates the International Clas- Gardening with husband
sification of Functioning (ICF) model and the dynamic in- Stair climbing
teractions between the components for Mrs. Smithson,
whose history is described in the Clinical Vignette. The
ICF treats all dimensions as interactive and dynamic, rather
than linear or static. The interactions are in both directions,
Environmental factors Personal
such that the presence of a disability may modify the health (facilitators/barriers) factors
condition. Studies have linked outcome measures to the
ICF domains to better reflect all aspects of health, body
function, activity, and participation in musculoskeletal con- Two-story home Husband
ditions (Cieza et al., 2002; Kjeken et al., 2005; Tremayne, Stairs (into home and Very active individual
up to second floor)
Taylor, McBurney, & Baskus, 2002). Qualitative studies
have aimed to validate ICF core sets for various conditions Bedroom on second
B floor
through input from stakeholders, including people with the
condition (Coenen et al., 2006; Stamm et al., 2005) and FIGURE 101 A, ICF as related to Mrs. Smithson’s condition.
therapists (Kohler, Xu, Silva-Withmory, & Arockiam, B, Interactions among the International Classification of Functioning
dimensions for Mrs. Smithson, a 78-year-old woman with osteoarthritis.
2011). With the emergence of this broader model of health,
L/E = lower extremity; ROM, range of motion. (Adapted from World
clinical research has begun to focus on how the ICF might Health Organization. (2003). International statistical classification of
explain health outcomes across a spectrum of health condi- diseases and related health problems, 10th revision (ICD-10). Geneva,
tions (Stucki, Ewert, & Cieza, 2003) and comorbid condi- Switzerland: World Health Organization, with permission.)
tions (Lorbergs & MacIntyre, 2013).
with the environment. Some of the most salient age-related
Neuromusculoskeletal and Movement changes in the neuromusculoskeletal system include the
following:
Function in Older Adults
■ Decreased muscle strength and power
As described in Chapter 2, theories of aging abound. Age- ■ Marked loss of skeletal muscle mass
related tissue changes have been conceptualized as accumu- ■ Decreased number of functional motor units
lation of micro-insults resulting in damage to or changes in ■ Decreased percentage of Type II (fast twitch) fibers
body tissues, eventually leading to the diminution of physio- ■ Changes in postural alignment (see Chapter 11)
logical systems (Jin, 2010). These tissue and system changes ■ Bone and cartilage changes
affect older adults’ function, mobility, and ability to interact ■ Changes in balance and gait (see Chapters 11, 16)
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CHAPTER 10 ■ Neuromuscular and Movement Function: Muscle, Bone, and Joints 147

■ Decreased maximal speed of movement and initiation of
responses (see Chapter 11)
■ Increased threshold for vibration sensation and decreased
proprioception (see Chapter 9)
It is clear that alterations in the neuromuscular and skele-
tal systems occur with the passage of time. However, aging
is a personal and unique experience, not only because older
adults differ from one another with respect to their personal
and environmental factors but also because their physiological
systems age at different rates. The rate of physiological change
and resultant impact on function is highly individualized, and
individual differences among older adults become strikingly
more apparent with increasing age.
A continuum of functioning among older adults has
been described by Spirduso, Francis, and MacRae (2005)
(Fig. 10-2). At the highest level of the physical-performance
hierarchy, physically elite older adults train on a daily basis,
compete in sports competitions, or continue to work in a
physically demanding occupation, such as firefighting or
ski instruction. Although not many can continue working
in these occupations into very old age, some do. Those
who do represent older individuals with maximum physical
capabilities. Physically fit individuals may still work in their
chosen occupation, may participate in activities with indi-
viduals younger than themselves, and continue to exercise
on a regular basis for their health and well-being. Physically
independent older adults are those individuals whose phys-
ical function status allows them to participate in advanced
activities of daily living (ADL) and who continue to be ac-
tive in hobbies and leisure and social activities. These in-
dividuals may have one or more chronic conditions, but
they are still able to function independently, although they
engage in less physically demanding activities than those
who are physically fit. Physically frail older adults can per-
form ADL but may have a debilitating condition or disease
that is physically challenging on a daily basis. They can live
independently with human or environmental assistance but
may be unable to engage in certain instrumental ADL
(IADL). Physically dependent older adults cannot perform
some or all basic ADL (BADL) because of acute or chronic
conditions, cognitive problems, or personal factors, such as
physical inactivity, smoking-related impairments, or in-
creased weight. These individuals require institutional care
or full-time assistance (Spirduso et al., 2005). Considering
the heterogeneity of aging and the continuum of physical

Physically Elite
• Sports competition
(i.e., Senior
Olympics)
• Participates in
high-risk and Physically Fit
power sports • Moderate
(e.g., hang-gliding, physical work
weight lifting)
• Participates in
• Continues to work Physically
endurance sports
in physically Independent
and games, and
demanding regular exercise
occupation • Very light
physical work
Physical Function

• May still be
working • Hobbies (e.g.,
walking,
gardening) Physically Frail

• Low physical • Light

demand activities housekeeping
(e.g., golf, social • Food preparation
dance, hand Physically
crafts, traveling, • Grocery shopping Dependent
automobile • Can perform some • Cannot complete
driving) IADLs, all BADLs some or all
• Can perform • Needs assistance BADLs:
all IADLs to live • Walking
independently • Bathing
• May be • Dressing
homebound • Eating
• Transfers
• Needs full-time
home or
institutional care
BADLs = basic activities of daily living; IADLs = instrumental activities of daily living.
FIGURE 102 The continuum of physical function for older adults. BADL, basic activities of daily living; IADL,
instrumental activities of daily living. (Adapted from Spirduso & MacRae, 2005, with permission.)
4605_Ch10_145-162 31/10/17 11:52 AM Page 148
148 PART II ■ Aging: Body Structures and Body Functions
functioning of older adults, it is important to remember
that although age-related changes do occur, deterioration
in physical abilities and functioning is not inevitable for all
older adults (Fig. 10-3). As described in Chapter 27, oc-
cupational and physical therapists must be aware of the
variety of age-related impairments during assessment for
preclinical disability.
Age-Related Changes in Muscle Strength
and Power
Muscle size and function change dramatically across the life
span, with initial growth-related rapid increases and aged-
related declines later on. It is thought that maximal muscle
strength, the amount of force produced in a single maxi-
mum contraction of a muscle or muscle group, is achieved
in the second or third decade and then declines. The effects
of aging on muscle strength have been examined by inves-
tigating various factors, including type of strength loss
(isometric, isotonic, or isokinetic), location of muscle strength
loss, and physical activity and comorbidities of the individ-
uals assessed.
Isometric strength has been found to change insignifi-
cantly until about the sixth decade but then decreases by
about 1 to 1.5 percent per year from 50 to 70 years of age
and about 3 percent thereafter (Vandervoort, 2002). Con-
centric strength decreases in a pattern similar to isometric
strength, with the most dramatic losses occurring after
70 years of age, with upper extremity muscles tending to
demonstrate less decline than the lower extremity muscles
(Amaral et al., 2014). Interestingly, eccentric strength de-
clines are not as dramatic as concentric strength changes
(Vandervoort, 2002) (Fig. 10-4).
FIGURE 103 This woman continues to be vigorous and active,
despite age-associated neuromusculoskeletal changes. (Courtesy of
the Menorah Park Nursing Home, Cleveland, Ohio, with permission.)
120
% Young Adult Isometric Strength
Eccentric
110
100
Isometric
90
80
70 Concentric
60
50
40
30
20 30 40 50 60 70 80 90
Age (Years)
FIGURE 104 Effect of age on maximal strength throughout the
human life span. The shape and height of the schematic curves
depend on the type of strength being measured: isometric,
concentric, or eccentric. (From Vandervoort, A. A. (2002). Aging of the
human neuromuscular system. Muscle and Nerve, 25, 17–25, with
permission.)
Dynamic strength changes over time in functional muscle
groups using an isokinetic dynamometer, which assesses iso-
kinetic strength, the maximum torque that can be generated
through a specific joint ROM at a preestablished velocity of
limb movement have been examined. Isokinetic knee exten-
sion strength decreases of 25 to 35 percent over a 12-year pe-
riod have been reported (Frontera et al., 2000); a 14-percent
decrease per decade in isokinetic knee extensor strength and
a 16-percent decrease per decade in isokinetic knee flexor
strength have also been reported (Hughes et al., 2001). The
findings of the study by Hughes and colleagues (2001) sug-
gest there is variability in the response to aging by different
muscles groups, particularly in women. See Vandervoort
(2002) for a comprehensive review of age-associated muscle
strength loss.
Muscle power is the ability to generate force rapidly
(calculated as the product of the muscle force generated mul-
tiplied by the velocity of movement), thus is a combination
of both force and speed. Generating peak power requires tim-
ing and coordination. Strength and power are separate but
related muscle attributes. Measuring muscle power requires
more sophisticated and expensive instrumentation, and thus
it is performed less frequently in clinical settings. Age-related
declines in muscle power are greater than declines in muscle
strength, but age-related absolute power and relative power
(scaled to body mass) decrease at a similar rate: about 6 to
11 percent and 6 to 8 percent per decade, respectively
(Spirduso et al., 2005).
Sarcopenia and Age-Related Changes
in Muscle Structure
Why do strength and power decrease with aging? Both mus-
cle strength and muscle power are dependent on the number
and diameter of the myofibrils within muscle cells, specific
muscle fiber types, and the coordination of the neurological
elements that control muscle contraction. A variety of changes
in skeletal muscle structure occur with aging (Kirkeby &
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CHAPTER 10 ■ Neuromuscular and Movement Function: Muscle, Bone, and Joints
Garbarsch, 2000; Power, Dalton, & Rice, 2013; Suetta,
Magnusson, Beyer, & Kjaer, 2007, see Box 10-1). The loss
of muscle mass associated with aging, sarcopenia, is one of
the main determinants of musculoskeletal impairments and
reduced function in older adults. According to the interna-
tional Working Group on Sarcopenia, the definition of
sarcopenia has evolved to its current definition, “the age-
associated loss of skeletal muscle mass and function” (Fielding,
et al., 2011, pp. 249–256). Sarcopenia is a complex syndrome
that is associated with muscle mass loss alone or in conjunc-
tion with increased fat mass (Fielding et al., 2011). The
prevalence of clinically significant sarcopenia increases with
age. Although sarcopenia is prevalent in both men and
women, some evidence suggests that sarcopenia is more
prevalent in older men. For example, Iannuzzi-Sucich, Prest-
wood, and Kenny (2002) found the prevalence of sarcopenia
to be 22.6 percent in women and 26.8 percent in men. A sub-
group analysis of those 80 years or older revealed prevalence
rates of 31.0 percent in women and 52.9 percent in men.
AROUND THE GLOBE: Sarcopenia, Sarcopenic Obesity,
and Disability in Older Adults
Sarcopenic obesity—low muscle mass combined with high fat
mass—is more common in older adults because of the natural
changes in body composition associated with aging and is a
global concern. Sarcopenia and sarcopenic obesity among older
adults (aged 65 years and older) in nine high-, middle-, and low-
income Asia, Africa, Europe, and Latin America countries were
examined.
The prevalence of sarcopenia ranged from 12.6 percent
(Poland) to 17.5 percent (India). Prevalence of sarcopenic
obesity by country was as follows: China (2.9 percent), Ghana
(5.4 percent), India (1.3 percent), Mexico (10.2 percent),
Poland (8.5 percent), Russia (8.3 percent), South Africa
(10.3 percent), and Spain (11 percent). Both sarcopenia and
sarcopenic obesity were found to be significantly associated
with disability. In all or most of the countries, advanced age,
BOX 101 Age-Related Changes in Muscle Morphology
■ Decline of total muscle fiber number
■ Atrophy of some fibers, hypertrophy of other fibers
■ Loss of muscle mass
■ Increased lipofusion
■ Increased fatty and connective tissue
■ Ringbinden (aberrant myofibril wrapped around muscle
fibers) found
■ Cytoplasmic bodies found
■ Myofibrillar degeneration
■ Streaming of Z lines
■ Denervation of muscle fibers
149
female sex, lower education and wealth, lower physical activ-
ity, and greater number of chronic conditions were signifi-
cantly associated with higher levels of disability. This study
highlights the need for early preventive measures that specifi-
cally target sarcopenia and sarcopenic obesity to promote
healthy aging and minimize the risk for disability and its as-
sociated lower quality of life (Tyrovolasa et al., 2015).
Sarcopenia should not be confused with muscle atrophy
that occurs with lack of physical activity, disuse atrophy.
Sarcopenia is present in healthy, independent older adults
and occurs even in master athletes who maintain very high
levels of physical activity, suggesting that aging per se is the
main cause of muscle mass loss (Cruz-Jentoft, et al., 2014).
With sarcopenia, the size of the muscle mass that is able to
contract decreases, and thus, there is a decrease in strength.
This loss in muscle mass is clearly evident when comparing
the cross-sectional muscle area of a young adult and an older
adult (Fig. 10-5). Studies have found high correlations be-
tween muscle mass and strength in both longitudinal and
cross-sectional studies (Frontera et al., 2000; Hughes et al.,
2001). Decreases in muscle mass are consistent with respect
to timing and magnitude of strength loss with aging and
directly or indirectly affect weakness (Suetta et al., 2007).
However, in adults over 70 years of age, muscle weakness
occurs at a faster rate than the rate of loss of muscle mass
(Goodpaster et al., 2006). Although sarcopenia accounts for
a large amount of strength loss in older adults, clearly it does
not fully explain the strength loss picture. The underlying
cause of decreased muscle strength and function is multifac-
torial, and more than likely the extent of contributions and
interactions of numerous factors varies among individual
older adults (Fig. 10-6).
Muscle fibers are characterized as slow- or fast-twitch
fibers. Slow-twitch fibers (type I) contract very slowly, are
fatigue resistant, and are recruited when muscle contractions
must be maintained for long periods (e.g., maintaining an
upright position). Fast-twitch fibers (type II) contract very
rapidly and develop high tension, although this tension can
only be sustained for short periods. Type IIb (fast glycolytic)
fibers are recruited for activities that require rapid and powerful
FIGURE 105 Magnetic resonance images through the mid-thigh
of a healthy 25-year-old (left) and a healthy 75-year-old (right),
illustrating sarcopenia. The older adult’s image shows smaller
muscle mass (light gray), more subcutaneous fat (dark gray), and
increased intramuscular fat (dark gray lines). (From Roubenoff, R.
(2003). Sarcopenia: Effects on body composition and function. Journal of
Gerontology: Series A. Biological Sciences and Medical Sciences, 58,
1012–1017, with permission.)
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150 PART II ■ Aging: Body Structures and Body Functions
Body Function and Structure Changes
Muscle
changes
Nervous Hormonal and
system immunological
(morphology
changes changes
and physiology)
Loss of muscle strength, power, and mass
Decreased
Health status, Nutrition Age,
activity level,
comorbidities status gender
inactivity
Environmental and Personal Factors
FIGURE 106 Multiple factors cause age-related changes in muscle
strength and power.
contractions, whereas type IIa fibers (fast oxidative-glycolytic)
contract at an intermediate speed. Studies of the aging ef-
fects on the microstructure of muscle, including fiber size,
number, and arrangement of fibers have found that there
is an overall loss of muscle fibers, both type I and type II,
and a significant decrease in the average size and propor-
tion of type II fibers (see Power et al., 2013). Age-related
muscle weakness may also be attributable to a decrease in
muscle force, specifically the amount of force each muscle
fiber can produce. An increase in fat and connective tissue
has also been found in aging muscle, resulting in decreased
muscle quality (Kent-Braun, Ng, & Young, 2000). The
accumulation of fat within and around muscle tissue is
associated with muscle weakness, mobility limitations, and
increased risk of hip fractures (Lang et al., 2010; Marcus,
Addison, Kidde, Dibble, & Lastayo, 2012; Tuttle, Ward,
& Lieber, 2012; Visser et al., 2005) suggesting that these
age-related changes in muscle composition contribute to
slowness and incoordination of muscle contractions. This
replacement of muscle tissue is important because it may
disrupt the normal orientation of the myofilaments. Loss
of muscle tissue in combination with a decline in skeletal
muscle fiber numbers reduces the tension a contracting
muscle can generate.
Muscle fibers are innervated by motor neurons, and all
of the muscle fibers innervated by one motor neuron com-
prise the motor unit. Approximately 1 percent of the total
number of motor neurons is lost per year beginning in the
third decade, and this rate increases after age 60 (Power et al.,
2013). Age-related loss of motor neurons preferentially
affects type II motor units (Power et al., 2013), and age-
related decreases in motor axon conduction velocity also
occur (Delbono, 2003). These changes result in a decreased
ability to generate muscle force in general and to generate
force rapidly.
Skeletal muscle function relies on protein metabolism.
Decreased rates of myofibrillar protein synthesis and increased
protein turnover that occur with aging may be responsible
for increased muscle fatigability and a decrease in type II
fibers, respectively (Iannuzzi-Sucich et al., 2002; Short &
Nair, 2001). Diets low in protein have been shown to lead
to decreased muscle mass and function in older individuals
(Campbell, Trappe, Wolfe, & Evans, 2001; Iannuzzi-
Sucich et al., 2002). Although decreased nutrition may be
more prevalent in older adults in hospital or institutions,
community-dwelling older adults may also have inadequate
intakes of protein and energy requirements (Vellas et al.,
2001) for a variety of reasons, including age-related changes
in the digestive and sensory systems, depression, social
isolation, and functional losses secondary to acute and
chronic health problems.
Another factor that may affect age-related changes in mus-
cle strength is a decrease in the number of capillaries per mus-
cle fiber. The larger the number of capillaries per muscle fiber
or the larger the number of capillaries that surround a muscle
fiber, the better the oxygen exchange capacity. Last, hormonal
and immunological alterations may contribute to sarcopenia.
Aging is associated with a decrease in the growth hormone,
insulin-like growth factor-1, and the sex hormones testos-
terone and estrogen. These decreases may also contribute to
age-related changes in muscle structure and strength (Power
et al., 2013). Different muscles in an older adult change to
different degrees, with respect to reduction in the numbers of
fibers. Despite the inevitable changes with aging, several stud-
ies dating back years have demonstrated that older individuals
who have higher levels of physical activity tend to preserve
their muscle architecture and performance and experience only
moderate losses in muscle strength and physical function (see
Ciolac, 2013).
Age-Related Muscle Changes and Function
Muscle strength is one of the main determinants of movement
and performance of almost every ADL: 13 percent of men
aged 65 to 74 years and 40 percent aged 85 years and older
are unable to perform at least one of the following activities:
lift a 10-pound weight, stoop or kneel down, reach overhead,
write or grasp small objects, or walk two to three blocks.
Among women, 19 percent of those aged 65 to 74 years and
53 percent of those aged 85 years and older are unable to per-
form at least one of these activities (Federal Interagency
Forum on Aging-Related Statistics, 2016). Skeletal muscle
weakness can lead to impaired mobility and functional per-
formance, decreased walking speed, loss of independence,
poor balance, an increased risk of falls, hospitalization, and
mortality (Cawthon et al., 2009; Federal Interagency Forum
on Aging-Related Statistics, 2016; Newman et al., 2006;
Suetta et al., 2007; Visser et al., 2005). Decreases in lean body
mass and concomitant increase in fat mass associated with old
age, and displacement of the body, such as during walking,
will place a greater metabolic load on muscle fibers, causing
an increase in the energy cost of walking (Malatesta et al.,
2003). Hence, sarcopenia not only leads to muscle weakness
4605_Ch10_145-162 31/10/17 11:52 AM Page 151
CHAPTER 10
and reduced function and mobility but is also associated with
increased metabolic cost of movement.
Muscle power may be even more influential than muscle
strength on an older adult’s mobility, physical function, and
functional performance (Bean et al., 2002; Marsh, Miller,
Rejeski, Hutton & Kritchevsky, 2009; Mayson, Kiely,
LaRose, & Bean, 2009). This is extremely relevant because
mobility and most ADLs (e.g., walking or rising from a chair)
require the generation of power in addition to strength.
Lower extremity muscle power has been shown to be predic-
tive of self-reported disability in community-dwelling older
women (Foldvari et al., 2000) and correlated with gait speed,
chair-rise time, and stair-climb time (Bean et al., 2002), bal-
ance problems, and falls (Marsh et al., 2009; Mayson et al.,
2009; Skelton, Kennedy, & Rutherford, 2002).
Studies that have investigated the relationship between
functional activities and muscle strength and power suggest
that there are important reasons to maintain or to increase
muscle strength and power in older adults (Bean et al., 2002;
Marsh et al., 2009; Mayson et al., 2009) because there is a
link between impairments and the development of activity
limitations and participation restrictions (disability). For ex-
ample, impaired balance is a predictor of disability, with the
risk increasing when combined with muscle weakness
(Rantanen et al., 2001; Vermeulen, Neyens, van Rossum,
Spreeuwenberg, & de Witte, 2011). Slow gait speed and
lower extremity muscle strength are predictors of ADL dis-
ability (Vermeulen et al., 2011).
✺ PROMOTING BEST PRACTICE
Improving Peak Power in Older Adults
Community-dwelling older adults aged 60 years and older
were randomly assigned to one of four groups: no training,
low-intensity (20 percent 1 repetition maximum [RM]),
moderate-intensity (50 percent 1 RM), or high-intensity
(80 percent 1 RM) training. Training took place 2 days per week
for 8 or 12 weeks. The authors found explosive resistance training
at the three intensities produced similar relative improvements
in peak power; however, high-intensity training provided the
best improvements in strength and local muscle endurance.
The authors concluded that high-intensity explosive resistance
training is the best exercise strategy to simultaneously improve
whole-body peak power, muscle strength, and local muscular
endurance in healthy older adults (de Vos et al. 2005).
Age-Related Changes in the Skeletal System
This section describes the ways in which the skeletal system
forms and then changes in later life. The skeletal system
functions to:
■ provide a stable framework (mechanical support) that
enables muscle contractions to generate force and move-
ment (e.g., act as a lever system for muscle action),
■ protect soft tissues and vital organs,
■ Neuromuscular and Movement Function: Muscle, Bone, and Joints 151
■ serve as a reservoir for calcium homeostasis and a site for
red blood cell production, and
■ trap toxic minerals.
Late-life changes affect the extent to which these occur
effectively. Alterations in function can result in loss of func-
tion, even in the absence of specific disease or disorder.
Changes in Bone
Peak bone mass (PBM) is achieved during young adulthood;
after the third decade, bone mass declines. Initially the rate
of bone loss is slow and similar for men and premenopausal
women. It is important to note that the balance between
formation and resorption differs not only in different bones
(weight bearing and non–weight bearing) but also in different
bone tissue (cortical and trabecular). By 50 years of age,
women experience 6 percent and 37 percent of their total life-
time bone loss in cortical and trabecular compartments, re-
spectively, and men experience 15 percent and 42 percent of
total lifetime loss, respectively (Riggs et al., 2008). From
midlife onward, trabecular bone—spongy bone found in
joints and vertebrae—is lost at a steady rate, whereas the rate
of cortical bone—the dense bone found in long bones of arms
and legs and covering trabecular bone of joints and vertebrae—
increases (Riggs et al., 2004; Uusi-Rasi, Sievänen, Pasenen,
& Kannus, 2007). During the menopause transition, women
experience rapid bone loss at a rate of 2.5 to 3.0 percent of
their total bone each year (Greendale et al., 2011). After
about 10 years, the rate of loss slows again to match that of
men. For both men and women, PBM is tightly controlled
by genetics, and the bone lost due to temporary perturbations
such as bed rest, quickly recovers after successful rehabilita-
tion. For older adults, the consequence of the inevitable bone
loss depends upon PBM, the extent and rate of bone
turnover, and the “quality” of the bone tissue. If the strength
of the bone is not sufficient to resist the forces that act on it
during typical daily activities, stress fractures or osteoporotic
fractures will occur.
Adult bone undergoes continuous repair, accrual, and re-
lease of mineral stores and adaptive (re) shaping of the skele-
ton. The primary process through which the adult skeleton
repairs and adapts is called bone remodeling. The rate of bone
turnover is determined by the number of remodeling units
within a given space at a given time. The major types of bone
cells activated in a coordinated fashion within each remodel-
ing unit are osteocytes, cells embedded in mineralized bone
that direct remodeling when fatigue damage and changes in
the mechanical environment are detected; osteoblasts, cells
responsible for bone formation; and osteoclasts, cells respon-
sible for bone resorption. Remodeling is initiated on the bone
surface and the trabecular bone, found in spine, flat bones,
and the ends of long bones, and has greater surface area than
the less porous cortical bone surrounding the trabecular bone
and marrow. Therefore, more remodeling units are active in
the trabecular bone tissue, which explains the greater loss of
trabecular bone by midlife noted earlier. Modeling, the process
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152 PART II ■ Aging: Body Structures and Body Functions

responsible for bone shape, is less active during the second
half of life (Cointry, Capozza, Negri, Rold, & Ferretti, 2004).
Nevertheless, with aging, isolated osteoblast activity on the
outer surface of long bone cortical compartments results in
bone mineral spatial distribution such that the mechanical
strength is preserved to some extent as bone is lost.
Bone health is affected by nonmodifiable factors such as
age, cellular regulation and vitality, gender, and ethnicity and
by modifiable factors such as nutrition, exercise, body weight,
and hormones. After achieving PBM, strategies for increasing
bone mass have limited success (Karinkanta, Piirtola, Sievänen,
Uusi-Rasi, & Kannus, 2010). However, the rate at which
bone is lost may be attenuated by targeting modifiable factors.
For example, a 12-month trial randomized late perimenopausal
women to one of four groups—hormone replacement therapy
(HRT), exercise (primarily high-impact progressive resist-
ance), HRT and exercise, or usual physical activity (control);
all three treatment groups experienced an increase in bone
mineral content, but the combination HRT and exercise
group experienced the greatest positive adaptations at
almost every skeletal site assessed (Cheng et al., 2002).
Bone mineral was redistributed in the region that is weakest
for resisting bending; therefore, the small change in mineral
placement associated with HRT and high-impact progres-
sive resistance exercise may have significant effects on the
strength of the aging skeleton. Current research is examining
the role of muscle quality, fat distribution, and intercellular
communication on bone health. Two prevailing theories
describe the two-way communication between bone and
muscle: One is a biochemical/molecular theory of bone-
muscle crosstalk (Pedersen & Febbraio, 2012) and the other
is a mechanical theory (Frost, 2003). Bone, muscle, and fat
are derived from the same mesenchymal stem cells (MSCs),
and the development of MSCs depends to some extent
on environmental conditions. For example, the increased
adiposity observed in postmenopausal women accompanies
the drop in estrogen that promotes the development of
MSCs into osteoblasts rather than adipocytes (Okazaki
et al., 2002), whereas the decline in muscle strength pre-
cedes these changes. Others have shown that bouts of
low-intensity vibration stimulate bone and muscle forma-
tion, increase muscle force activity, and promote MSC dif-
ferentiation into osteoblasts rather than adipocytes (Sen
et al., 2011) It is possible that these two theories are com-
plementary rather than mutually exclusive in aiding the
understanding of the interconnection among muscle, fat,
and bone in health and disease.
Changes in Cartilage, Joints, and Tendons
Age-related changes in cartilage, tendons, and joints are asso-
ciated with alterations in collagen and elastin extensibility and
decreases in various proteins found in cartilage (Table 10-1).
Connective tissue is found nearly everywhere in the body, and

TABLE 101 ■ Normal Age-Related Changes That Affect Bone, Cartilage, Tendons, and Joints

DESCRIPTION, STRUCTURE, AND FUNCTION CHANGES WITH AGING FUNCTIONAL IMPLICATIONS

Collagen The main protein of connective tissue and main Increased cross-linkage of fibers Increased stiffness of tissues
component of cartilage, ligaments, tendons, and bone
Increased shortening and Decreased mobility of
distortion of collagen fibers tissues
Arranged in crisscross pattern to provide structure Becomes more dense and stiff Decreased hydration
and tensile strength to connective tissue Decreased tensile strength
Elastin A connective tissue protein Progressive decrease in amount Decreased elasticity of
of elastin tissues
Lattice-type network arrangement allows elastin to return Decreased ease of
to its original shape after being stretched movement of tissues
Hyaluronic acid Secreted by connective tissue ribosomes, especially those Decrease in hyaluronic acid Decreased tensile strength
in cartilage secretion
Helps regulate viscosity of tissue Decrease in hyaluronic acid Tissue degradation
Decreases amount of friction molecule size
Glycoproteins Small molecules of soluble protein Decreased production and Decreased hydration of
release of glycoproteins tissues
Produces osmotic force in extracellular matrix, which
helps maintain fluid content of tissues
Proteoglycans Made up of a core protein to which chains of Aggrecan (large proteoglycan Decreased hydration of
glycosaminoglycans are attached found in articular cartilage) tissues
molecules become smaller
and structurally altered
Resist complete compression of cartilage during joint
motion
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CHAPTER 10 ■ Neuromuscular and Movement Function: Muscle, Bone, and Joints
all types of connective tissue have similar features. Collagen is
the basic protein component in fibrous connective tissue found
in bone, tendon, ligaments, and cartilage. Collagen fibers are
arranged in criss-crossing bundles that are chemically linked
(cross-linkage) to form structure in the body and are strong and
flexible in the younger years. As a person ages, there is in-
creased cross-linkage of fibers, resulting in more dense matri-
ces. As these matrices become denser, the collagen structures
become stiffer, and the cellular movement of nutrients and
wastes becomes impaired. Elastin molecules also have a specific
arrangement (a lattice-type network) that allows elastin to return
to its original shape after being stretched. With aging, the
amount of elastin also decreases, further affecting the elasticity
of tissues. Many of the cellular changes seen with aging are
also seen in cases of inactivity or when the effects of weight
bearing are limited, such as bed rest. Thus, lack of exercise and
activity can accentuate the normal effects of aging on connec-
tive tissue.
Synovial joints are typically found at the end of long bones
of the upper and lower extremities. The ends of the bones are
covered with hyaline cartilage, which acts as a shock absorber
and, along with synovial fluid, greatly decreases the amount
of friction during joint movement. Cartilage is a unique con-
nective tissue that is avascular. Rather, blood flow in adjacent
bones and synovial fluid provide the nutrients to the chon-
droblasts. Chondroblasts secrete glycoproteins and hyaluronic
acid that lubricate the joint. The joint capsule that surrounds
the joint is composed of a thick layer of dense connective tis-
sue, and a synovial membrane lines most of the joint cavity.
The membrane produces synovial fluid that fills the joint cavity
and provides lubrication, nourishes the articular cartilage, and
acts as a shock absorber when the joint is compressed. With
aging, the cartilage that normally covers the joints thins and
deteriorates, especially in the weight-bearing joints. Decreases
in water content of the cartilage, decreased hydration of the
joint, decreased elasticity of the joint capsule, and increased
fibrous growth all contribute to increased joint stiffness. In
addition to the muscle structure and characteristic changes de-
scribed previously in this chapter, muscle tissue becomes less
flexible and more rigid, secondary to a decrease in elastin and
an increase in collagen. Tendons and ligaments also become
less resilient to length changes.
Flexibility and ROM depend on the condition of the soft
tissues of the joints, tendons, ligaments, and muscles and
are specific to each joint of the body. Maximum ROM is
achieved in the mid- to late-20s and gradually decreases
with age, about 20 percent to 30 percent between the ages
of 30 and 70 years. Older adults tend to be less flexible than
their younger counterparts, although there is a sex differ-
ence with women typically being more flexible than men
(Milanović et al., 2013). Descriptive data on age-related dif-
ferences (age range of 55–85 years) in flexibility in a large
cross-sectional sample of male and female community-
dwelling older adults suggests a decrease in flexibility of the
shoulder and hip joints by approximately 6 degrees per
decade across ages 55 to 86 years in both men and women.
153
Further, both shoulder and hip joints demonstrate signifi-
cant declines after 70 years (Stathokostas, McDonald,
Little, Vandervoort, & Paterson, 2013). Inadequate ROM
and inflexibility in older adults may affect functional tasks
(e.g., putting on one’s coat), ADL (e.g., reaching into the
cupboard to put away groceries), and general mobility (e.g.,
walking, bending, and stair climbing). Loss of flexibility
(e.g., spine) and ROM (e.g., ankle) have important impli-
cations for older adults because these impairments can lead
to an increased risk of falls and gait changes seen with aging
(see Chapters 11 and 16).
Age-Related Changes in the Nervous System
As it ages, the nervous system also undergoes numerous
changes, resulting in alterations in sensory (see Chapter 9
and 14), reflex, and motor function. The changes that com-
monly occur in the nervous system of older adults are summa-
rized in Box 10-2, and possible causes include the following:
■ Biochemical and morphological changes in the neurons
and receptors
■ Loss of neurons
■ Defects in neuronal transport mechanisms
■ Decreases in myelin reducing the conduction velocity of
nerves
■ Defects in protein synthesis
■ Cumulative trauma
■ Oxidative stress and vascular changes
Alterations in specific morphological and biochemical
parameters have not always been directly correlated with
functional changes. The functional integrity of the nervous
system in most healthy, older adults is maintained despite
the reported structural, biochemical, and metabolic changes
in the aging nervous system. However, disorders of the
BOX 102 Age-Related Changes of the Nervous System
■ Cerebral atrophy
■ Increased cerebrospinal fluid space
■ Specific neuronal loss
■ Reduced dendritic branching
■ Increased lipofuscin granules
■ Decreased effectiveness of neurotransmitter systems;
selectively reduced activities in dopaminergic, cholinergic,
and noradrenergic systems
■ Reduced cerebral blood flow
■ Diminished glucose utilization
■ Alterations in electroencephalogram
■ Loss of motor nerve fibers
■ Decreased number and size of motor units
■ Slowing of nerve conduction velocities
■ Increased plaques and neurofibrillary tangles in selective
brain regions
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154 PART II ■ Aging: Body Structures and Body Functions
central nervous system (CNS), such as stroke (Chapter 15),
are the most common cause of disability in older adults.
Changes in the aging nervous system may contribute to
postural instability, impaired sensation, muscle weakness,
abnormal gait patterns, and falls. It is important to remem-
ber that each older individual responds to changes in the
neuromuscular system in a unique manner. For example,
slowing of reaction time may not be a function of a nervous
system decline but rather may be related to the unique ac-
tivity levels of older individuals. Many of the balance prob-
lems and gait disorders in the older adults are probably
related to pathology rather than a manifestation of a gen-
eralized aging process.
Assessing the Neuromusculoskeletal
System in Older Adults
A comprehensive assessment provides the health-care pro-
fessional with the necessary information to design appropriate
intervention and management programs. However, because
the older adult may present with normal age-related changes
in addition to changes related to chronic illnesses or comor-
bidities, assessment may be more challenging, and differen-
tiating between changes due to normal aging and changes
due to pathology may not be straightforward. Chapter 27
provides conceptual frameworks for assessment of functional
performance and extensive detail regarding the purposes of
assessing the older adult, a philosophy of client-centered and
contextually based assessment, assessment issues specific to
the older adult, and methods and tools one can use to assess
older adults.
Range of Motion and Flexibility Assessment
Measurement of joint ROM is commonly assessed using a
universal standard goniometer or through observation of
functional movement, noting deficits in function based on
joint range. Comparisons are also made with the unin-
volved limb or with age and gender norms expected for
each joint. Comparison to standard norms is not appropri-
ate unless the norms include older groups because studies
have found differences in ROM in older subjects compared
with younger subjects and differences in older adults by
age-groups (McIntosh, McKenna, & Gustafsson, 2003;
Milanović et al., 2013). These differences should be kept
in mind to develop realistic management goals. However,
for many older adults, a more important issue centers on
the requirements for completing desired occupations. Even
if ROM is within normal limits for individuals of a partic-
ular age, if greater ROM is required for, say, hobbies such
as weaving or car repair, it is the latter that has a greater
impact on the individual’s quality of life.
Flexibility is a measure of the extent to which joint ROM
is limited by the extensibility of joint soft tissues as well as
tendons and muscles. Lower and upper extremity flexibility
can be measured by the “sit-and-reach test” (Nieman, 2003)
and the “back-scratch test” (Rikli & Jones, 2001), respec-
tively. These tests should be administered only after mea-
suring and confirming normal individual joint range of
motion (e.g., hip flexion allowing the knee to simultaneously
flex, and elbow flexion with the arm at rest by the side).
With the sit-and-reach test, the individual completes a
warm-up activity such as walking or cycling and then sits
facing a flexibility box with shoes off, knees fully extended,
and feet flat against the box. The individual is instructed to
reach directly forward as far as possible along a measuring
scale four times, and the distance point reached on the fourth
trial is measured (Nieman, 2003). Rikli and Jones’s (2001)
“chair sit-and-reach test” is a modification of the sit-and-reach
test, which allows the older adult to remain seated in a chair
for testing. The individual is instructed to reach toward his
or her toes keeping the knee extended, and the distance the
person can reach beyond the toes is recorded. Limitation of
reach indicates shortness in hamstring muscle group inhibit-
ing full hip flexion and decreased flexibility in the posterior
ligaments and muscles of the vertebral column. The back-
scratch test is administered by instructing the individual to
reach one hand over the shoulder and one up the middle of
the back, and the distance between the extended middle fin-
gers is recorded (Rikli & Jones, 2001). Limitation noted in
this test points to shortened triceps in the upper extremity
reaching over the shoulder or (and) shortness in the external
rotators, posterior joint capsule, and scapular retractors of
the extremity reaching up the back.
Muscle Strength and Power Assessment
Assessing strength is an important element in the overall
assessment of the older adult, and baseline measurements
are necessary before the initiation of an exercise program to
determine who would most benefit from an intervention
and to quantify the outcome of the intervention. Muscle
strength can be assessed in clinical settings using various
methods including manual techniques, instrumentation,
and functional activities. It is important to note that with
some older adults, it may be necessary to modify the meth-
ods that are commonly used when performing these proce-
dures because of pain, joint deformities, or limitations in
endurance and flexibility. These strength-testing methods
are listed in the online ancillary materials. The more sophis-
ticated and expensive dynamometers that measure isokinetic
torques also have their place in testing muscle force in older
adults. One of the greatest advantages of isokinetic testing
is that it can be used to determine movement capability at
different speeds and thus may be better able to quantify
age-related changes than manual muscle testing. Assessing
dynamic strength is important in older adults because com-
mon ADL and activities (e.g., walking and rising from a
chair) require speed and the generation of power in addition
to strength. Additional methods that have been developed
to assess lower extremity muscle power in older individuals
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CHAPTER 10 ■ Neuromuscular and Movement Function: Muscle, Bone, and Joints
include vertical jump on a force platform, unloaded leg
extensor power evaluation, and evaluating muscle power
output using lower extremity pneumatic resistance train-
ing equipment (Callahan, Carabello, Phillips, Frontera, &
Fielding, 2007). Therapists should be aware that isokinetic
testing velocities are still significantly lower than many
everyday movements (Kisner & Colby, 2012). Caution
should be used, especially when testing older adults with
osteoporosis or when testing the upper extremity of older,
frail individuals because testing the isokinetic strength of
these muscles may cause an exaggerated blood pressure re-
sponse. The use of isokinetic dynamometers is also limited
because they are not transportable.
As an alternative to more standardized tests for muscle
weakness, an older adult’s performance of a functional activity
can be used to assess strength, for example, as an individual
rises from a chair, climbs stairs, or walks. A functional test
might indicate that the individual is able to ascend six steps
without assistance but needs minimal assistance to complete
a total of 12 steps. The sit-to-stand test is a measurement of
the time taken to complete several chair stands and examines
lower extremity strength (Csuka & McCarty, 1985; MacRae,
Lacourse, & Moldavon, 1992). For older adults, this kind of
assessment may be the most relevant because it measures
function, rather than absolute strength. It is not unusual for
an older adult to be more functional than might be expected
on the basis of manual muscle testing or dynamometer testing
because motivation and other factors work in combination
with muscle strength to produce movement. In addition,
physical assessment measurement tools, such as the Physical
Performance Test (Reuben & Sui, 1990) and the Continuous-
Scale Physical Functional Performance Test (Cress et al.,
1996), can be used in the clinical setting. Although they do
not specifically measure muscle strength per se, the test items
simulate ADL and components of fine or gross motor func-
tion and muscular endurance. These functional concerns are
of greatest importance in working with older adults as they
manage their daily lives.
Management of Neuromusculoskeletal
Impairments in the Older Adult
Positive aging equates to sustaining a high quality of life, pri-
marily through the maintenance of functional independence.
Research suggests that participation in physical activities may
help control chronic conditions and decrease the impact of
the normal changes associated with aging. Resistance training
exercises can also reverse many of the age-related physiologic
changes, in addition to improving strength and function.
Numerous benefits of participation in regular physical activity
have been identified for older adults in the past 2 decades.
The extent to which changes related to aging, such as de-
creased muscle mass and strength, can be ameliorated with
interventions, including specific exercise programs, have been
the focus of numerous research studies.
155
✺ PROMOTING BEST PRACTICE
Lifestyle-Based Occupational Therapy Intervention
Promotes Well-Being in Older Adults
A randomized controlled trial investigated the effectiveness
of a lifestyle-based occupational therapy intervention in
promoting well-being among older people living in the
community. The Well Elderly 2 study recruited ethnically
diverse (37 percent white, 32 percent African American,
20 percent Hispanic or Latino, 4 percent Asian, and 6 percent
“other”) adults aged 60 to 95 years and randomly assigned
them to a lifestyle-based occupational therapy intervention
or no intervention. The intervention comprised 6 months
of small group (6–8 people) and individual sessions led by a
trained occupational therapist and included identification
and implementation of feasible and sustainable activity-
relevant changes, developing plans to overcome obstacles to
participating in activities (e.g., pain or lack of transport), and
participation in selected activities, and rehearsal and repetition
of changes to everyday routine. Older adults in the intervention
group had significantly greater improvements than those in
the control group in several SF-36 domains: bodily pain, vitality,
social function, mental health, as well as improvement in life
satisfaction and decreased depression. The intervention was
also deemed cost-effective (Clark et al., 2012).
Examination of positive aging reveals the degree to which
factors extrinsic to aging and disease process (nutrition,
lifestyle and daily routine, degree of social support, amount
of exercise, and sense of autonomy and control) play a strong,
positive role in enabling older individuals to maintain their
health and independence. Research has shown that remain-
ing active and productive is a critical component of healthy
aging (Cherry, Marks, et al., 2013; Cherry, Walker, et al.,
2013; Lin, Hsieh, Cheng, Tseng, & Su, 2016; Nilsson,
Nyqvist, Gustafson, & Nygård, 2015). Occupational and
physical therapists play key roles in promoting healthy
lifestyles in older adults. Health and quality of life can be pro-
moted through specific exercise programs and management
plans, and occupation-based interventions that include mean-
ingful choices of activities and productive activities (Fig. 10-7).
A variety of factors have been found to determine adherence
to exercise in older adults. Some of these increase adherence
(motivators), whereas others decrease adherence (barriers).
One of the strongest motivators affecting exercise adherence
in older adults is self-efficacy (Resnick, 2001; Resnick &
Spellbring, 2000), the concept that a person is capable of con-
trolling his or her own behavior (see Chapter 30 for more
information about self-efficacy). Outcome expectation, the
belief that specific consequences will result from specific per-
sonal actions, is another strong motivator (Resnick, 2001;
Resnick & Spellbring, 2001). Barriers to exercise for older
adults include fear of falling or injury; lack of time, social sup-
port, a physical space to exercise, or transportation to the
exercise site; and insufficient resources either to buy exercise
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156 PART II ■ Aging: Body Structures and Body Functions
FIGURE 107 Regardless of physical abilities or function, exercising
and remaining physically active are key to successful aging,
especially when personally meaningful and enjoyable. (Courtesy
of the Geriatric Day Hospital, Specialized Geriatric Services, Saskatoon
Health Region, Saskatoon, Saskatchewan, with permission.)
equipment or to join an exercise facility (King et al., 2002).
In addition, stress and depression, increased age, decreased
health status, and lack of enjoyment while exercising are
associated with poor exercise adherence (Resnick, 2001;
Resnick & Spellbring, 2000).
Older adults have specific purposes and goals when seek-
ing interventions or when beginning an exercise program, and
these client-specific needs must be considered when devel-
oping a management plan. For example, some may want to
address the age-related changes that have manifested and in-
terfere with physical function; others may want to prevent
further decline. Some may seek to participate in an exercise
program to improve overall fitness or for general health ben-
efits, and others may be drawn by the social interactions of-
fered by group exercise programs. Because of the variability
in personal preferences, lifestyle, fitness levels, and potential
or actual comorbidities, it is important that exercise and phys-
ical activity programs are tailored and appropriate for the
older individual. Areas of focus for intervention need to be
based on the older adult’s needs and interests to be meaning-
ful and purposeful.
Because typical age-related changes can cause impair-
ments, older adults are at risk for functional decline and may
have difficulty performing their daily occupations. Programs
should be comprehensive and include exercises to increase or
maintain strength, flexibility, postural stability, and en-
durance (see Chapters 8 and 13 for endurance exercise pre-
scriptions and Chapter 16 for a balance exercise prescription).
Activities should also be included that are tailored to the
functional needs of the client. Any exercise or activity pro-
gram should be designed to emphasize safety in addition to
meeting its goals and objectives. Age-related differences in
response to exercise need to be taken into consideration, and
modifications may be required when developing a program.
Exercise prescription and training guidelines for older adults
have been published (e.g., American College of Sports
Medicine [ACSM], 2009; Haskell et al., 2007; World
Health Organization, 2010), are described briefly below, and
are summarized in Table 10-2.
Strength and Resistance Exercises
Although there is no evidence to date suggesting that
strength training halts the age-related loss of muscle fibers,
it has been well documented that systematic strength training
programs can improve skeletal muscle strength in the older
adult population, including the young-old, the very-old,
those who are frail (see de Labra, Guimaraes-Pinheiro,
Maseda, Lorenzo, & Millán-Calenti, 2015; Liu & Latham,
2009), and those who have sustained an injury, such as post
hip fracture (Mangione, Craik, Palombaro, Tomlinson, &
Hofmann, 2010) or injurious fall (Sherrington, Tiedemann,
Fairhall, Close, & Lord, 2011). Changes in the muscles of
older adults following strengthening programs are similar to
the gains observed in younger subjects who participate in
exercise. In addition, various training methods, including
endurance-training programs (see Chapter 8, 13), have been
used with varying degrees of success to accomplish an in-
crease in strength in older persons (see de Labra et al., 2015;
Liu & Latham, 2009).
✺ PROMOTING BEST PRACTICE
Importance of Dose in Strength Training Programs
for Older Adults
The American Physical Therapy Association partnered
with “Choosing Wise” to identify specific evidence-based
recommendations that encourage both patients and physical
therapists to make wise decisions about the most appropriate
care. One of the final recommendations was for older adults:
Don’t prescribe underdosed strength training programs for
older adults. Instead, match the frequency, intensity, and
duration of exercise to the individual’s abilities and goals
(White, Delitto, Manal, & Miller, 2015).
Research across the globe on the effects of strengthening
exercises for older adults has been summarized in a systematic
review of progressive resistance strength training by Liu &
Latham (2009). Progressive resistance training was found to
improve physical disability, gait speed, chair rise speed, and
muscle strength. Aerobic capacity also improved (Liu &
Latham, 2009). In general, older men and women were able
to safely engage in a strength-training exercise program with
supervision, regardless of the type of exercise and the intensity
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CHAPTER 10 ■ Neuromuscular and Movement Function: Muscle, Bone, and Joints 157

TABLE 102 ■ Evidence-Based Exercise Prescription for the Older Adult

EXERCISE TYPE EXERCISE PARAMETERS BENEFITS PRECAUTIONS FOR THE OLDER ADULT
Stretching ■ Static stretches—10–30 second hold for Documented benefits ■ Stretching exercises should be
each major U/E and L/E muscle/tendon ■ Improved flexibility performed through pain-free
group ■ Improved joint ROM ROM only
■ At least 4 repetitions for each muscle Potential benefits
group ■ Improved function

■ At least 2 to 3 days/week; every day is ■ Decreased risk of injury

preferable
Strengthening/ ■ Moderate (60 percent of 1 RM) to high Documented benefits ■ Severely deconditioned older
Resistance intensity (70 to 80 percent of 1 RM) ■ Increased strength adults or those with known
■ 8 to 12 repetitions ■ Increased walking endurance exercise risk factors require close
■ 1 to 3 sets ■ Improved mobility supervision and an initial low
■ 3 times/week ■ Increased stair-climbing endurance intensity program
■ Decreased functional/ADL decline ■ Exercises should be performed
■ Increased functional ability pain-free ROM
Potential benefits ■ Movements should be controlled
■ Improved quality of life

■ Improved sense of well-being

Balance See Chapter 11 and 16

Endurance/ See Chapter 8 and 13
Aerobic

Note. ADL = activities of daily living; L/E = lower extremity; RM = repetition maximum; ROM = range of motion; U/E = upper extremity.
Data in part from American College of Sports Medicine. (2009). Special communication: Position stand. Exercise and physical activity for older adults. http://journals.lww.
com/acsm-msse/Fulltext/2009/07000/Exercise_and_Physical_Activity_for_Older_Adults.20.aspx

of the program. Adverse events were not typically reported, but
when they were, joint and muscle pain were the most common
adverse events. Older adults who participate in strength-
training research studies are typically carefully screened for risk
factors and exercise contraindications, but some studies did not
monitor and report adverse events, making it difficult to assess
the risk of injury (Liu & Latham, 2009). Thus, it is not known
whether participation in strength training increases an older
adult’s cardiovascular risk. Before the initiation of any vigorous
exercise program, the older adult, especially if known cardio-
vascular risk factors are present, should undergo a medical eval-
uation and appropriate stress testing (ACSM, 2009).
Isometric, isotonic, and isokinetic muscle strengthening
programs, simple active exercises using body weight as resist-
ance, and walking and aerobic exercise programs have been
found to be successful at increasing U/E and L/E strength in
older men and women. Early strengthening studies focused
on low-intensity programs. However, in the past decades
the benefits of moderate- to heavy-resistance programs have
been demonstrated, with remarkable gains. Strength gains
achieved in the healthy, older adult are maintained for at least
short periods after the formal exercise program is discontin-
ued, and some studies have documented structural changes
of the muscles, specifically increases in cross-sectional type
IIb fiber areas, following formal exercise programs in older
individuals. In addition, there is evidence that even frail older
adults in long-term care or nursing home settings can tolerate
heavy-resistance programs and can make similar gains as
healthy, community-dwelling older adults. Improvements ex-
tend beyond impairments, with significant functional benefits
reported (see de Labra et al., 2015; Liu & Latham, 2009).
However, effects of strengthening exercises on psychological
well-being and participation restrictions remain unclear be-
cause these areas have not been well studied, and the few
studies completed report inconsistent results.
It is worthwhile to remember that some older adults may
not be particularly interested in traditional exercise programs.
Identifying more functionally based activities such as yoga, tai
chi, cycling, or ballroom dancing that the individual may find
more enjoyable can promote greater health benefits because of
the increased probability of actual participation. Determining
what might appeal to the individual is an area for important
collaboration between the physical and occupational therapists.
INTERPROFESSIONAL PRACTICE
Exercise Considerations for the Older Adult
■ Use simple directions and gestures.
■ Ensure adequate warm-up and cool-down.
■ Take into consideration current and potential musculoskeletal
problems, chronic conditions, and functional limitations.
■ Institute short and graded exercise sessions, but apply the
overload principle.
■ Use a variety of muscle contractions: isometric, isokinetic,
concentric, and eccentric.
■ Establish an exercise program with a focus on multiple
components (low-impact aerobic, muscular strength, power,
endurance, flexibility, and balance).
■ Monitor skin for signs of heat stress, and monitor respiration,
and pulse rate in response to exercise.
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158 PART II ■ Aging: Body Structures and Body Functions
■ Exercise at a rate of perceived exertion (RPE) of 12 to 14
(“somewhat hard”) or use the talk test: the older adult should
be able to engage in a conversation during the exercise.
■ Older adults may gain less absolute strength.
■ Older adults may gain strength slowly.
■ Older adults may have less adaptability to exercise stress:
■ More susceptibility to injuries? Increased cramping during
exercise?
■ Older adults may have decreased oxygen consumption:
May fatigue more easily?
Flexibility (Stretching) Exercises
Flexibility exercises increase the length and elasticity of peri-
articular tissues and muscle, increase joint mobility, prevent
soft-tissue contractures, decrease risk of injury, and are
important to overall joint ROM (Kisner & Colby, 2012). The
following are types of flexibility exercises:
■ Static—a position is assumed, held for a period of time,
and then relaxed.
■ Ballistic—repetitive bouncing motions where the muscle
is rapidly stretched and immediately relaxed.
■ Proprioceptive neuromuscular facilitation—alternating iso-
metric muscle contraction (hold-relax), alternating isotonic
muscle contraction (contract-relax) or passive stretching
through a series of movements.
■ Dynamic—the joint is moved through full ROM repeti-
tively, such as with dancing or tai chi.
Of the types of exercises, flexibility exercises have not been
as well studied in older adults, and the ideal type and duration
of stretching exercises have yet to be determined. Studies have
found that older adults who participate in a program of regular
exercise or general exercise interventions can increase ROM of
various joints (Stathokostas et al., 2012). Engaging in activities
such as tai chi and dancing has also been found to improve
flexibility (Keogh, Kilding, Pidgeon, Ashley, & Gillis, 2009;
Manson, Rotondi, Jamnik, Ardern, & Tamim, 2013).
✺ PROMOTING BEST PRACTICE
Flexibility-Specific Interventions Increase Range
of Motion in Older Adults
A systematic review suggests flexibility-specific interventions
may have effects on ROM-related outcomes. However, the
authors report that there is conflicting information regarding
the relationship between flexibility interventions and functional
outcomes or daily functioning. Because of the wide range of
intervention protocols, body parts studied, and functional
measurements, conclusive recommendations regarding
flexibility training for older adults or the validity of flexibility
training interventions as supplements to other forms of
exercise, or as significant positive influences on functional
ability, require further investigation (Stathokostas, Little,
Vandervoort, & Paterson, 2012).
SUMMARY
Clearly, changes that occur in the neuromusculoskeletal sys-
tems with aging can have negative consequences on functional
abilities. There is no clear line between “normal” aging and
what constitutes “disease” or “dysfunction.” Most older adults
manage their daily tasks quite well until some specific event,
such as a fall or an acute illness, changes their physical status
or an accumulation of small decrements or chronic disease im-
pairments reaches a breakpoint at which a particular activity
or set of activities becomes impossible. Although changes in
the neuromusculoskeletal systems may be a major factor as-
sociated with the loss of independence in ADL, factors other
than neuromuscular integrity, such as comorbidities (i.e.,
arthritis, impaired vision, changes in cognition and cardiores-
piratory symptoms), may cause a decline in functional abilities.
This chapter discussed the typical and expected age-related
changes in the neuromusculoskeletal systems and the resulting
impact on functional performance. It is important to recognize
that these generalizations about change reflect an “average”
and that individual variability is great. Physically active older
adults tend to have less disability than frail older adults who
are housebound or get out only infrequently.
Although not all-inclusive, a variety of assessments and
intervention strategies were presented in this chapter. An ex-
ercise program consisting of strength, flexibility, balance, and
endurance training can improve functioning of the neuro-
musculoskeletal systems. The training response is dependent
on a multitude of factors and requires a thorough understand-
ing of all the subsystems involved, and several factors should
be evaluated before establishing an appropriate program. If
the goal of care is to return or to maintain the older adult at
his or her highest functional level, it is paramount for health-
care providers to view each aging person as having unique life
experiences that influence mobility.
CASE STUDY
Elmer Stevens is a 78-year-old man who lives with his wife
in a two-story home. The bedroom and bathroom are on the
second floor, and he has no home equipment. Mr. Stevens
is a retired cattle farmer. When he retired from cattle farm-
ing at age 70, Mr. Stevens decided he would “take life easy
and let my son do all the hard work.” He helps his wife with
the gardening in the summer but finds it difficult to find
things to do “to keep busy” in the winter. He no longer goes
golfing. He has quit his recreational curling team and no
longer skates in the winter because he doesn’t feel like he
can keep up with his friends and is embarrassed that he
might fall. His current hobbies include playing bridge once
a week. Other than the beginnings of cataracts in both eyes,
he has no other health problems. Mr. Stevens states he is
independent with mobility and all ADL except tub transfers,
with which he needs minimal assistance from his wife.
Mr. Stevens has difficulty getting up from low levels and soft
surfaces. Upper extremity muscle strength was graded as 4
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CHAPTER 10 ■ Neuromuscular and Movement Function: Muscle, Bone, and Joints
(on MMT) for all major muscle groups. Lower extremity
muscle strength was graded as 4– for all major muscle groups
except bilateral hip flexion and abduction (graded 3) and
bilateral ankle DF (graded as 3–). Mr. Stevens uses arm
pushups to facilitate rising from the chair with extra effort.
This case will be continued in Chapter 11 to consider
how these changes affect Mr. Stevens’s gait and balance.
Questions
1. Using the ICF framework and the older adult
continuum of function, describe Mr. Stevens and
his current functional status.
2. What assessment findings might be related to normal
age-related changes in bone, muscle, and joints?
3. What other tests and measures might you include in
your evaluation to assess bone, muscle, joints, and
any associated changes in Mr. Stevens’s ability to
complete his daily activities? Why?
Critical Thinking Questions
1. What are the most profound changes in the aging
neuromusculoskeletal system? What are the func-
tional implications of these changes in the everyday
lives of older adults?
2. Your neighbor, Mrs. Elena Sampson, is a 73-year-old
woman without chronic illness. How would you
expect Mrs. Sampson’s muscular system to differ
from that of a 35-year-old individual? Be sure to
include both structural and histochemical aspects.
3. Compare three strength assessment procedures that
are commonly used with the older individual. Under
what circumstances should each be used?
4. Muscle strengthening programs in the older adult
have been successful. Describe any special considera-
tions that should be adhered to during strength
training of an older adult.
5. What components need to be considered when
prescribing a comprehensive exercise program to
an older adult?
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Neuromuscular and Movement Function:
Coordination, Balance, and Gait
Vanina Dal Bello-Haas
“Most old(er) people are young people—Bernard
LEARNING OUTCOMES
By the end of this chapter, readers will be able to:
1. Discuss the effects of aging on posture, coordination,
balance, and gait.
2. Explain assessment considerations for the older adult
and the specific procedures used for assessing posture,
coordination, balance, and gait.
3. Discuss the relationship between older adult function and
balance, coordination, and gait.
4. Identify interventions that may be used to prevent or lessen
age-related neuromusculoskeletal changes in posture,
coordination, balance, and gait in older adults.
Clinical Vignette
Mrs. Boupha Voeum is a 92-year-old widow who lives with
her adult son (age 67), his wife (age 73), and 30-year-old
grandson. Mrs. Voeum has her own living space on the main
floor of the house, which includes a bedroom, four-piece bath,
kitchen, and small den. Mrs. Voeum has osteoporosis, macular
degeneration, and diabetes. She uses a cane in her right hand
to walk because she has a severe thoracic kyphosis and hip flex-
ion contractures. Mrs. Voeum is originally from Cambodia and
continues to volunteer at her local church and the local immi-
grant community center. Both are located within 2 miles of
the home, and Mrs. Voeum either walks or takes the bus to
the church and volunteer center. Lately Mrs. Voeum has no-
ticed that she is becoming increasingly unsteady on her feet
and her walking is slower, such that she is rarely able to make
it through the crosswalk without the crossing sign changing
from “Walk” to “Don’t Walk.” Mrs. Voeum does not want to
give up her volunteer activities, nor does she want her son to
drive her to the church or community center.
1. What changes has Mrs. Voeum experienced that
would be considered “normal” age-related changes?
What changes would be considered “abnormal”?
CHAPTER 11
■ Norma J. MacIntyre ■ Sirirat Seng-Iad
in old bodies.
Isaacs
”
2. What additional information would be important for
you to gather from Mrs. Voeum?
3. On the basis of the information provided about
Mrs. Voeum, what issues might be the focus of your
intervention(s)?
A s described in Chapter 10, the variety of tissues that
make up the neuromusculoskeletal system undergo
normal age-related changes. These changes affect posture,
coordination, balance, and gait in older adulthood. This
chapter reviews:
■ The effects of aging on posture, balance, and gait and the
resultant impact on the older adult’s function.
■ The tests and procedures used for assessing posture, coor-
dination, balance, and gait.
■ Interventions and specific exercise programs that may be
used to prevent or lessen age-related changes in posture,
coordination, balance and gait.
Age-Related Changes in Postural
Alignment
Posture is the biomechanical alignment of body parts in
relation to one another and the orientation of the body as a
whole to the environment. Posture is typically viewed as a
static process, but gravity and neural control mechanisms
constantly effect subtle shifts in weight and body alignment
to counteract the effects of gravity, which necessitate a dy-
namic type of postural control. Posture is a key element to
maintaining postural control, and the ability to control pos-
tural balance is a necessity for the safe performance of many
daily tasks (Haddad, Rietdyk, Claxton, & Huber, 2013;
Haddad, Ryu, Seaman, & Ponto, 2010). The aging process
modifies normal postural alignment, and a flexed posture
frequently predominates (see Figs. 11-1 and 11-2). Thoracic
163
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164 PART II ■ Aging: Body Structures and Body Functions
Age 60
FIGURE 111 Lateral posture of (A) a 60-year-old man, (B) a 78-year-old man, and (C) a 93-year-old man. (From
Kaufman, T., (1987). Posture and age. Topics in Geriatric Rehabilitation, 2, No. 4, Aspen, 1987, p. 16, with permission.)
hyperkyphosis with a forward head position is typical, and
many older adults develop an altered lordotic curve (flattened
or exaggerated), rounded shoulders, and flexed hips and knees
as well (Balzini et al., 2003). What causes this hyperkyphosis
posture is not clearly understood and is most likely multifac-
torial in the absence of vertebral compression fracture. In ad-
dition to vertebral compression fractures, spinal extensor
muscle weakness, decreased range of motion (ROM), loss of
spinal flexibility, degenerative changes in the spine ligaments
and tendons, and disk annulus and nucleus can all be related
to the postural changes frequently seen in older adults.
A flexed or stooped posture can result in chronically
stretched neck, trunk, and hip and knee extensor musculature
and may be associated with other changes in postural align-
ment, including a compensatory shift in the vertical displace-
ment of the center of body mass back toward the heels.
Hyperkyphotic spinal changes may cause pain secondary to
stretching of ligaments and muscles, and a compensatory
hyper- or hypolordosis in the lumbar spine can cause lower
back pain (Katzman Wanek, Shepherd, & Sellmeyer, 2012).
The more forward head position may cause impairments of
anterior gaze, an important sensory modality for external
world exploration and obstacle avoidance. In addition, the
combination of abnormal postural alignment and decreased
Age 78 Age 93
spinal mobility and flexibility interferes with the use of nor-
mal strategies for static and dynamic balance control.
Numerous changes in the aging spine have been de-
scribed (Benoist, 2003; Wilmink, 2011). Among the various
structures of the spine, the aging process begins in the in-
tervertebral disc at the beginning of the second decade of
life. The initial precipitating event is not yet known, but
when the degenerative cycle begins a complex interplay of
biochemical and biomechanical factors create a vicious cir-
cle, which progressively enhances the degenerative process
(Benoist, 2003). Intervertebral disc degeneration can cause
hyperkyphosis (Bartynski, Heller, Grahovac, Rothfus, &
Kurs-Lasky, 2005). The forward head position alters load
distribution on vertebral joint surfaces and can lead to
spondylosis (Kumaresan, Yoganandan, Pintar, Maiman, &
Goel, 2001; Wilmink, 2011) and vertebral compression
fractures when bone structure is weakened by osteoporosis
(Siminoski, Warshawski, Jen, & Lee, 2011). Cervical
spondylosis is common in older adults (Shedid & Benzel,
2007) and causes pain, stiffness, and decreased range of
motion of the neck. Research has found that people with
cervical spondylosis have signs of instability in quiet stance
(Nardone, Galante, Grasso, & Schieppati, 2008). To what
extent degeneration of the mechanoreceptors of the spinal
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CHAPTER 11 ■ Neuromuscular and Movement Function: Coordination, Balance, and Gait
Age 60
FIGURE 112 Posterior posture of (A) a 60-year-old man, (B) a 78-year-old man, and (C) a 93-year-old man. (From
Kaufman, T., (987). Posture and age. Topics in Geriatric Rehabilitation, 2, No. 4, Aspen, 1987, p. 17, with permission.)
apophyseal joints play a role in postural stability in older
adults has yet to be determined.
In addition, changes in postural alignment may result
from muscular impairments (e.g., weakness) or compensating
for other impairments secondary to neurologic (e.g., stroke)
or musculoskeletal conditions (e.g., hip or knee arthritis).
Age-related changes in the axial skeleton are common and
include the following:
■ Forward head position and rounded shoulders
■ Increased thoracic kyphotic curvature (hyperkyphosis)
■ Increased knee flexion angle
■ A more posterior hip position (Balzini, et al., 2003)
The head-forward position is often considered to be abnor-
mal, but to some degree, it may be a normal compensation
necessitated by other postural changes, such as age-related flat-
tening of the lumbar spine. Scoliotic curvatures occur in the
older adult and may be due to spinal or appendicular changes
(Kebaish, Neubauer, Voros, Khoshnevisan, & Skolasky, 2011).
In the extremities, the most common postural variations in
aged adults are rounded shoulders with protracted scapula and
slightly flexed elbows, hips, and knees. In addition, changes in
the articular surfaces and joint capsules often cause varus or
165
Age 78 Age 93
valgus deformities at the hips, knees, or ankles. The normally
obtuse angle between the neck and shaft of the femur may
become more acute, which emphasizes the flexed posture. As
described earlier, the numerous changes that occur in the skele-
tal system with aging may diminish the maintenance of upright
posture. Postural variations are associated with mobility and
balance problems as well as falls in older adults (Edmond,
Kiel, Samelson, Kelly-Hayes, & Felson, 2005; Sinaki, Brey,
Hughes, Larson, & Kaufman, 2005). Additionally, changes in
muscle, connective tissue, and skin alter postural alignment.
Postural muscles, such as the quadriceps and soleus, have
been noted to have more age-related atrophy than nonpostural
muscles (Rowan, Purves-Smith, Solbak, & Hepple, 2011).
Trauma, lifestyle, or habits such as prolonged wearing of high
heels also contribute to postural changes with aging.
Age-Related Changes in Coordination
The ability to perform coordinated movement requires the
integration of multiple muscle groups (muscle synergies) and
involves afferent as well as efferent pathways. Intact sensory and
neuromusculoskeletal are necessary to produce movements that
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166 PART II ■ Aging: Body Structures and Body Functions

are smooth and accurate. Functional activities that require
either gross- or fine-motor responses or a combination of these
(e.g., walking, getting out of bed, buttoning and zipping cloth-
ing) are dependent on coordinated movements, and timing and
force of muscle contractions and joint motions are crucial for
these controlled movements. Coordination is the ability to
execute smooth, accurate, controlled movements, which is de-
pendent on an intact neuromusculoskeletal system; inputs from
visual, somatosensory, and vestibular systems; and sensorimo-
tor processing. Coordinated movements involve multiple joints
and muscles, which need to be activated at the appropriate time
and with the appropriate force, so the movement is accurate,
smooth, and efficient (Shumway-Cook & Woollacott, 2007).
Changes in the ability to execute smooth, accurate, and con-
trolled motor responses occur with normal aging, and these
changes may be accentuated further by impairments of the
sensory systems (Goble, Coxon, Wenderoth, Van Impe, &
Swinnen, 2009). In addition to slower eye–hand coordination
(Guan & Wade, 2000), aging causes decreases in interlimb co-
ordination (Serrien, Swinnen, & Stemach, 2000), homolateral
(same side) hand and foot movements (Capranica, Tessitore,
Olivieri, Minganti, & Pesce, 2004), motor coordination
(Seidler et al., 2010), and manual dexterity (Martin, Ramsay,
Hughes, Peters, & Edwards, 2015).
Age-Related Changes in Balance
and Gait
The systems that control balance have an important role
in the performance of functional activities. Postural control,
the ability to control the body’s position in space for the pur-
poses of postural orientation and postural stability (balance),
occurs through the complex interaction of many systems
(Box 11-1). Thus, postural control is not regulated by a sin-
gle system but instead by the integrated interaction of many
systems (Shumway-Cook & Woollacott, 2007). Problems
with balance may occur because of changes in one or more
of the subsystems that contribute to postural control, rather
than from an age-related decline in the nervous system
alone. For a comprehensive discussion about postural con-
trol, from development to aging, see Shumway-Cook and
Woollacott (2016). Postural stability in normal healthy
adults is affected by the availability and validity of visual,
vestibular, haptic, and proprioceptive information that can
provide a referential context for updating the body’s location
in space (Horak, 2006). Age-related changes such as visual
and vestibular information (see Chapter 9), muscular atro-
phy, loss of proprioception and vibration sense, extrapyra-
midal dysfunction, slowed reaction times, decreases in
muscle strength and power (Chapter 10), and hyperkyphosis
may contribute to postural control and stability problems
(Cook, 2003; Katzman et al., 2012).
Both the visual and vestibular systems show a reduction
of function in aging. The numerous changes in the eye and
vision described in Chapter 9 result in less light transmitted
to the retina and an increase in visual threshold. Thus,
older adults need more light to see an object. In addition,
loss of visual field, decreases in visual acuity, and contrast
sensitivity cause difficulties with depth perception. The
vestibular system works with other sensorimotor systems,
such as the visual system and musculoskeletal system, to
check and maintain the body position at rest or when in
motion and helps to maintain a steady visual focus on ob-
jects even though the body’s position changes. The vestibu-
lar system, particularly the semicircular canals and otolithic
organs, does via the detection mechanical forces, including
gravity, that act on vestibular organs during movement. An
intact vestibular system is important for balance, especially
in older adults who have declines in other senses that pro-
vide orientation information to the CNS. A decrease in the
number of hair cells and neurons in the vestibular system
in older people has been described in the literature (Iwasaki
& Yamasoba, 2015). Diminished vestibular function with
age would result in the nervous system having increased
difficulty resolving conflicting afferent information coming
in from the visual and somatosensory systems (Shumway-
Cook & Woollacott, 2016).
The extrapyramidal system, which refers to the basal
ganglia and its connections, is reported to change with

BOX 111 Postural Control for Stability and Orientation Requires a Complex Interaction of Many Components and Systems
■ Musculoskeletal system
■ Individual sensory systems
■ Sensory/perceptual processes
■ Neuromuscular synergies
■ Adaptive mechanisms
■ Anticipatory mechanisms
■ Higher-level neural processes
Joint range of motion, spinal flexibility, muscle properties, biomechanical relationships among
linked body segments
Visual, vestibular, somatosensory
The organization and integration of individual sensory systems
Organization, coordination, and sequential activation of muscles and muscle groups
Sensory and motor system modifications in response to changing task and environmental demands
Sensory and motor system pretuning based on previous experience and learning
Cognitive influences essential for mapping sensation to action and for adaptive and anticipatory
mechanisms; internal representations

Source: Data from Shumway-Cook & Woollacott, 2007.

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CHAPTER 11 ■ Neuromuscular and Movement Function: Coordination, Balance, and Gait
aging, resulting in the slowing of skilled motor movements
and alterations of gross movements (Seidler et al., 2010).
The basal ganglia and cerebellum play a major role in con-
trol of movement. Tics or tremors may become evident, and
movement may be slowed (bradykinesia), altered or absent,
leading to postural instability in the older adult (Seidler, et al.,
2010). Reaction time, the ability to respond to a stimulus,
is often used as a measure of neuromuscular function in older
adults because it requires afferent impulses, central process-
ing, and efferent impulses to affect a response (Spirduso,
Francis, & MacRae, 2005). Slowing of simple reaction time
(SRT) is considered one of the most measurable and recog-
nizable behavioral changes that occur with aging (Spirduso
et al., 2005). Studies of choice reaction time suggest that as
the task difficulty increases, reaction times of older adults
are significantly slower than the reaction times of those who
are younger (Hultsch, MacDonald, & Dixon, 2002). Wide
individual variations in reaction times at all ages have been
reported, and as age increases, heterogeneity in reaction
times increases (Hultsch et al., 2002; Spirduso et al., 2005).
Slowed central processing is likely the primary factor lead-
ing to increased reaction time (Seidler et al., 2010), rather
than other factors such as decreases in motor or sensory
nerve conduction velocities or rate of muscle contraction.
Interestingly, weaker and physically inactive older adults
show the more typical age-related decline in speed of motor
activities and slowing on tasks (Hunter, Thompson, &
Adams, 2001).
Changes in Proprioception
As described in Chapter 9, virtually all sensory modalities
decrease in acuity with age, and proprioception and vibra-
tion are no exception. Proprioception is described as the
awareness of body segments in relationship to each other
and in relationship to the environment (orientation). Some
research has found no major decline in small joint proprio-
ception (e.g., finger and toes), but others have found joint
position sense of the knee decreases with age (Bullock-
Saxton, Wong, & Hogan, 2001) and higher detection thresh-
olds for angular displacement at the ankle (Verschueren,
Brumagne, Swinnen, & Cordom 2002). In addition, older
adults may have impaired integration of proprioceptive input
(Beauchamp et al., 2004). Decreased awareness of the body
or limbs in space, combined with other sensory losses or cog-
nitive changes such as those described in Chapter 7 and 12,
may result in safety issues during daily activities, transfers, and
ambulation. However, evidence suggests regular physical ac-
tivity may attenuate age-related decreases in proprioception
(Ribeiro & Oliveira, 2007).
Changes in Gait
Balance control is a primary contributor to stable walking.
Decreased postural stability is a major factor leading to a loss
of ambulatory ability in the older adult (Shumway-Cook &
167
Woollacott, 2016). The gait of older adults and the manner
in which they adjust their gait to accommodate obstacles
have been found to differ from that of the younger or
middle-aged adults. The most typical gait changes with aging
are the following:
■ Decreased step length (Freire Júnior et al., 2016; Mbourou,
Lajoie, & Teasdale, 2003)
■ Decreased stride length (Kressig et al., 2004; Mbourou et al.,
2003)
■ Slower walking velocity (Ko, Hausdorff, & Ferrucci, 2010;
Kressig et al., 2004)
■ Decreased cadence (Laufer, 2005; Mbourou et al., 2003)
■ Decreased ankle range and push-off (Chung, & Wang,
2010; McGibbon & Krebs, 2004)
■ Increased double-stance time (Freire Júnior et al., 2016;
Kressig et al., 2004; Mbourou et al., 2003)
■ Decreased vertical displacement of center of mass (Mbourou
et al., 2003; Shkuratova, Morris, & Huxham, 2004)
It has been suggested that older adults become “stiffer”
when walking and that some of these gait changes occur
because older adults try to improve their balance or adopt a
more cautious walking pattern in general or when confronted
with obstacles (Chung & Wang, 2010; Weerdesteyn, Nienhuis,
& Duysens, 2005). Inactive older adults tend to have slower
gait speeds (Ruggero et al., 2013), and impairments are more
predominant in persons with functional limitations or in
those individuals who tend to fall (Middleton, Fritz, &
Lusardi, 2015).
Assessing Posture, Coordination,
Balance, and Gait in Older Adults
The reader is encouraged to review Chapter 27 to review the
conceptual frameworks for assessment of functional perform-
ance and the methods and tools that can be used to assess
performance in older adults.
Static Posture Assessment
Standard assessment methods for postural alignment are ap-
propriate for the older adult. Posture is visually assessed from
the anterior, posterior, and lateral views, and using a plumb
line may be of benefit as a reference point. The lateral view of
normal postural alignment is represented by a straight line pro-
jecting through the ear, the acromion, the greater trochanter,
the posterior patella, and the lateral malleolus (Schmitz &
O’Sullivan, 2014). When using a plumb line to assess posture
in the older adult, postural sway may become more apparent
to the evaluator and may increase the difficulty of the postural
assessment. Postural sway, small oscillating movements of the
body over the feet during bipedal standing, can be assessed by
observation or, more formally, through the use of a computer-
assisted postural sway analyzer or force platforms in a labora-
tory setting.
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168 PART II ■ Aging: Body Structures and Body Functions
Coordination Assessment
The most common clinical approach to evaluating coordina-
tion in the older adult is to observe the performance of func-
tional movements and activities and the resultant movement
characteristics. More formal clinical tests of coordination can
be divided into tasks that require equilibrium, which generally
reflect the coordination of multijoint movements required
for postural control and ambulation (see Interprofessional
Practice: Equilibrium Coordination Tests) and those that do
not (see Interprofessional Practice: Nonequilibrium Tests)
(Schmitz & O’Sullivan, 2014). When assessing coordination,
the accurate ability to perform the task and the speed required
to complete the task must be considered. Movement should
be in the correct direction, and the movement trajectory
should be smooth and fluid and well timed throughout. In
addition, problems with muscle tension and movement con-
trol achieved by groups of muscles working together (syner-
gies) and difficulty initiating or stopping the movement
should be noted. Body or extremity posture should be main-
tained during the movement, and movements should be eas-
ily reversed, even with changes in speed and direction of
movement (Shumway-Cook & Woollacott, 2007).
INTERPROFESSIONAL PRACTICE
Equilibrium Coordination Tests
Occupational and physical therapists may use any or all of
these brief tests to assess equilibrium coordination.
■ Standing in a normal, comfortable posture
■ Standing, feet together (narrow base of support)
■ Standing, with one foot directly in front of the other (toe of
one foot touching heel of opposite foot)
■ Standing on one foot
■ Arm position may be altered in each of the above four postures
(i.e., arms at side, over head, hands on waist, and so forth)
■ Displace balance unexpectedly (while carefully guarding
patient)
■ Standing, alternate between forward trunk flexion and return
to neutral
■ Standing, laterally flex trunk to each side
■ Walking, placing the heel of one foot directly in front of the
toe of the opposite foot
■ Walk along a straight line drawn or taped to the floor, or
place feet on floor markers while walking
■ Walk sideways and backward
■ March in place
■ Alter speed of ambulatory activities (increased speed will
exaggerate coordination deficits)
■ Stop and start abruptly while walking
■ Walk in a circle, alternate directions
■ Walk on heels or toes
■ Normal standing posture: Observe patient both with
patient’s eyes open and with patient’s eyes closed (or vision
occluded). If patient is able to maintain balance with eyes
open but not with vision occluded, it is indicative of a
proprioceptive loss. This inability to maintain an upright
posture without visual input is referred to as a positive
Romberg sign.
Source: Schmitz & O’Sullivan (2014).
INTERPROFESSIONAL PRACTICE
Nonequilibrium Coordination Tests*
Occupational and physical therapists may use any or all of
these tests to assess coordination; in some clinical settings,
Occupational therapists may focus more on upper extremity
coordination assessment, and physical therapists may focus
more on lower extremity coordination assessment.
Finger to The shoulder is abducted to 90 degrees with
nose the elbow extended. The patient is asked to
bring the tip of the index finger to the tip
of the nose. Alterations may be made in the
initial starting position to assess performance
from different planes of motion.
Finger to The patient and therapist sit opposite each
therapist’s other. The therapist’s index finger is held
finger in front of the patient. The patient is asked
to touch the tip of the index finger to the
therapist’s index finger. The position of the
therapist’s finger may be altered during
testing to assess ability to change distance,
direction, and force of movement.
Finger to Both shoulders are abducted to 90 degrees
finger with the elbows extended. The patient is
asked to bring both hands toward the
midline and approximate the index fingers
from opposing hands.
Alternate The patient alternately touches the tip of
nose to the nose and the tip of the therapist’s finger
finger with the index finger. The position of the
therapist’s finger may be altered during
testing to assess the patient’s ability to
change distance, direction, and force of
movement.
Finger The patient touches the tip of the thumb to
opposition the tip of each finger in sequence. Speed
may be gradually increased.
Mass grasp An alternation is made between opening
and closing fist (from finger flexion to full
extension). Speed may be gradually
increased.
Pronation/ With elbows flexed to 90 degrees and held
supination close to the body, the patient alternately
turns the palms up and down. This test also
may be performed with shoulders flexed to
90 degrees and elbows extended. Speed
may be gradually increased. The ability to
reverse movements between opposing
muscle groups can be assessed at any joint.
Examples include active alternation between
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CHAPTER 11 ■ Neuromuscular and Movement Function: Coordination, Balance, and Gait 169

flexion and extension of the knee, ankle, (a table or the floor also may be used). This
elbow, fingers, and so forth. also may be done using a finger-eight
Rebound The patient is positioned with the elbow pattern. This test may be performed in the
test flexed. The therapist applies sufficient supine position for lower extremity
manual resistance to produce an isometric assessment.
contraction of biceps. Resistance is suddenly Fixation Upper extremity: The patient holds arms
released. Normally, the opposing muscle or position horizontally in front.
group (triceps) will contract and “check” holding Lower extremity: The patient is asked to hold
movement of the limb. Many other muscle the knee in an extended position.
groups can be tested for this phenomenon, *Tests should be performed first with eyes open and then with
such as the shoulder abductors or flexors, eyes closed. Abnormal responses include a gradual deviation
elbow extensors, and so forth. from the “holding” position and a diminished quality of
Tapping With the elbow flexed and the forearm response with vision occluded. Unless otherwise indicated,
(hand) pronated, the patient is asked to “tap” the tests are performed with the patient in a sitting position.
hand on the knee. Source: Schmitz, T.J., & O’Sullivan, S.B. (2014).
Tapping The patient is asked to “tap” the ball of one
(foot) foot on the floor without raising the knee;
Standardized assessments of arm–hand function and
heel maintains contact with floor.
motor coordination, and eye–hand coordination for use in
Pointing The patient and therapist are opposite each
older adults are numerous and include the Purdue Pegboard
and past other, either sitting or standing. Both patient
Test (Desrosiers, Hebert, Bravo, & Dutil, 1995a; Tiffin,
pointing and therapist bring shoulders to a horizontal
1968), the Jebsen Hand Function Test (Jebsen, Taylor,
position of 90 degrees of flexion with elbows
Treischmann, Trotter, & Howard, 1969), the Timed Manual
extended. Index fingers are touching or
Performance (Williams, Gaylord, & McGaghie, 1990), and
the patient’s finger may rest lightly on the
the Upper Extremity Performance Test for the Elderly
therapist’s. The patient is asked to fully flex
(TEMPA) (Desrosiers et al., 1995b).
the shoulder (fingers will be pointing toward
ceiling) and then return to the horizontal
position such that index fingers will again Balance Assessment
approximate. Both arms should be tested,
The ability to maintain balance is crucial for the successful
either separately or simultaneously. A normal
performance of most activities of daily living (ADL). Assess-
response consists of an accurate return to
ment of balance in older adults can assist in defining move-
the starting position. In an abnormal
ment capacity, and changes in balance scores are commonly
response, there is typically a “past pointing,”
used to judge improvement following therapeutic programs.
or movement beyond the target. Several
As described earlier, because multiple systems contribute to
variations to this test include movements in
postural stability, a comprehensive assessment of all systems
other directions such as toward 90 degrees
that may contribute to balance problems is essential. Thus,
of shoulder abduction or toward 0 degrees
an assessment of postural alignment, ROM, flexibility, mus-
of shoulder flexion (finger will point toward
cle strength, sensation, and cognition, in addition to specific
floor). Following each movement, the
balance tests, would compose the multiple evaluation com-
patient is asked to return to the initial
ponents of balance.
horizontal starting position.
Evaluation of balance in the laboratory setting typically
Alternate From a supine position, the patient is asked
includes the following: (1) a force plate system that measures
heel to to touch the knee and big toe heel to toe
the changing pressures under the feet during the maintenance
knee alternately with the heel of the opposite
of static posture or during movement, (2) a computerized dy-
extremity.
namic posturography system that assesses motor and sensory
Toe to From a supine position, the patient is
contributions to balance, and (3) electromyography and high-
examiner’s instructed to touch the great toe to the
speed filming systems that evaluate the spatial and temporal
finger examiner’s finger. The position of finger may
components of muscle activation and interlimb coordination
be altered during testing to assess ability to
during movement or balance perturbations. Balance in the
change distance, direction, and force of
older adult is assessed clinically using a variety of balance
movement.
measures that evaluate the following areas:
Heel on From a supine position, the heel of one foot
shin is slid up and down the shin of the opposite 1. Static balance—standing quietly
lower extremity. 2. Limits of stability
Drawing The patient draws an imaginary circle in 3. Anticipatory postural control
a circle the air with either upper or lower extremity 4. Reactive postural control
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170 PART II ■ Aging: Body Structures and Body Functions

5. Sensory strategies and integration
6. Functional balance skills
7. Effects of cognitive demand on balance
8. Self-report measures of balance activities
Several of the balance measures have well-established
norms that can be used for comparisons, and many are used
to identify older adults at risk for falls (Table 11-1). Because
the older adult will be asked to perform various tasks that
will cause instability, safety is essential, and the therapist
should closely guard and protect the person at all times to
prevent a fall.
Static Balance
To assess static balance, clinicians typically observe sponta-
neous postural sway during quiet stance. Altering the base of
support by asking the older adult to bring his or her feet to-
gether then stand in tandem stance or on one leg increases the
difficulty of the initial static balance task. Differences in the
amount of postural sway with eyes open and eyes closed for
each of the positions are also noted, and the amount of time
the older adult can maintain each of the positions is recorded.
Postural sway increases with age (Kim et al., 2010) and has
been found to be greater in older subjects with declining bal-
ance (Lajoie & Gallagher, 2004). The ability to perform one-
legged stance, with eyes open and with eyes closed, declines
with aging (Springer, Marin, Cyhan, Roberts, & Gill, 2007).
Maintaining the ability to balance with a reduced base of sup-
port is important when considering functional activities be-
cause walking and stair-climbing require the ability to stand
on one leg.
Limits of Stability
The Functional Reach Test (FRT) is a single-item quick
screening test to assess the capacity of an older adult to per-
form a voluntary movement while challenging balance. The
older adult is asked to stand with feet shoulder distance apart,
flex one arm to 90 degrees, and reach as far forward as he or
she is able. The functional reach is recorded in inches as the
greatest distance the person is able to reach forward beyond
arm’s length while maintaining a fixed base of support, and
that can be compared to gender- and age-related norms. The
FRT has been found to be predictive of falls among older
adults (Duncan, Weiner, Chandler, & Studenski, 1990).
The Multi-Directional Reach Test (MDRT), an expan-
sion of the FRT, examines the older adult’s limits of stability
backward and laterally to the right and left, in addition to the
forward direction (Newton, 2001). The distance the person
can reach in each direction is recorded.
Anticipatory Postural Control
In the clinical setting, it is more difficult to quantitatively ex-
amine anticipatory postural control. This aspect of balance
can be assessed by telling the older adult a nudge is going to
be applied in advance of the action and he or she needs to re-
sist it, or by asking the individual to negotiate an obstacle
course. An older adult with good anticipatory postural control
abilities will be able to quickly respond to the perturbation
by stabilizing the body and negotiate the obstacles with little
hesitation.
The Dynamic Gait Index is an eight-item measure of gait.
Although considered a mobility test, several test items exam-
ine the older adult’s ability to modify gait in response to
changes in tasks, providing an indication of anticipatory pos-
tural control (e.g., “turn and stop,” stepping over a shoe box,
and going around a cone) (Shumway-Cook & Woollacott,
2001). Scores below 19 are associated with increased fall risk
(Shumway-Cook, Gruber, Baldwin, & Liao, 1997).
Reactive Postural Control
The nudge test developed by Tinetti (1986) is one method
of assessing reactive postural control. An unexpected nudge
is lightly applied against the older adult’s sternum three
times and the response is graded using a 3-point scale. A
more sophisticated test that has been developed to test re-
active postural control clinically is the Postural Stress Test
(Wolfson, Whipple, Derby, Amerman, & Kleinberg, 1986).
The PST unexpectedly perturbs the older adult in a back-
ward direction using a weighted pulley system connected to
a belt worn around the pelvis. Weights representing 1.5, 3.0,

TABLE 111 ■ Evidence-Based Balance Exercise Prescription for the Older Adult

EXERCISE PARAMETERS BENEFITS PRECAUTIONS FOR THE OLDER ADULT

■ Dynamic exercises Documented Benefits ■ A fall risk screen should be conducted before exercise prescription
■ Static exercises ■ Improved balance performance ■ Close supervision required for those at risk for falls
■ Exercises for specific postural ■ Improvement in fall risk scores ■ Need to sufficiently challenge balance, while ensuring safety
control problem ■ Decreased falls ■ The older adult should use his or her typical assistive device while
■ Tai chi Potential Benefits exercising, as needed
■ Combined exercise programs ■ Improved agility
■ Improved quality of life
■ Improved sense of well-being

Data in part from American College of Sports Medicine. (2009). Special Communication: Position Stand. Exercise and physical activity for older adults. Retrieved from http://
journals.lww.com/acsm-msse/Fulltext/2009/07000/Exercise_and_Physical_Activity_for_Older_Adults.20.aspx
4605_Ch11_163-180 31/10/17 1:48 PM Page 171
CHAPTER 11 ■ Neuromuscular and Movement Function: Coordination, Balance, and Gait
and 4.5 percent of total body weight are used to simulate
small, medium, and large perturbations.
Sensory Strategies and Integration
The Clinical Test of Sensory Interaction in Balance (CTSIB)
assesses balance in six sensory conditions (Shumway-Cook
& Horak, 1986). The CTSIB is based on postural stability
research and the interaction of the somatosensory, visual, and
sensory systems and is the clinical equivalent to more expen-
sive laboratory-based assessments of sensory strategies and
integration. The older adult individual is tested under the
following six conditions, and the time balance that can be
maintained in each of the conditions is recorded:
1. Without visual restrictions
2. With a blindfold
3. With a visual conflict dome
4. Without visual restrictions, but standing on foam to
control proprioceptive sensory input
5. With a blindfold and standing on foam to control
proprioceptive sensory input
6. With a visual conflict dome and standing on foam to
control proprioceptive sensory output
The six-condition test has been modified to a four-condition
version (the Modified-CTSIB), which eliminates the visual
conflict dome (Rose, 2003). The CTSIB provides useful infor-
mation about the individual’s ability to use and integrate sensory
information to maintain postural stability.
Functional Balance Skills and Balance Measures
When concern centers on the functional performance of an
older adult, the ability of the individual to respond appropri-
ately while performing everyday activities and skills may pro-
vide meaningful information. Numerous measures examine
functional balance skills. It is important to note that func-
tional balance tests have limitations:
1. Tests typically do not examine all aspects of postural
control.
2. Most do not provide insight into quality of movement
used to accomplish the task. It may be difficult to
determine the specific subsystem responsible for the
performance problem.
3. The older adult’s performance is examined under a lim-
ited environmental condition; thus, results may not be
able to predict actual performance in more complex en-
vironments (Shumway-Cook & Woollacott, 2007).
The Timed Get-Up-and-Go tests are used to measure an
individual’s functional dynamic balance. The Get-Up-and-Go
test was originally described by Mathias, Nayak, and Isaacs
(1986) and later modified by Podsiadlo and Richardson
(1991). The Timed Up and Go test, a commonly used screen-
ing test, measures the time it takes a person to rise to standing
from a standard armchair, walk a distance of 3 meters, turn,
walk back to a chair, and sit down.
171
✺ PROMOTING BEST PRACTICE
Single Test of Mobility Should Not Be Used to Identify
Fall Risk in Older Adults
A systematic review and meta-analysis suggests that a single
falls risk assessment tool, the Timed Up and Go, should not be
used to identify community-dwelling older adults at increased
risk of falls. The authors suggest that clinicians who assess older
adults for risk of falling should ideally do so in a comprehensive
manner rather than relying on a single test of mobility and that
the multifactorial nature of falls should be taken into account
(Barry, Galvin, Keogh, Horgan, & Fahey, 2014).
The Berg Balance Scale (BBS), and the balance portion of
the Tinetti Performance-Oriented Mobility Assessment
(POMA) are commonly used clinically to screen for balance
impairments and to assess components of functional per-
formance. The POMA, consisting of both a balance and gait
section, was developed as a falls risk index and examines pos-
tural stability and mobility skills (Tinetti, 1986). The balance
portion includes assessments of static sitting and standing
balance, anticipatory and reactive balance, and the ability to
use somatosensory inputs. The BBS consists of 14 balance
items common to many functional tasks, such as reaching,
bending forward, transferring, standing, and getting up from
a chair. The BBS includes items that examine static balance
(including positions of reduced base of support), dynamic
balance, anticipatory balance, the ability to use somatosensory
inputs, and forward limits of stability (Berg, Wood-Dauphinee,
Williams, & Maki, 1989). Both the POMA and the BBS
have cutoff scores for increased falls risk.
The Fullerton Advanced Balance (FAB) scale (Rose, 2003)
is intended for use in higher-functioning older adults because
the majority of items are considerably more challenging than
the POMA or BBS (O’Hoski et al., 2014). No cutoff scores
for falls risk are available for the FAB; however, more balance
dimensions are examined, including the ability to use so-
matosensory and vestibular inputs, forward limits of stability,
anticipatory and reactive postural control, and static and dy-
namic balance in a position of reduced base of support.
The Balance Evaluation Systems Test (BESTest) is a
standardized functional balance tool that is aimed at identi-
fying the components contributing to dysfunctional balance
but targeting six postural control subsystems: biomechanical
constraints, stability limits/verticality, anticipatory postural
adjustments, postural responses, sensory orientation, and
stability in gait (Horak, Wrisley, & Frank, 2009). The
BESTest has been used in people with Parkinson’s disease,
vestibular disorders, peripheral neuropathy, total hip replace-
ments, fibromyalgia, and chronic obstructive pulmonary dis-
ease (Beauchamp, Sibley, & Lakhani, 2012; Horak, Wrisley
& Frank, 2009; Jones, Horak, & Winters-Stone, 2009;
Leddy, Crowner & Earhart, 2011)
Because administration time of the BESTest ranges from
20 to 60 minutes (Horak et al., 2009; Padgett, Jacobs, &
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172 PART II ■ Aging: Body Structures and Body Functions

Kasser, 2012), an abbreviated version, the Mini-BESTest that examine balance ability include the Activities-specific
(Franchignoni, Horak, & Godi, Nardone, & Giordano, 2010), Balance Confidence (ABC) scale (Powell & Meyers, 1995)
was developed as a brief measure of dynamic balance. The and the Modified Falls Efficacy Scale (MFES; Hill,
Mini-BESTest comprises 14 of the 36 BESTest items and Schwarz, Kalogeropolous, & Gibson, 1996). The ABC is
scored on a 3-point rather than a 4-point scale. The Mini- a 16-item questionnaire that examines how confident the
BESTest has been used to test balance in people with stroke, older adult feels about performing various activities without
multiple sclerosis, vestibular disorders, and traumatic brain losing his or her balance on a scale from 0 percent (no con-
injury (Franchignoni et al., 2010). fidence) to 100 percent (complete confidence; Powell &
As the Mini-BESTest only provides a total score for dy- Meyers, 1995). The MFES, a 14-item questionnaire, asks
namic balance and does not identify underlying impair- the client to rate on a 10-point visual analogue scale how
ments, another abbreviated version, the Brief-BESTest confidently he or she can do an activity without falling
(Padgett et al., 2012) was developed. To maintain the the- (0 = not confident/not sure at all; 5 = fairly confident/fairly
oretical basis of the original BESTest, the Brief-BESTest sure; 10 = completely confident/completely sure; Hill et al.,
comprises one item from each of the six sections, with two 1996). Gathering this type of information is useful in deter-
items (single-leg stance and functional forward reach) mining which aspects of postural control may be impaired
scored bilaterally. In preliminary testing, the Brief-BESTest and assists the clinician in structuring the examination, gen-
was shown to have interrater reliability comparable to those erating hypotheses, and developing an intervention plan
of the BESTest and the Mini-BESTest and accuracy supe- (Shumway-Cooke & Woollacott, 2016).
rior to those of the other tests for identifying people with
and without a neurological diagnosis and people who fall
Gait Assessment
versus people who do not fall (Padgett et al., 2012). In a
population of older adults with a mean age of 70 years, the In the clinical setting, visual observation is the most common
ability of the Mini-BESTest to discriminate between those method for assessing gait (observational gait analysis). De-
with a history of falls in the past year exceeded that of the spite widespread use, evidence to support the validity against
full BESTest, BBS, or the Timed Up and Go (TUG). The kinematic (i.e., characteristics of movement) analysis is lacking
Mini-BESTest cutoff score of 16 (out of 28) had an accu- and a majority of studies have poor to moderate reliability
racy of 85 percent with a sensitivity of 85 percent and a (McGinley, Goldie, Greenwood, & Olney, 2003). Timed
specificity of 75 percent (Yingyongyudha, Saengsirisuwan, measures of gait using a stopwatch have moderate to high
Panichaporn, & Boonsinsukh, 2016). reliability but are limited to collecting data on gait velocity,
stride length, and cadence (Morris, Morris, & Iansek, 2001;
Effects of Cognitive Demand on Balance Youndas & Atwood, 2000) and may require an individual
to perform several repeat trials to collect the necessary in-
Balance requires attentional resources (Brauer, Woollacott, formation. Regardless, measuring gait velocity is simple and
& Shumway-Cook, 2000; Rankin, Woollacott, Shumway- quick, and velocity is considered a composite measure of
Cook, & Brown, 2001), and the effect of cognitive demand distance and temporal gait variables. Gait velocity has been
and attentional capacities on balance abilities has been the demonstrated to be a sensitive test for detecting mobility
focus of research (see Boisgontier et al., 2013, for a review). impairments and a strong predictor of adverse events, even
The dual-task TUG (TUGDT) was developed to examine for highly functional older adults (Cesari et al., 2005;
whether adding a secondary task to the TUG would increase Middleton et al., 2015; Montero-Odasso et al., 2005).
the specificity and sensitivity of the TUG as a fall risk mea-
sure (Shumway-Cook, Brauer, & Woollacott, 2000). The
TUGDT_cognitive asks the older adult to complete the TUG AROUND THE GLOBE: Around the Globe: Percentage
while counting backward by threes, and the TUGDT_manual
of Older Adults Categorized as
asks the older adult to complete the TUG while carrying a
Slow Walkers Reporting Difficulty
cup of water. Although the TUG alone was found to be a
Walking 1 Kilometer, by Country,
sensitive and specific indicator of fall risk, the time to com-
Age, and Sex
plete the TUGDT was significantly longer. This finding indi-
cates that adding a secondary task may provide insight into Country Ages 65–69 Ages 75–79
how an older adult can maintain balance under multitask Male Female Male Female
conditions (Shumway-Cook et al., 2000). China 50.5 43.2 78.4 94.8
India 71.3 88.5 95.2 85.9
Russia 46.9 72.9 87.0 89.5
Self-Report Measures of Balance Ability
South Africa 76.4 83.5 90.6 75.8
An essential component of balance assessment is finding Ghana 71.9 85.9 79.4 91.5
out from the older adult the circumstances that lead to a Mexico 42.6 77.0 75.9 95.1
loss of balance and his or her perceptions about how bal- From Capistrant, Glymour, & Berkman, 2014.
ance abilities affect daily activities. Self-report measures
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CHAPTER 11 ■ Neuromuscular and Movement Function: Coordination, Balance, and Gait 173

Although there is no consensus regarding optimal testing
distance for determining gait velocity, a suggested and com-
mon method is to calculate usual walking speed (gait velocity)
over a predetermined distance, such as 10 meters. To accom-
modate the acceleration phase of walking, most normative
values are based on measuring the middle two-thirds of a
walking or distance (Bohannon, 2008).
In older adults, gait speed is an indicator of functional status
and the need for rehabilitation (Fritz & Lusardi, 2009). Gait
speed has been found to be a predictor of functional mobility
(Paulson & Gray, 2015), mobility disability, mortality, falls,
institutionalization (Van Kan et al., 2009), hospitalization
(Cesari et al., 2005), and cognitive decline (Buracchio, Dodge,
Howieson, Wasserman, & Kaye, 2010). Small improvements
in gait speed (e.g., even as little as 4 cm per second) can result
in meaningful improvements in physical function (Oh-Park,
Holtzer, Mahoney, Wang, & Verghese, 2011). Fritz and
Lusardi (2009) suggest that gait velocity (walking speed)
should be considered the sixth “vital sign” (other vital signs
are blood pressure, heart rate, respiratory rate, temperature,
pain). Although walking speed alone cannot be used as the only
predictor of functional abilities, as a functional vital sign, walk-
ing speed can predict future events, including mortality, and
reflects various underlying physiological states such as health
or disease states (Studenski et al., 2003); see Figure 11-3.
Clinicians may also use standardized gait assessment forms,
such as the Gait Assessment Rating Scale (GARS; Wolfson
et al., Whipple, Amerman, & Tobin, 1990) or the modified
version of the GARS (VanSwearingen, Paschal, Bonino, &
Yang, 1996), and the Dynamic Gait Index (DGI; Shumway-
Cook & Woollacott, 1995). These measures have been tested
in healthy adults and older adults with a history of falls, are
reliable, are sensitive indicators of gait function changes, and
have been found to distinguish older adults with or without a
history of recurrent falls. For example, DGI scores below 19
(out of 24) are indicative of increased fall risk in older adults
(Shumway-Cook, Gruber, Baldwin, & Liao, 1997).
Cognitive demand and attentional capacities on gait have
been garnering attention, and as such it is recommended that
gait speed and performance be measured under a no secondary
task and an attentional task condition (e.g., animal naming,
counting backward from 100 by seven). The “Stops Walking
When Talking” (SWWT) test examines the ability of the
older adult to perform a secondary task, talking, while
walking (Lundin-Olsson, Nyberg, & Gustafson, 1997). The
examiner begins a conversation with the walking client and
a positive test is defined if the client stops walking in order
to talk. The SWWT has been found to be a predictor of falls
among frail, institutionalized older adults (Lundin-Olsson
et al., 1997).

Walking Speed

Extremely Intervention to reduce falls, risk for LE limitation and Less likely to be hospitalized or
frail for death and hospitalization in 1 year, personal care have adverse event, indep in ADL

Cognitive decline
Risk of death, hospitalization, and falls Carry groceries and light yard work
in 5 years

Functional impairments, Extremely

severe walking disability fit

Mortality, mobility and ADL disability at 2 years,

Able to do household activities
increased AD at 7 years, 2x probability of frailty if > 75 yo

Dependent
Highly
for in-hospital Increased independence in self-care
dependent
ambulation

Cross
Household walker Community ambulator Limited community ambulator street
safely

0 0.2 0.4 0.6 0.8 1 1.2 1.4

M/S
FIGURE 113 Walking speed and associated outcomes. m/s, meters per second; ↑, increased; LE, lower extremity;
indep, independent; ADL, activities of daily living; AD, Alzheimer’s disease; yo, years old; d/c, discharge. (From:
Middleton, Fritz, & Lusardi, 2015).
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174 PART II ■ Aging: Body Structures and Body Functions
Laboratory assessment of gait typically requires sophisticated
and costly equipment, including high-speed digital video
recording systems, floor-mounted force plates, and electromyo-
graphy, and thus it tends to be limited to the research setting.
Although costly, this type of assessment allows the kinematic
and kinetic (i.e., analysis of forces) qualities of the gait pattern,
and the spatial and temporal qualities of muscle activation pat-
terns (via electromyography) throughout the gait cycle to be
captured. Studies using these sophisticated methods for evalu-
ating gait have been extremely useful in providing an under-
standing of how age and pathology influence gait. Portable
walkways, consisting of a long strip of walking surface with
an array of embedded pressure-sensing strips, and foot-switch
systems, pressure-sensitive switches placed either on the feet
or inside or outside of the shoes, are less expensive but allow
more objective and reliable methods of evaluating temporal
and spatial gait parameters and the timing, symmetry, and
sequencing of gait events. These less-expensive methods of
gait assessment are often used in rehabilitation settings where
more comprehensive gait analysis is warranted.
Management of Posture, Coordination,
Balance, and Gait Problems in the
Older Adult
As described in Chapter 10, research evidence suggests that
participation in exercise and physical activities have numerous
benefits, including controlling chronic conditions, decreasing
the impact of the normal changes associated with aging, re-
versing many of the age-related physiologic changes, and im-
proving mobility and function. Strength, ROM, and flexibility
all play a role in posture, coordination, balance, and gait, so
engaging in physical activity and incorporating a comprehen-
sive and safe exercise program tailored to the functional needs
of the older adults may be beneficial in preventing and man-
aging the posture, coordination, balance, and gait problems
associated with aging. The reader is referred to Chapter 10 for
more information on prescribing these types of exercises for
older adults.
Postural Problems and Skeletal Deformities
Common postural problems in older persons may result from
the age-related changes in the muscles and joints and may
respond to an exercise program designed to increase ROM,
flexibility, and strength. Educating the older adult in correct
body posture during sedentary activities, such as reading or
watching television, is important. The older adult should be
educated regarding proper body mechanics during daily activ-
ities. Posture correction can be helpful in alleviating some of
the problems that can occur with skeletal changes in the older
adult. In addition, leg-length discrepancy may be corrected
simply by providing a heel lift (Silva & Lenke, 2010).
Coordination
Treatment of movement impairments relating to incoordi-
nation must take into consideration the cause. For example,
alleviating musculoskeletal problems (e.g., decreased ROM,
decreased flexibility) may improve coordination. Direct practice
of functional activities, practice of nonfunctional movements
such as tracing a figure eight with a limb, weight-bearing
activities for lower extremity incoordination, and environ-
mental modifications to reduce performance deficits may
assist in improving coordination. Because requirements
for accuracy create increasing demands for coordination,
selecting functional tasks with increasing accuracy de-
mands may also train coordination (Shumway-Cook &
Woollacott, 2016).
Balance and Gait
Therapeutic intervention for balance or gait dysfunction in
the older adult should be specific to the cause or causes of the
problem and the impact on function, as determined by a
comprehensive assessment. Not only should the individual
level be considered, but task and environmental constraints
should also be taken into account (Rose & Clarke, 2000).
With some older adults, simply changing shoes, altering the
lighting or other environmental influences, applying a prop-
erly fitting orthosis, or using an assistive device may be all
that is necessary. Other older adults may require a more
focused management plan that addresses specific postural
control problems identified in an evaluation.
Various types of exercises to improve balance and gait can
be prescribed, and research has yet to find one form of
balance exercise to be more beneficial than another. Specific
balance training (e.g., Sherrington, Tiedemann, Fairhall,
Close, & Lord, 2011) and balance training programs that
emphasize postural stability (e.g., Alfieri et al., 2012) have
been shown to improve balance performance in older adults.
Combined exercise approaches that incorporate balance
training in addition to flexibility, coordination, strength, and
endurance exercises have also been shown to improve balance
(e.g., Day et al., 2002; Hauer et al., 2001; Sherrington et al.,
2011). Power training, specifically low-intensity power train-
ing, has also been shown to significantly improve balance per-
formance in older adults (Orr et al., 2006).
Balance programs should include a variety of elements and
sufficiently challenge the older adult’s individual abilities.
Static balance exercises, such as standing on one leg, require
no body movement; dynamic balance exercises generally con-
sist of moving the center of mass over the base of support,
such as walking or side-stepping. Decreasing the size of the
base of support, incorporating upper extremity and head
movements during balance activities, altering sensory de-
mands, changing directions suddenly, and changing speed
during a balance activity are methods of challenging the indi-
vidual’s balance. Because balance requires attentional resources
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CHAPTER 11 ■ Neuromuscular and Movement Function: Coordination, Balance, and Gait
and cognitive demands, balance activities with concurrent dual
task activity may be beneficial, and balance activities that are
closely related to everyday activities and function can also be
incorporated into exercise programs. Tai chi has been found
to be beneficial in decreasing fall risk (Tsang & Hui-Chang,
2003), and improving balance in older adults often addresses
gait problems as well (Chou, Hwang, & Wu, 2012). See
Table 11-1 for considerations for prescribing balance exercises
to older adults.
As described in Chapter 16, fall risk factors include im-
paired gait, decreased lower extremity muscle strength and
flexibility, and decreased reaction times and coordination.
Many impairments and functional limitations affect balance
and gait, which can be remediated with physical activity and
exercise (see references in Promoting Best Practice: Benefits of
Exercise and Physical Activity for Older Adults) In some cases,
the factors that contribute to balance dysfunction may be less
specific or undiagnosed; thus, the overall postural control
mechanism must be “exercised.”
✺ PROMOTING BEST PRACTICE
Benefits of Exercise and Physical Activity
for Older Adults
A meta-analysis found that compared with the control
group, exercise intervention in older adults significantly
increased gait speed, increased BBS scores, and improved
ADL performance; however, significant effects on the TUG
performance and quality-of-life measures were not found
(Chou et al., 2012).
Meta-analysis was performed to compare exercise versus
control in older adults. Exercise was found to improve normal
gait speed, fast gait speed, and the Short Physical Performance
Battery (see Chapter 27 or more information about the SPPB).
However, results were inconclusive for endurance outcomes,
and no consistent effect was observed for balance and ADL
functional mobility (Giné-Garriga, Roqué-Fíguls, Coll-Planas,
Sitjà-Rabert, & Salvà, 2014).
An updated systematic review concluded that several types
of exercise and activities (gait, balance, coordination, and
functional tasks; strengthening exercise; three-dimensional
exercise such as tai chi; and multimodal exercise) are effective
in improving clinical balance outcomes in older people (Howe,
Rochester, Neil, Skelton, & Ballinger, 2011).
Sustained physical activity in older age is associated
with improved overall health, and significant health
benefits were even seen among older adults who became
physically active relatively late in life (Hamer, Lavoie, &
Bacon, 2014).
Sustained physical activity was associated with improved
survival and healthy aging in older men, and that vigorous
physical activity seemed to promote healthy aging. Vigorous
physical activity should be encouraged when safe and
feasible (Almeida et al., 2014).
175
SUMMARY
This chapter has discussed the typical and expected age-
related changes in posture, coordination, balance, and gait.
It is important to recognize that these generalizations about
change reflect an “average” and that individual variability is
great. Although not all inclusive, a variety of assessments and
intervention strategies were presented.
CASE STUDY: MR. STEVENS REVISITED
Mr. Stevens was introduced in Chapter 10. He is a
78-year-old man who lives with his wife in a two-story
home. Refer to the previous chapter for details about
Mr. Stevens’s status regarding bone, muscle, and joint.
It is important now to consider the ways in which nor-
mal age-related change affects his balance and gait, and
how the changes in musculoskeletal system and mobility
might influence his ability to participate in meaningful
activities.
As described previously, upper extremity muscle
strength was graded 4 (on MMT) for all major muscle
groups. Lower extremity muscle strength was graded as
4– for all major muscle groups except bilateral hip flexion
and abduction (graded 3) and bilateral ankle DF (graded
as 3–). TUG time was 12.8 seconds. Mr. Stevens used his
arms to push up from the chair and rose from the chair
very slowly. Slight postural instability was noted with
immediate standing and turning. Stride length and foot
clearance were decreased.
Questions
1. How might Mr. Stevens’s gait and balance be
affected by his muscle strength and the findings
regarding his postural stability?
2. What gait and balance assessment findings might be
related to normal age-related changes?
3. Given the information provided in the scenario, what
balance and gait interventions might include?
4. What are the critical considerations raised by these
findings for Mr. Stevens’s occupational profile?
Critical Thinking Questions
1. What are the most profound age-related changes in
posture, coordination, balance and gait? What are
the functional implications of these changes in the
everyday lives of older adults?
2. Define the following terms: postural sway, postural
control, postural orientation, postural stability, static
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176 PART II ■ Aging: Body Structures and Body Functions
posture, static balance, and dynamic balance. Why
are each important? How are each assessed?
3. Compare and contrast the various tests and measures
that can be used to assess coordination in older
adults.
4. Compare and contrast the various tests and measures
that can be used to assess balance and gait in older
adults.
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SECTION 2: Age-Related Health Conditions, Impairments, and Limitations

CHAPTER 12
Cognitive and Emotional
Function: Health Conditions
Katherine S. Judge ■ Nicole T. Dawson

“I have Dementia.memory
My eyes do see, my ears do hear. I am still me. So let’s be clear. My
may fade, my walk may slow. I am ME inside, don’t let me go.
LEARNING OUTCOMES
By the end of this chapter, readers will be able to:
1. Understand the underlying assumptions and key tenets
of atypical cognitive changes across the life span.
2. Describe the prevalence, etiology, and symptoms of key
cognitive conditions including neurodegenerative
disorders, and mental health conditions.
3. Discuss the current pharmacological and nonpharmacologi-
cal treatment protocols for managing and coping with the
symptoms of cognitive conditions.
4. Describe the importance of understanding, examining, and
intervening on the illness experience of individuals with
cognitive conditions.
5. Identify strategies to assist individuals with cognitive
conditions to live as independently as possible and in
achieving the highest quality of life possible.
Clinical Vignette
Henry Webster is a 65-year-old man who recently lost his
wife after 40 years. Overall, Henry is in good physical shape;
he likes to keep active by swimming and taking long walks
in the park. Lately, however, he has been less motivated to
swim or go on walks. He also is less interested in socializing
with friends and family. Henry still works full time but does
not seem as enthusiastic as he once was in his work as an en-
gineer. Although he hasn’t made any significant mistakes at
his job, his work performance has deteriorated. Henry’s chil-
dren have noticed subtle differences in him as well, including
—www.keepinmindinc.com
”
changes in his personality, energy level, and his mental
sharpness. Some of Henry’s family and friends think these
changes are a passing phase due to the recent loss of his wife;
others think this is part of the normal aging process; and yet
others think these may be early symptoms of something
more serious.
1. Why do you think Henry is experiencing these changes?
2. What strategies can you think of to begin to deter-
mine what is contributing to these subtle changes in
cognition?
A s discussed in Chapter 7, the majority of older adults
experience healthy cognitive aging across the life span
and do not experience significant declines in cognitive abilities
that impact day-to-day functioning. However, some older
adults will experience changes in their cognition that negatively
affect their daily lives. These changes in cognitive functioning
are not considered part of the healthy, normal aging process
but rather are pathological in nature.
The preceding case vignette highlights the importance of
seeking medical attention when one encounters even subtle
changes in cognitive and day-to-day functioning, including
slight differences in motivation, personality, socialization, and
work performance. All too often individuals or family mem-
bers may attribute these changes to the normal process of
aging. However, it is imperative to conduct a thorough eval-
uation to discern whether these subtle changes are associated
with the aging process or are early symptoms of an illness,
such as Alzheimer’s disease or depression. This is important

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182 PART II ■ Aging: Body Structures and Body Functions
because some conditions are treatable (e.g., depression), some
are reversible (e.g., dementia symptoms due to thyroid dis-
order), and others are irreversible (e.g., Alzheimer’s disease)
requiring further care planning and management.
Key Tenets for Understanding and
Maximizing Success With Atypical
Cognitive Changes
Conditions that affect individuals’ cognitive abilities require
that they and their families learn how to effectively cope and
manage the symptoms of the disorder. This is especially true
for conditions that are progressive or irreversible, particularly
when there is not an “easy fix” or treatment protocol that
adequately addresses the myriad care needs experienced by
individuals and their families. Another important feature of
cognitive conditions is the interconnectedness and resulting
impact between an individual’s cognitive abilities and other
abilities, such as functional abilities, social engagement, and
emotional and behavioral reactions. To illustrate, arthritis is
a chronic health condition that primarily impacts an indi-
vidual’s functional abilities (i.e., opening a jar, buttoning a
shirt) and also may be accompanied by pain that can affect
or restrict other occupations (i.e., social engagement, phys-
ical functioning). However, with the proper pain medica-
tion, rest, and perhaps assistive devices, many older adults
with arthritis are able to effectively cope with and manage
their symptoms.
In contrast, cognitive conditions affect all areas (or domains)
and occupations of an individual’s life, and to date many of these
conditions do not have medications or other treatment strate-
gies that would directly improve the cognitive symptoms
(Ahlskog, Geda, Graff-Radford, & Petersen, 2011). Addition-
ally, many individuals with cognitive conditions are not in-
cluded as active participants in their treatment plans, leaving
their voices unheard and discounted. This is often due to neg-
ative stereotypes or lack of education on part of the clinicians.
Emerging research has demonstrated that individuals with
dementia can participate and provide reliable information
regarding their subjective experiences (Clark, Tucke, &
Whitlatch, 2008; Krestar, Looman, Powers, Dawson, & Judge,
2012; Logsdon, Gibbons, McCurry, & Teri, 2002; Snow et al.,
2005). For example, imagine you have difficulty communicating
(both verbally and written) due to the effects of a stroke. Al-
though your comprehension may be intact, others may not take
the time to listen to your care wishes and preferences. This can
lead you to feel depressed and frustrated and become increas-
ingly agitated and socially withdrawn.
✺ PROMOTING BEST PRACTICE
Assessing Individuals With Dementia
Individuals with mild to moderate dementia are able to
provide reliable and valid information about their subjective
illness experience. Krestar et al. (2012) examined how the type
of response category impacted an individual’s ability to
complete and answer questions. One hundred and twenty-
five individuals with mild to moderate dementia answered a
variety of questions about their illness experience (e.g.,
symptoms of depression, dyadic relationship strain, self-
efficacy). Results found for individuals with greater cognitive
impairment, the type of response category made a difference.
Response categories that were simplified (e.g., “ yes” or “ no”),
and response categories that were one-directional (e.g.,
anchored from “none” to “a lot”) were more likely to be
answered compared with those that were bidirectional
(e.g., anchored from “strongly disagree” to “strongly agree”).
Clinically, these results can be implemented to include
individuals with dementia in their care process by asking
questions that can be answered with “yes” or “no” or with
one-directional anchored responses instead of ignoring or
discounting their input.
Unfortunately, incorrect and negative assumptions about
individuals with cognitive impairment can have an impact on
how friends, family, and professionals interact with and de-
liver care, resulting in increased dependency, lower quality of
life, less effective treatment, and ineffective symptom man-
agement (Borbasi, Jones, Lockwood, & Emden, 2006). The
following tenets will be used as a framework for examining
atypical cognitive changes across the life span, for under-
standing the full impact of living with a cognitive condition,
and as the basis for developing and implementing effective
treatment protocols for managing and coping with the symp-
toms of cognitive impairment.
Tenet 1: Older adults with cognitive conditions must
receive the proper evaluation and treatment. Specifically,
a proper evaluation ensures reversible or other conditions
can be excluded while the proper treatment ensures indi-
viduals are receiving effective medical and nonmedical care
for their condition. This tenet underscores the importance
of using a holistic approach to address the wide range of
care needs experienced by individuals with cognitive impair-
ments. Medical care refers to biological- or physiological-
based treatments (e.g., drug therapies, diet/nutrition, pain
management), whereas nonmedical care refers to social-,
emotional-, mental health–, and function-based care
needs (e.g., counseling, occupational [OT]/physical [PT]/
speech-language pathology [SLP] therapies, and social
work services). Ongoing monitoring and treatment of both
medical and nonmedical care needs of individuals and
their families are essential for effective management and
coping with cognitive conditions. Additionally, it is im-
portant to keep in mind that individuals and their families
may have different care needs and issues. For example, an
individual with cognitive impairment may want to live in
her own home and remain as independent as possible,
whereas her family’s top priority may be to address safety
issues. Both issues are important and require attention
from health-care providers.
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CHAPTER 12
INTERPROFESSIONAL PRACTICE
Return to Highest Level of Function
Each patient is a part of an important team that is responsible
for developing and implementing a plan of care to help the
individual return to the highest level of function. In the
rehabilitation realm, three distinct types of therapists are
integral to this process: physical therapists, occupational
therapists, and speech-language pathologists. The physical
therapist focuses on the individual’s level of functional mobility
including posture, balance, and walking, and the occupational
therapist assists with maximizing the individual’s level of
independence in daily activities such as bathing, dressing,
or cooking. The speech-language pathologist focuses
on improving the individual’s functional cognition and
communication ability as well as swallowing. Together, these
therapists must coordinate interventions to maximize the
patient’s strength and abilities.
In addition to these rehabilitation professionals, the in-
terprofessional team also will consist of physicians, nurses,
social workers, psychologists, family members, and other
caregivers to ensure that interventions are translated to daily
care to maximize the carryover from therapy. Therapists will
also rely on input from these team members to continually
assess and modify the plan of care.
Tenet 2: Cognitive conditions need to be understood in
the context of an individual’s entire life course and not in iso-
lation. The Developmental Lifespan Approach states that
development occurs across the life span and incorporates both
biological and environmental aspects, including normative
age-graded influences, normative sociohistorical influences,
and nonnormative life events (Baltes, 1987) (for more infor-
mation, see Chapter 7). Individual differences can positively
or negatively affect the experience of living with a cognitive
condition. For example, key factors such as educational at-
tainment, financial resources, perceived need, social support,
and coping styles are all important in how individuals expe-
rience and manage the symptoms of their illness.
Tenet 3: The subjective illness experience of living with a
condition that affects cognitive functioning (and other do-
mains) must be understood from the perspective of the in-
dividual and his or her family. This tenet is important
because it highlights the need to examine, understand, and
intervene to address the subjective aspects of living with and
providing care for an individual with a cognitive impairment.
Many cognitive conditions have objective indicators of the
illness (e.g., short-term memory loss, problems with decision-
making, communication difficulties), yet the subjective ill-
ness experience is less understood. For example, how do
individuals experience their illness? How do people with
cognitive impairment cope and manage with their illness?
How do individuals remain engaged with their friends and
family? How do families manage and cope with their new
roles and responsibilities in providing care? Cognitive con-
ditions affect not only individuals living with an illness but
■ Cognitive and Emotional Function: Health Conditions 183
also their families, in particular informal family caregivers
who provide the vast majority of care for individuals
(Zwaanswijk, Peeters, van Beek, Meerveld, & Francke,
2013). Informal family caregivers are the family and friends
who provide ongoing care and social support to individuals
requiring assistance and do so without formal training or
monetary compensation for their work.
To illustrate, consider two individuals who have the same
objective symptoms of an illness (i.e., same cognitive and
functional symptoms) but subjectively experience the illness
very differently because of differences in personality, coping
abilities, and social support. One might be deeply distressed
by the changes, have limited family to pitch in, and experi-
ence significant functional decline. Another might take these
difficulties as a personal challenge and focus energy and
attention on problem-solving and on those abilities that
remain, with the help and support of a loving family. These
individuals and their families have very different care needs
and issues that stem from subjective, not objective, aspects
of the illness. This tenet underscores the importance of
understanding how the subjective aspects of living with a
cognitive impairment can affect individuals and their fami-
lies (Aminzadeh, Byszewski, Molnar, & Eisner, 2007; Ory,
Hoffman, Yee, Tennstedt, & Schulz, 1999; Robinson,
Clare, & Evans, 2005) and furthermore, the need to develop
interventions that address the subjective illness experience
(Judge, Menne, & Whitlatch, 2010).
Tenet 4: Conditions that affect cognitive functioning are
best conceptualized using the following theoretical frame-
works for developing and implementing interventions: the
Environmental Press Model and the Strength-Based Ap-
proach. The Environmental Press Model (Lawton, 1982)
describes the complex interaction between an individual’s
abilities and the fit (or lack of fit) with his or her environ-
ment. Environments that do not adequately match the needs
of an individual’s personal competencies, because of either
over- or understimulation will result in a wide range of
negative outcomes, such as boredom, social isolation, and
frustration. The Environmental Press Model is especially im-
portant and relevant for assisting individuals with cognitive
conditions because it is important to tailor or modify their
environments to meet their individual abilities. For example,
an older adult with mild short-term memory loss may benefit
from using external memory aids (e.g., lists, labels) to de-
crease the amount of “to-be-remembered” information or
cognitive load. In this example, the individual’s environment
(i.e., use of external memory aids) is used to offset his short-
term memory loss (i.e., individual abilities). On the other end
of the spectrum, an individual with dementia residing in a
nursing home may encounter an understimulating environ-
ment if her day consists primarily of watching television alone
in her room. This could result in apathy, boredom, symptoms
of depression, and feelings of isolation for the individual. In
this scenario, the individual would greatly benefit from an
environmental context that had stimulating mental, physical,
and social activities that matched her current abilities.
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184 PART II ■ Aging: Body Structures and Body Functions
In contrast to traditional medical models, a strengths-based
approach focuses on (1) identifying strengths and abilities
rather than deficits and limitations, (2) including individuals
as active rather than passive participants in the treatment
process, and (3) emphasizing current possibilities and options
rather than past events and performance (Fig. 12-1) (George,
Iveson, & Ratner, 1999).
Beneficial results are found for using a strengths-based ap-
proach as a social work clinical tool for assessing and treating
behavioral and psychosocial issues for individuals and their
families (George et al., 1999; Gingerich & Eisengart, 2000;
McKeel, 1996) and more recently as a model for counseling
(Dahl, Bathel, & Carreon, 2000; Kropf & Tandy, 1998). A
strengths-based approach is best suited for treating vulnerable
populations with progressive and/or irreversible diseases. For
example, people with dementia experience difficulties with
their short-term memory but little to no difficulty with their
long-term memory or ability to read. Using a strengths-based
approach, individuals would be encouraged to draw on long-
term memory while actively compensating for difficulties in
short-term memory (i.e., using an external memory aid, such
as a list).
Tenet 5: An overarching goal for older adults, family mem-
bers, clinicians, researchers, and policy-makers is for all indi-
viduals to positively age with their condition while being as
independent as possible and achieving the highest quality of
life possible. This tenet highlights the importance of respect-
ing and honoring individuals who are living with a chronic
health condition that affects their cognitive abilities and not
discounting, invalidating, or ignoring these individuals.
Using these tenets, this chapter focuses on two main health
conditions that influence cognitive functioning across the life
span: neurodegenerative illnesses and mental health condi-
tions. In addition to discussing the prevalence, etiology, symp-
toms, and current treatment protocols for each condition, this
chapter also discusses the psychosocial implications of man-
aging and coping with cognitive conditions from the perspec-
tive of the individual and his or her family. Stroke, which has
significant cognitive and emotional consequences, is discussed
FIGURE 121 Elders with dementia can benefit from a focus on their
strengths. Ocskaymark/iStock/Thinkstock
briefly; greater detail about this condition is presented in
Chapter 15. Last, innovative research aimed at addressing the
medical and nonmedical care needs of individuals with cog-
nitive conditions is discussed as it pertains to older adults,
researchers, clinicians, and policy-makers.
Neurodegenerative Illnesses: Dementia
and Associated Disorders
Neurodegenerative illnesses have a direct and negative impact
on one’s brain health and, in many cases, cognitive abilities.
Examples include dementia (such as Alzheimer’s disease),
Parkinson’s disease, Huntington’s disease, and amyotrophic
lateral sclerosis (ALS, or Lou Gehrig’s disease). All neurode-
generative disorders disrupt neural functioning in the brain,
leading to disruptions in functioning and eventually cell
death. For the purpose of this chapter, dementia is discussed
in further detail.
Prevalence of Dementia and Associated
Disorders
Dementia is a global term used to describe changes in cog-
nitive functioning that are atypical or pathological in nature.
As the population ages, a growing number of older adults will
be diagnosed with some form of dementia. In the United
States, 4.3 percent of older adults age 70 to 74 have dementia,
and 47.5 percent of older adults over age 90 have dementia
(Prince et al., 2013). The prevalence rates for dementia are
higher for individuals living in institutional settings such as
a nursing homes or assisted living facilities (Seitz, Purandare,
& Conn, 2010). More than 15 conditions have dementia as
the primary or secondary symptom (National Institutes of
Health, 2013). Currently, the most common form of diag-
nosed dementia is Alzheimer’s disease, with an estimated
5.2 million individuals currently living with the illness in the
United States (Alzheimer’s Association, 2014).
Etiology and Types of Dementia
Dementia can be classified as either reversible or irreversible.
Reversible dementias may be caused by thyroid disorder,
urinary tract infection, electrolyte imbalance, a hormonal
imbalance, or normal pressure hydrocephalus (Duinkerke,
Williams, Rigamonti, & Hillis, 2004; Insel & Badger, 2002).
Proper assessment and treatment of these conditions typically
leads to reversal of the associated cognitive symptoms, allow-
ing individuals to regain their former level of cognitive
functioning. Irreversible dementias permanently impair an
individual’s cognitive abilities and are progressive, which means
that the severity of the dementia symptoms will worsen over
time. In addition to Alzheimer’s disease, irreversible demen-
tias include vascular dementia, frontal-temporal dementia,
Lewy-body dementia, Korsakoff’s syndrome, and Huntington’s
disease. Individuals with certain illnesses, such as Parkinson’s
disease, multiple sclerosis, HIV/AIDS, and ALS, may also
4605_Ch12_181-200 31/10/17 12:24 PM Page 185
CHAPTER 12
develop and experience dementia symptoms that are progres-
sive and irreversible. Understanding the specific type of de-
mentia is important as the prognosis and future care planning
can be quite different. For many of these illnesses, such as
Alzheimer’s disease, scientists are still investigating the spe-
cific causes and origins. A summary of the differing symp-
toms of the various causes of dementia can be found in the
online ancillary materials.
Symptoms of Dementia
Most of us from time to time experience forgetfulness or
memory loss, such as forgetting where we put our car keys or
the name of an acquaintance. When this type of forgetfulness
or memory loss occurs on a regular basis and begins to inter-
fere with an individual’s ability to complete regular activities,
however, these changes may reflect a dementing illness (see
Box 12-1). Primary cognitive symptoms of dementia include
difficulties with short-term memory, attention, orientation
to time, place, and person, visuospatial processing, language
production and comprehension, and executive functioning.
Individuals with dementia also experience difficulties per-
forming day-to-day activities, such as handling finances, gro-
cery shopping, participating in leisure activities and hobbies,
and carrying out self-care tasks.
Following are examples of how cognitive symptoms of
dementia translate to real-world functional activities:
■ Repeating the same story or asking the same question
within a short amount of time
■ Confusing the past with the present
■ Saying “brother” when you mean “uncle”
■ Forgetting to turn off the stove
■ Forgetting to pay bills or file taxes
■ Difficulty following a conversation or watching a movie
■ Trouble learning a new phone number or password
■ Wearing a heavy coat during the summer or wearing clothes
out of order (i.e., under garments over shirt and pants)
BOX 121 A Case Example
Madelyn is a 73-year-old woman who has been married for 40 years.
Madelyn has moderate symptoms of vascular dementia in addition
to hypertension and arthritis. Her most notable cognitive symptom
is difficulty with short-term memory; she repeats herself frequently
and tells the same five to eight stories continually. Because of this,
many of her friends and family feel uncomfortable or unsure how to
interact and converse with her, with some limiting their time or even
deciding not to visit with her. Madelyn is aware that something is
amiss. She feels more socially isolated and disconnected from her
friends and family. Functionally, Madelyn is able to complete self-
care activities without assistance but can no longer manage an array
of daily tasks, such as cooking, grocery shopping, and paying bills.
With assistance, she can do the laundry and light housework and
■ Cognitive and Emotional Function: Health Conditions 185
■ Using a toothbrush instead of a hairbrush to brush one’s hair
■ Mistaking one’s child for a sibling
■ Not recognizing oneself in the mirror
■ Getting lost or wandering
Traditionally, researchers and clinicians have focused on the
effects of dementia on cognitive and functional abilities and
emotions and behaviors. More recently, researchers and clini-
cians have begun to examine and address the domains of men-
tal health and coping and staying active, as these have been
found to be important determinants of the illness experience
of individuals with dementia (Dawson, Powers, Krestar, Yarry,
& Judge, 2013).
Communication
Individuals with dementia may experience difficulties pro-
ducing language (e.g., thinking of a specific word) or un-
derstanding what is being said to them (e.g., following a
conversation or directions). It is common for individuals with
dementia to feel frustrated and confused when others do not
understand them or they do not understand others. Other
common communication issues include substituting words
that are similar but not the correct word, such as mother for
daughter; feeling uneasy or unsure about talking with others;
and asking repetitive questions or retelling the same story or
information within a short amount of time.
Functional engagement: Individuals with dementia have diffi-
culties remembering things like appointments, names of family
members or friends, or when to eat. They also may experience
difficulties with regular activities that they used to perform eas-
ily, such as banking, shopping, or completing household tasks.
An early symptom of an individual with dementia is difficulty
completing one or more instrumental activities of daily living
(IADL), such as forgetting to pay bills or getting lost when
driving, because these usually require more cognitive resources
(Njegovan, Man-Son-Hing, Mitchell, & Molnar, 2001). In-
dividuals with dementia typically perform personal or basic
also garden. Although she appreciates assistance with these tasks,
she feels frustrated, agitated, and, at times, a deep sense of loss that
she needs help to accomplish activities that she easily performed all
of her life. Madelyn also has experienced changes in her energy level
and feels as if she does not get enough quality sleep; leaving her
feeling tired and less motivated throughout the day.
This example highlights the interconnectedness between cognitive,
functional, and behavioral symptoms of dementia and how these
symptoms can affect other domains, such as well-being, social en-
gagement, and one’s sense of self. The example also underscores
the importance of treating both the medical and nonmedical symp-
toms of dementia.
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186 PART II ■ Aging: Body Structures and Body Functions
activities of daily living (PADL or BADL), such as bathing,
grooming, toileting, and dressing, with little to no assistance
because these tasks are well engrained in procedural long-term
memory. Individuals may require assistance later in the illness
with PADLs, which can range from verbal prompts, redirec-
tion, and cuing to full care.
Emotions and behaviors: Individuals with dementia may ex-
perience changes in their emotions and usual behaviors.
Many of these changes are due to the dementia and the spe-
cific neurological damage; others may be due to difficulties
in communication or feelings of sadness or loss related to ac-
knowledgment of the illness. Changes in emotions and be-
haviors can range from feelings of stress or indifference to
more severe changes such as emotional outbursts and neu-
ropsychiatric symptoms such as delusions and hallucinations.
Other changes include feelings of frustration, anger, agita-
tion, apathy, sleep–wake cycle disruptions, and appetite
changes. These changes can occur during any stage of the ill-
ness. It is estimated that 90 percent of all individuals with
dementia will experience behavioral and psychological symp-
toms (Cerejeira, Lagarto, & Mukaetova-Ladinska, 2012);
however, these symptoms are not well predicted on the basis
of an individual’s cognitive or functional symptoms.
Mental Health and Coping
Individuals with dementia are at risk for experiencing symp-
toms of depression and anxiety, along with other negative out-
comes such as strained family relationships, loss of self-identity,
and feelings of isolation and embarrassment (Dawson et al.,
2013; Gurland, 1980; Judge et al., 2010; Kunik et al., 2003).
Additionally, many individuals may find it difficult to initiate
and maintain positive coping strategies for addressing these
concerns. Mental health issues can exacerbate symptoms of
dementia and can also be a result of the illness. It is important
for researchers and clinicians to address mental health issues
in individuals with dementia and implement effective coping
strategies for individuals.
Staying Active and Engaged
Because of changes in cognition, function, emotions, and be-
haviors, many individuals with dementia face challenges in
remaining active and engaged. Difficulties can affect leisure
and work-related activities as well as socializing with friends
and family. Rehabilitation professionals must encourage older
adults, especially those with dementia or mental health con-
cerns, to remain active. Different modifications and compen-
satory strategies may need to be added to allow successful
completion of various activities based on the current abilities
of the individual.
Diagnosing Dementia
Proper evaluation for diagnosing a dementing disorder con-
sists of the following: a thorough medical and nonmedical
history with the individual; interview with family or a close
family member to collect additional information and, if
needed, substantiate information reported by the individual;
a review of coexisting medical conditions and current drugs
or treatments; physical, neurological, and functional exam in-
cluding mental status and depression assessment; laboratory
tests (e.g., blood work); brain imaging; and neuropsycholog-
ical testing (Insel & Badger, 2002). Further evaluation may
not be needed if testing at any point reveals the underlying,
reversible cause (e.g., electrolyte imbalance) of the symptoms.
Additionally, it is important to note that these conditions
may not be mutually exclusive. The prevalence of reversible
delirium superimposed on dementia is extremely high in both
community (13–19 percent) and hospital (40–89 percent)
populations (Fick et al., 2014). For example, an individual
with dementia may experience delirium resulting in an exac-
erbation of symptoms due to a urinary tract infection.
Types of Dementia
To highlight differences in type of dementia, the following
illnesses are briefly discussed: Alzheimer’s disease, vascular
dementia, and Lewy body dementia. Key neuropathological
indicators of Alzheimer’s disease include neurofibrillary tan-
gles and beta-amyloid plaques, decreased production and
reuptake of the neurotransmitter acetylcholine, and loss of
the dendritic network that is crucial for neuronal communi-
cation. It is thought the initial brain damage occurs in the
hippocampus, which is responsible for new learning and con-
solidation of new information from short-term to long-term
memory systems.
Diagnosing Alzheimer’s disease is a process of excluding
other conditions because there is not a specific test used to di-
agnosis or a specific biomarker that indicates the presence of
Alzheimer’s disease (e.g., blood work, cerebrospinal fluid, re-
sults from functional magnetic resonance imaging [MRI], or
positron emission tomography [PET] scans). Subsequently,
confirmation of Alzheimer’s disease as the official diagnosis
is only available upon death via autopsy. Alzheimer’s disease
symptoms can be classified as mild, moderate, or severe. In
the mild stages of the illness, individuals usually are able to
continue their daily activities with minimal assistance. For ex-
ample, individuals are able to complete self-care activities (e.g.,
bathing, dressing, toileting, grooming, and transferring); so-
cialize and engage with friends and family; and continue to
complete day-to-day activities that are familiar and well prac-
ticed, such as driving a familiar route, playing a game of skill
or a musical instrument, or participating in a physical activity.
As the illness progresses, individuals experiencing severe
symptoms may require complete assistance for completing
personal care activities and may no longer be able to effectively
communicate or actively engage in certain activities because
they are bed ridden.
The progression of Alzheimer’s disease usually unfolds over
many years. After receiving a diagnosis, many individuals will
live an average of 4 to 8 years with some living as many as
20 years (Alzheimer’s Association, 2014). This underscores
4605_Ch12_181-200 31/10/17 12:24 PM Page 187
CHAPTER 12
the importance of developing efficacious pharmacological
and nonpharmacological intervention protocols for both in-
dividuals and their families for managing and coping with
the multitude of symptoms. Although Alzheimer’s disease
most commonly affects individuals more as they age, approx-
imately 5 percent of individuals with Alzheimer’s disease are
diagnosed with early-onset Alzheimer’s disease, which can
begin as early as 30 years old (Alzheimer’s Association,
2014). Scientists do not completely understand the cause of
this form of Alzheimer’s disease; however, they do believe
there is a genetic link.
Vascular dementia is the second most commonly diag-
nosed form of dementia and is caused by an overall inefficient
supply of oxygenated blood to the brain that may be caused
by small transient ischemic attacks (i.e., small, unnoticeable
strokes), major strokes, or untreated high blood pressure.
More than four million older adults have vascular dementia
(Grossman, Bergmann, & Parker, 2006). A primary risk fac-
tor for vascular dementia is a history of having one or more
major strokes (Grossman et al., 2006). Additional risk factors
include hypertension, diabetes, and history of smoking, all of
which either directly or indirectly affect the body’s ability to
efficiently pump oxygenated blood to the brain. Compared
with individuals with Alzheimer’s disease, individuals with
vascular dementia may not experience progressive cognitive
changes across time but instead will typically experience daily
fluctuations in their cognitive abilities, with symptoms be-
coming worse over the course of the day. Symptoms of vas-
cular dementia can be similar to those of Alzheimer’s disease,
or may be more localized. For example, an individual with
vascular dementia may have specific focal impairments in
short-term memory and attentional processing but may retain
executive functioning abilities, such as decision-making, rea-
soning, problem-solving, and judgment.
Lewy body dementia (LBD) is a progressive dementia and
represents two related diagnoses, dementia with Lewy bodies
and Parkinson’s disease dementia. LBD affects approximately
1.4 million older adults (Lewy Body Dementia Association,
2016); however, some researchers and clinicians indicate LBD
may be underdiagnosed given the overlap of symptoms with
other types of dementias. The basal ganglia, which is important
in motor control and planning as well as procedural learning,
is primarily affected by LBD. Although cognitive symptoms
of LBD include difficulties with attention and executive func-
tion, memory may remain relatively unaffected in the early
stages of the disease. Additionally, hallucinations and sponta-
neous parkinsonism may be present due to the involvement of
the basal ganglia. Diagnosing LBD includes a physical exam-
ination as well as brain imaging (e.g., computed tomography
[CT] or PET scans); however, as in Alzheimer’s disease, con-
clusive diagnosis can only be made after death. In contrast to
Alzheimer’s disease and vascular dementia, LBD has several
motor-based symptoms that may have a negative impact on
individual’s physical health and mobility (e.g., balance and co-
ordination difficulties, changes in gait, tremors, and falls),
which can complicate treatment plans.
■ Cognitive and Emotional Function: Health Conditions 187
Regardless of the type of dementia, it is important that in-
dividuals and their families receive the appropriate pharma-
cological treatment, educational information, and supportive
resources for managing and coping with the symptoms of de-
mentia. Currently, the majority of people living with dementia
are cared for at home by their families (Alzheimer’s Associa-
tion, 2014). Providing care for a loved one with dementia
typically rests on the shoulders of one individual, usually
the spouse or the daughter/daughter-in-law (Bouldin &
Andreson, 2010). It is imperative that both the individual and
his or her family are equipped to effectively manage and cope
with their respective roles, and particularly to share the re-
sponsibility for meeting the individual’s needs. Further assess-
ment may be warranted to address their respective care issues
and needs. For example, the individual may benefit from oc-
cupational therapy and counseling, whereas the family may
benefit from receiving additional educational information
about future care planning, information pertaining to adult
day care services, and respite care and from the physical ther-
apist to consider how to maintain the individual’s physical
capacity for as long as possible.
Pharmacological and Nonpharmacological
Interventions for Dementia
To date there is not a cure for Alzheimer’s disease or any of
the illnesses that cause dementia. Several U.S. Food and Drug
Administration–approved medications mitigate the cognitive
symptoms experienced by individuals with dementia. These
include cholinesterase inhibitors that increase levels of the
neurotransmitter acetylcholine (i.e., donepezil [Aricept],
galantamine [Razadyne], and rivastigmine [Exelon]) and an
N-methyl-D-aspartate (NMDA) receptor antagonist (i.e.,
memantine [Namenda]) that target the neurotransmitter
glutamate (Raina, Santaguida, Ismaila, & Patterson, 2008).
These drugs do not halt the progression of the illness and are
primarily designed for individuals who are experiencing mild
to moderate symptoms of dementia, although Namenda is
used for individuals in all stages of the illness.
Because there is no known cure for many dementias like
Alzheimer’s disease and LBD, and current drug therapies do
not dramatically improve symptoms or stop the progression
of the illness, there is a growing emphasis on the development,
implementation, and evaluation of nonpharmacological inter-
vention programs that address the care needs of both the
individual and his or her family members. The Alzheimer’s
Association is one of the leading social service agencies dedi-
cated to providing individuals and their families with a wide
range of educational and supportive service programs. Exam-
ples of resources and programs include a multitude of educa-
tional information and programs, the 24/7 Helpline, the
Safe Return program, support groups for individuals and fam-
ilies, and online resources and message boards (Alzheimer’s
Association, 2014).
In addition to resources through the Alzheimer’s Asso-
ciation, more than 40 interventions have been identified as
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188 PART II ■ Aging: Body Structures and Body Functions
effective in managing or improving symptoms; however, few
of these are readily available to the general population of
community-dwelling older adults (Maslow, 2013). These in-
terventions included various combinations of cognitive re-
habilitation techniques, counseling support, and exercise
training with those encompassing multiple domains being
most effective (Maslow, 2013). Unfortunately, it is difficult
to aggregate these various programs because they have differ-
ent methods of delivery as well as different classification sys-
tems of symptoms and outcomes. More research is needed
to determine which components and dosage (e.g., number
of sessions, number of times required to practice a skill) are
most important in addition to translating this research into
community settings (Bass & Judge, 2010).
Stroke
Unlike most dementing illnesses that take years to progress
from mild to more severe symptoms, a stroke happens quickly
and can result in abrupt and long-lasting changes in an indi-
vidual’s cognitive, physical, emotional, social, and behavioral
functioning. As discussed in Chapters 13 and 15, stroke in-
volves the cardiovascular system and has consequences not
only for cognition but also for movement. It typifies the kinds
of conditions that occur in later life that have complex eti-
ologies and equally complex consequences.
Prevalence
Stroke is the fourth leading cause of death in the United
States and affects 8.3 percent of those aged 65 years and older
(Centers for Disease Control and Prevention [CDC], 2012).
Each year, approximately 795,000 people will experience a
new or recurrent stroke (Roger et al., 2011). Research has
found higher prevalence rates for stroke based on age (older
adults), race (African Americans, American Indians, and
Alaska Natives), education level (less education), and geo-
graphic region in the United States (southeastern region)
(CDC, 2012). Suffering a stroke is a strong risk factor for
having another stroke; one in four stroke survivors will suffer
another stroke during their lifetime (Roger et al., 2011). Ad-
ditionally, research has found that recurrent strokes are asso-
ciated with higher levels of disability and mortality (Licon,
Evangelista, Mastrolia, & Whitaker, 2014).
Etiology and Types of Stroke
There are two types of stroke: ischemic and hemorrhagic. Is-
chemic strokes occur when there is a disruption in the flow
of oxygenated blood in the brain due to a blocked blood
vessel. Hemorrhagic strokes are due to bleeding caused by a
blood vessel that has burst, which can be due to an undetected
aneurysm or untreated long-term hypertension (Bederson et
al., 2009; Woo et al., 2004). Approximately 80 percent of
strokes are ischemic, 15 percent are hemorrhagic, and 5 percent
are undetermined (Langhorne, Bernhardt, & Kwakkel, 2011).
Individuals also can suffer from a transient ischemic attack
(TIA), which is a relatively small or minor stroke that may
be undetected and unnoticed. However, multiple TIAs that
occur in the same location, over time, can result in damage
and are a risk factor for suffering a major stroke in the future.
Research also has found that approximately 15 percent of in-
dividuals who have a TIA will suffer a stroke within 3 months
(Kleindorfer et al., 2005).
Symptoms of Stroke
Initial symptoms of a stroke may include one or more of the
following: facial and/or body numbness that occurs primarily
on one side of the body, difficulty producing language (i.e.,
slurred, incomprehensible); disorientation and confusion,
vision difficulty, trouble with walking or mobility, and severe
and sudden headache with unknown origin. The American
Heart Association and American Stroke Association use the
acronym FAST for recognizing and responding to stroke
symptoms:
F = FACE, does one side of the person’s face droop when
they smile?
A = ARMS, can the individual raise both of his or her
arms?
S = SPEECH, is the individual’s speech slurred? and
T = TIME, immediately call 911 if any of these symptoms
are present (Kleindorfer et al., 2007).
The resulting impairments of a stroke depend on the lo-
cation and severity of the damage to the brain. For example,
a stroke survivor may experience permanent paralysis on one
side of the body (contralateral to the location of the lesion);
problems with cognitive processing, including difficulties in
executive functioning, memory, and producing and compre-
hending language; and changes in emotions and behaviors.
Another stroke survivor may experience minor difficulties
with attentional abilities and gross-motor functioning that
are readily amenable to rehabilitation (i.e., OT, PT, SLP).
Given the range of recoveries poststroke, it is important to
keep several key questions in mind: What are the long-term
effects of the stroke? How do the effects of stroke effect the
individual and his or her sense of self? Who will provide care
for the stroke survivor or take on the roles and responsibilities
that the individual can no longer perform (e.g., work, house-
hold tasks, self-care)?
Similar to dementia, the effects of a stroke may affect all
aspects of an individual’s life, including cognitive, functional,
social, emotional, mental health, and behavioral. One of the
most challenging aspects of coping with and managing the
effects of a stroke is related to the abrupt nature of the onset
and resulting disability. Imagine if you woke up tomorrow
morning and could no longer perform any self-care activities
such as dressing, bathing, or grooming; had difficulties with
producing and comprehending language; and needed assis-
tance with walking and other activities that required using
the right side of your body. Clearly this would be a difficult
4605_Ch12_181-200 31/10/17 12:24 PM Page 189
CHAPTER 12
transition, not to mention the ripple effects of these symp-
toms that would affect you socially and emotionally. Most
stroke survivors with these types of disability require assis-
tance from a caregiver, typically an informal family caregiver.
Both individuals, the stroke survivor and the caregiver, are
faced with new roles and responsibilities that, without proper
assistance, may have a negative impact on well-being and lead
to negative health-related outcomes. Interventions aimed at
helping both individuals in effectively coping with and man-
aging the poststroke symptoms is imperative.
Stroke survivors may experience difficulties with produc-
ing and comprehending language, finding the right words,
forming complete sentences that are understandable to oth-
ers, asking repetitive questions, or telling the same story
repeatedly. Individuals also may experience changes in their
cognitive abilities that include difficulties with remembering
previous information, directing attentional resources, learning
new information (i.e., short-term memory loss), executive
functioning (i.e., decision-making, judgment, problem-solving,
reasoning, abstract thought), and self-awareness or insight.
Lack of self-awareness (or insight) can be especially difficult
for individuals and their family members to manage and cope
with because individuals are not aware of their limitations or
changes in abilities poststroke. Stroke survivors also can ex-
perience a wide range of emotions and behaviors because of
the effects of the stroke or in response to the illness experi-
ence of living with a stroke. Examples include symptoms of
depression and anxiety; neuropsychiatric symptoms, such as
delusions and hallucinations; feelings of isolation, sadness,
and anger; apathy and lack of motivation; and inappropriate
or impulsive mood and behavior. Individuals also can expe-
rience changes in their sleep–wake cycles, appetite, and sex-
uality. According to various disablement models, such as the
Nagi Model of Disability or the International Classification
of Functioning, Disability and Health, these physical symp-
toms or impairments may lead to higher-level difficulties in
functional activities or participation in societal roles (Jette,
2006). Functionally individuals may experience difficulties
completing PADL (i.e., dressing, bathing, grooming, toi-
leting, transferring) and IADL (i.e., shopping, household
activities, finances, meal preparation, medication adherence,
and leisure activities). Stroke survivors also experience
changes in their roles and responsibilities that could nega-
tively affect other domains as well (i.e., depressive symptoms,
feelings of isolation). Examples of changes in one’s roles and
responsibilities include working, parenting or grandparent-
ing, community engagement, spousal relationship, or house-
hold chores.
Diagnosing Stroke
Diagnosing a stroke usually involves getting a medical his-
tory, completion of physical and neurological examination,
reviewing laboratory tests, and obtaining brain imaging such
as CT or MRI scans to determine the location and extent of
damage. Stroke severity is typically rated on the National
■ Cognitive and Emotional Function: Health Conditions 189
Institutes of Health Stroke Scale (NIHSS), which ranges
from 0 (no stroke symptoms) to 42 (very severe stroke symp-
toms) or the modified Rankin Scale ranging from 0 to 5 that
are useful for determining rehabilitation services and future
care needs.
Pharmacological and Nonpharmacological
Interventions for Stroke
Although no pharmacological intervention can reverse the
effects of a stroke, time is of the essence in initiation treat-
ment. For ischemic stroke, there is a limited window of
opportunity during which clot-buster medications, such as
tissue plasminogen activator (t-PA), can be administered
(typically within the first 3 to 4.5 hours from the first symp-
tom). Timely administration of t-PA has been shown to re-
duce the associated disability of strokes (del Zoppo et al.,
2009). One of the goals of treating a stroke is preventing the
occurrence of another. Examples of pharmacological inter-
ventions aimed at reducing this risk include taking an aspirin
once a day and/or medications that prevent blood clots from
developing.
Depending on their needs, stroke survivors typically re-
quire a combination of rehabilitation services that can include
PT, OT, and/or SLP therapy. Regardless of the type of ther-
apy, the goal is to facilitate healing and the individual’s return
to the prior level of functioning, or as close to this level that
can be achieved. For some this may require minimal assis-
tance in regaining functioning; others may need to relearn
numerous functions (e.g., speaking, swallowing, walking, get-
ting dressed). Physical therapists primarily address impair-
ments in motor performance, both gross motor activities,
such as walking, transferring, balance, and strength, and fine
motor performance. Occupational therapists work to support
personal and instrumental activities of daily living, some cog-
nitive abilities, and other meaningful occupations that enhance
life satisfaction. Examples may include meal preparation,
bathing, leisure pursuits, and returning to work. Speech-
language pathologists assist in regaining swallowing, lan-
guage, and cognitive abilities. Specific areas addressed include
production and comprehension aspects of language and im-
proving memory and problem-solving as well as oral motor
exercises and swallowing techniques. For many stroke sur-
vivors, a multimodal therapeutic approach has been found to
be the greatest benefit for achieving maximal functioning and
outcomes (Langhorne et al., 2011).
Cardiopulmonary considerations associated with stroke
are discussed in Chapter 13, and musculoskeletal considera-
tions in Chapter 15.
Mental Health Conditions
At some point in their life span, many individuals will strug-
gle with symptoms of depression or anxiety, and some will
encounter more severe conditions, such as major depressive
disorder, bipolar disorder, or schizophrenia. As people age
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190 PART II ■ Aging: Body Structures and Body Functions

the likelihood of experiencing a mental health issue for the including higher levels of education, socioeconomic status,
first time declines (Kessler et al., 2010). Mental health con- social engagement, and spiritual or religious involvement.
ditions can impact a wide range of domains, including phys-
ical, emotional, and social. An important yet not widely Symptoms
understood aspect of mental health conditions is their impact
Symptoms of depression range from feelings of hopelessness,
on individuals’ cognition. For example, individuals with schiz-
sadness, and despair, to changes in appetite and sleep–wake
ophrenia experience cognitive difficulties with memory, exec-
cycles, or loss of energy and interest in activities. Depression also
utive function, and speed of processing which can affect daily
can have an impact on an individual’s cognitive abilities, result-
functioning across multiple spheres (e.g., physical, social, in-
ing in memory loss, difficulties in concentration and attentional
terpersonal) (Loewestein, Czaja, Bowie, & Harvey, 2012).
processes, learning, and problems with executive functioning
The following sections discuss depression, anxiety, schizophre-
(Insel & Badger, 2002). As noted previously in this chapter,
nia, bipolar disorder, and substance abuse, emphasizing
this overlap of cognitive symptoms with dementia is important
specific issues relevant to late-life mental disorders.
for researchers, clinicians, and individuals to understand and
address. A thorough evaluation is typically needed to discern
Depression the cause. Compared with younger adults, older adults tend to
report more somatic and cognitive depressive symptoms and
Depression occurs along a continuum, varying from mild
have reported that depressive symptoms impede daily activities
symptoms to more severe conditions, such as major depres-
(Edelstein, Bamonti, Gregg, & Gerolimatos, 2015; Fiske et al.,
sive disorder (MDD). Symptoms of depression can fluctuate
2009). Older adults who experience symptoms of depression
across time and age (Manetti, Hoertel, Le Strat, & Limosin,
are at risk for a wide range of negative health outcomes includ-
2014), but in general diagnosed depressive disorders decline
ing increased mortality (Cuijpers et al., 2014). Given that many
with age (Fiske, Wetherell, & Gatz, 2009).
older adults will struggle with symptoms of depression (rather
than be diagnosed with a depressive condition), it is imperative
Prevalence that research examines key predictors of depressive symptoms
Compared with other mental health conditions, depression is and how these symptoms impact older adults’ lives. Depressive
relatively common and across the life span has a prevalence conditions and even symptoms of depression can negatively
rate of 16.6 percent (Kessler, Petukhova, Sampson, Zaslavsky, affect older adults’ functioning, particularly in occupations that
& Wittchen, 2012). Whereas 12.02 percent adults aged 18 to rely heavily on cognitive skills (Fig. 12-2).
29 years are diagnosed with MDD, 8.19 percent older adults
over age 65 meet the diagnostic criteria (Manetti et al., 2014).
These prevalence rates dramatically vary based on the context
or setting. For example, diagnosed depression in a nursing
home setting has been documented at approximately 35 percent
(CDC, 2011), which is much higher than among the general
population. Symptoms of depression that do not reach the
threshold of diagnostic criteria are experienced more fre-
quently by older adults and have been reported to range from
15 to 25 percent (Agronin & Maletta, 2006). Although over-
all prevalence rates of depression decline across the life span,
older adults (men in particular) have the highest suicide com-
pletion rate (CDC, 2011). This is important to note because
rehabilitation professionals are often the clinicians spending
the most time with these individuals and may be crucial in
identifying those at high risk.

Etiology and Risk Factors

Depression is thought to be a combination of both genetic
and environmental factors. Interactions among a variety of
factors can increase the risk of depression for older adults.
Some of these risk factors can include neurobiological changes
in brain structure and chemistry, cardiovascular disease, age-
related cognitive changes, genetic predisposition, and acute or
chronic life stressors (e.g., bereavement, caregiver strain, social
isolation). Despite these risk factors, Fiske and colleagues FIGURE 122 Depression in later life is associated with social isolation
(2009) identify several protective factors that can reduce risk, and lethargy. Jevtic/iStock/Thinkstock
4605_Ch12_181-200 31/10/17 12:24 PM Page 191
CHAPTER 12
Additionally, symptoms of depression may be due to an-
other chronic health condition or life stress, such as cancer,
cardiovascular disease, or providing care to a loved one with
dementia. These conditions and life events are most likely to
occur later in life, potentially contributing to or exacerbating
older adults’ depressive symptoms (see Box 12-2).
Pharmacological and Nonpharmacological
Interventions
Antidepressant medications are effective in treating older
adults’ depressive symptoms (Kok, Heeren, & Nolen, 2011).
Drugs that affect the serotonin system, such as selective sero-
tonin reuptake inhibitors (SSRIs) and tricyclic antidepres-
sants (TCAs), can be helpful although doses are usually lower
than with younger adults. More than 67 percent of older
adults diagnosed with depression receive antidepressants for
treatment (Akincigil et al., 2011). When individuals with the
most severe cases do not respond to antidepressive medica-
tions, electroconvulsive therapy may be considered, especially
in individuals at high risk for suicide or those with psychotic
features such as hallucinations or delusions.
Some of these medications (tricyclic antidepressants and
SSRIs) can increase the risk for falls. Iaboni and Flint (2013)
recommend a thorough review of potential medication interac-
tions as well as titrating the dosage by starting off at a low dose
then slowly increasing to minimize falls. In addition, monitoring
changes in cognition, hypotension, or other issues such as elec-
trolyte imbalance can assist clinicians. Because older adults me-
tabolize or excrete many medications more slowly than younger
individuals and because these medications can, themselves,
result in cognitive change, careful monitoring is essential.
Behavioral rehabilitation used in combination with med-
ications is most effective in improving outcomes; however,
one or the other may be sufficient in milder cases (Alexopoulos,
2005). It is estimated that more than 71 percent of older
adults with depression are receiving some mode of treatment
(Akincigil et al., 2011). Interventions that effectively treat
depression include cognitive behavioral therapy, problem-
solving therapy, supportive therapy, and interpersonal therapy
(Kiosses, Leon, & Arean, 2011).
BOX 122 Case Example: Depression
Mr. Rabbin is a 74-year-old retired schoolteacher who lives with
his wife and two dogs. Over the past several months, his wife has
noticed that he is forgetful, confused at times, and just seems
“out of it.” Mr. Rabbin agrees with her assessment and fears that
he may have dementia, just as his father did. Friends of the
Rabbins suggest that the symptoms are minor and normal,
whereas the Rabbins’ children suggest contacting their father’s
primary care physician. Clearly, Mr. Rabbin would benefit from
further diagnostic testing to ascertain whether he is depressed
or showing early signs of dementia (or both).
■ Cognitive and Emotional Function: Health Conditions 191
✺ PROMOTING BEST PRACTICE
Exercise and Depression
In an article reviewing several studies examining the effects
of exercise on symptoms of depression, Carek, Laibstain, and
Carek (2011) reported that exercise is an efficacious treatment,
comparable to medications, for mild to moderate symptoms
of depression. Specifically, high-intensity weight training and
aerobic exercises are more effective than low-intensity weight
and aerobic training programs. Although more research is
needed, these findings are exciting for rehabilitation
professionals as physical activity and exercise can assist in
promoting not only physical health but also mental well-being.
Anxiety Disorders
Prevalence
Anxiety disorders are the most commonly diagnosed mental
health issue at every stage of life. Overall, prevalence rates for
later life anxiety disorders decrease across the life span and
range from 3.2 to 14.2 percent (Wolitzky-Taylor, Castriotta,
Lenze, Stanley, & Craske, 2010). These data suggest that a
large proportion of individuals with late-life anxiety disorders
were initially diagnosed in adolescence or young adulthood.
Anxiety triggers for older adults may include worry re-
lated to their health, disability, and dependence, whereas
anxiety triggers for younger adults center around work, fi-
nances, and family (Wolitzky-Taylor et al., 2009). Diagno-
sis and detection of anxiety disorders in later life can be
complicated by chronic medical conditions, cognition de-
cline, life changes, and medication side effects. Therefore,
it is likely that anxiety disorders are likely to be under- or
misdiagnosed in older adults compared with younger adults
(Wolitzky-Taylor et al., 2010).
Other types of anxiety disorders have lower prevalence rates
but can still be present in older adults. For example, panic dis-
order has the lowest prevalence at 0.1 to 1.0 percent, whereas
social phobias have prevalence rates of 0.6 to 2.3 percent
(Wolitzky-Taylor et al., 2010).
Etiology and Risk Factors
Similar to other mental health illnesses, the etiology for anx-
iety disorders is a combination of both genetic vulnerability
and environmental factors. Risk factors for developing later-
life anxiety include gender (female), chronic medical condi-
tions, marital status (single, divorced, separated), stressful life
events, physical limitations in daily activities, adverse events
in childhood, and neuroticism (Wolitzky-Taylor et al., 2010).
Symptoms
Symptoms of anxiety can be manifested cognitively, emo-
tionally, and/or physically. Examples include ruminating,
excessive worry and fear, difficulty concentrating or focusing,
restlessness, irritability, fatigue, body aches/pains, insomnia,
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192 PART II ■ Aging: Body Structures and Body Functions
and increased cardiovascular and respiratory response (i.e.,
pounding heart, irregular breathing). When assessing symp-
toms in older adults, using traditional assessments of anxiety
developed for younger adults may result in an overemphasis
on physical symptoms (e.g., fatigue, muscle aches, insomnia);
older adults are more likely to report these types of symptoms,
which may reflect age-related physical changes rather than
symptoms of anxiety. Older adults with generalized anxiety
disorder (GAD) experience a greater degree of worry with
more difficulty controlling their worry compared to individ-
uals without diagnosed anxiety. They are found to have a
lower quality of life along with higher rates of depression and
social fears (Wolitzky-Taylor et al., 2010). In specific phobia
disorders, older adults display different types of phobias,
specifically phobias to situations, compared with younger
adults, who have phobias associated with animals or injec-
tions (Lauderdale, Cassidy-Eagle, Nguyen, & Sheikh, 2011).
Pharmacological and Nonpharmacological
Interventions
Use of antianxiety medications is generally efficacious (i.e.,
does the protocol work?) in treating GAD and panic disorder
in older adults. Benzodiazepines are frequently prescribed for
older adults with anxiety disorders (Bartels et al., 2002); how-
ever few randomized-controlled trials have been conducted
to examine effectiveness (i.e., who does the protocol work
best for and in what types of settings/situations?) and long-
term effects for older adults, including those who have taken
antianxiety medication for many years.
Psychosocial interventions, including relaxation training,
cognitive behavioral therapy, cognitive restructuring, and sup-
portive therapy, appear helpful in reducing anxiety in older
adults (Bartels et al., 2002; Wolitzky-Taylor et al., 2010).
However, the effects appear to be less than those found in
younger adults (Wolitzky-Taylor et al.). It will be important
for researchers and therapists to develop more effective inter-
ventions for older individuals.
Schizophrenia
Schizophrenia is considered a severe mental illness that is
characterized by disturbances in an individual’s thought
processes and cognition, which can adversely affect all other
spheres of well-being (e.g., social, emotional, physical).
The prevalence of schizophrenia is extremely low, affecting
1 percent of the general population; 0.6 percent for 1-year
prevalence in individuals aged 45 to 64 years and 0.2 percent
for individuals aged 65 years and older (Karim & Burns,
2011). Schizophrenia typically is diagnosed in late adoles-
cence or younger adulthood. Individuals who have schizo-
phrenia often experience cognitive difficulties that continue
in to later life (Karim & Burns, 2011).
When diagnosed later in life, after age of 45, it is referred
to as late-onset schizophrenia. Late-onset schizophrenia is rare
and is not well researched or understood compared with early-
onset schizophrenia (diagnosed before age 45). Delusions are
the most common presenting symptom for individuals with
late-onset schizophrenia (Karim & Burns, 2011). Hallucina-
tions are common as well and may present in any of the sensory
modes. Symptoms like loss of pleasure in activities, a flat affect,
or decreased speech, are considered rarer in late-onset schizo-
phrenia (Karim & Burns).
Because it is a rare disorder among older adults, it will not
be covered in detail here. However, therapists need to be
aware that older adults with schizophrenia most likely have
had the disorder for many years. Decreases in levels of physical
activity are common, possibly the result of the disorder, side
effects from medications, or various lifestyle issues (Lindamer
et al., 2008). Antipsychotic medications have particularly sig-
nificant long-term side effects that can be pronounced in later
life. Older adults are more susceptible to side effects such as
parkinsonism or tardive dyskinesia (Bartels et al., 2002).
Bipolar Disorder
Bipolar disorder is a serious mental health condition that pri-
marily affects an individual’s mood. It is usually diagnosed in
late adolescence and young adulthood. Although there are
variations (e.g., bipolar I, bipolar II), individuals with bipolar
disorder typically vacillate between manic episodes and de-
pressive episodes.
Prevalence
One-year prevalence of bipolar disorder in older adults over
the age of 65 is 0.4 percent, which is lower than the 1.4 percent
reported for younger adults (Forester, Cannavo, & Kim, 2011).
Similar to the other mental health illnesses, the incidence of
bipolar disorder decreases as individuals age.
Etiology and Risk Factors
Bipolar disorder is related to both genetic and environmental
factors. A later life diagnosis has been related to lower rates
of familial illness compared to individuals diagnosed earlier,
suggesting less influence of genetics in late-onset bipolar dis-
order (Forester et al., 2011). Research also has found greater
incidence for men in their eighth and ninth decade of life
compared with women. Diagnosis in later in life poses mul-
tiple challenges stemming from comorbid medical and neu-
rological conditions that result in mania (or depression) as a
secondary symptom.
Symptoms
Although varying in severity and frequency, bipolar depressive
symptoms are similar to symptoms experienced with a unipolar
depression (e.g., sadness, hopelessness, changes in sleep–wake
cycle, withdrawal, apathy, appetite changes). Symptoms of
mania vary in severity and frequency and include delusions of
grandeur, feelings of euphoria, grandiose thinking, changes in
appetite, sleep–wake cycle disturbances, and lack of inhibitions
(which usually center on sexual promiscuity, alcohol/drug use,
or overspending).
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CHAPTER 12
Cognitive symptoms include disorganized thinking, poor
decision-making and judgment, and rapid production of
speech and thought processes (e.g., flight of ideas). Specific
cognitive processes also can be affected by bipolar disorders.
Most commonly, these include speed of processing, verbal
memory, attention, and executive function (Gildengers et al.,
2009; Martino et al., 2008). Cognitive dysfunction has been
found to decline more rapidly than expected for the individ-
ual’s age and level of education (Gildengers et al., 2009). Sub-
sequently, current research has focused on examining the
potential connection between bipolar disorder and prevalence
rates of dementia.
Compared with healthy controls, older adults with bipo-
lar disorder exhibited greater motor symptoms, including
more extrapyramidal symptoms (e.g., parkinsonism, dyski-
nesia) (Martino et al., 2009). Although not clear, this finding
could be attributed to pharmacological factors or could re-
flect the expression of late-onset bipolar disorder. Symptom
severity in both the motor and cognitive domains has been
found to increase the risk for negative psychosocial function-
ing (Martino et al., 2008).
Pharmacological and Nonpharmacological
Interventions
The most common, first-line pharmacological treatment for
bipolar disorder remains lithium (Shulman, 2010). Although
there is a strong evidence base for its efficacy, significant side
effects may occur in the older adult population. Aripiprazole,
an atypical antipsychotic, has been found to reduce the symp-
toms of depression and mania associated with bipolar disor-
ders in older adults (Sajatovic et al., 2008). The medication
was tolerated well by the older adult sample, which is of sig-
nificance given the potential adverse effects associated with
traditional antipsychotic medications.
Research regarding the efficacy of nonpharmacological
therapies in treating older adults with bipolar disorder is
sparse (Forester et al., 2011). It is recommended that tradi-
tional psychotherapy, such as cognitive behavioral therapy
and psychoeducational programs, should be used for working
with older adults with bipolar disorder (Forester et al., 2011).
Substance Use Disorders
Substance use disorders refer to the misuse of substances that
result in physical and/or psychological addiction; these sub-
stances include alcohol, prescription drugs, over-the-counter
medications, and illicit drug use. Although it is evident that
older adults experience such disorders, relatively little is
known about prevalence, etiology, or treatment.
Prevalence
Rates of substance use disorder are projected to rise signifi-
cantly in the coming years due to the aging of the Baby Boomer
generation, potentially doubling from 2.8 million to 5.7 million
by 2020 (Han et al., 2009). Substance abuse disorders are more
■ Cognitive and Emotional Function: Health Conditions 193
prevalent in veterans residing in VA nursing homes, with es-
timates ranging from 18 to 29 percent (Seitz et al., 2010).
Etiology and Risk Factors
Substance abuse disorders are due to both genetic vulnera-
bilities and environmental stressors. Individuals who have a
mental health illness (e.g., bipolar disorder, depression) are
more likely to develop a substance abuse disorder, usually due
to ineffective coping resources and the overwhelming diffi-
culties related to their primary mental health condition. The
risk factors for younger and older adults are similar (Llorente,
Oslin, & Malphurs, 2011), with psychological distress and
lack of positive coping resources being key factors. For alco-
holism, factors across one’s life span may also result in diffi-
culties seeking and receiving treatment, causing multiple
relapses (Llorente et al., 2011). It is important to note, that
older adults may develop alcoholism, without increased con-
sumption, due to normal age-related changes in metabolic
and physical changes. These changes can also lead to difficulty
with prescription and over-the-counter medications that are
not metabolized as efficiently in later life.
Symptoms
Symptoms of substance abuse can be categorized as short-
term (i.e., experienced while an individual is using) and
longer-term effects (i.e., experienced over months or years).
An important distinction to note is that short-term symp-
toms, in general, will be short-lived in duration and, in gen-
eral, reversible after using the substance. Longer-term effects
can be long-lasting and can result in irreversible damage, such
as alcoholism and Korsakoff’s syndrome.
Typical substance abuse symptoms include short-term
changes in cognitive processing resulting in poor decision-
making, reasoning, judgment, and problem-solving. Long-
term use could result in damage to short-term and long-term
memory processing, language difficulties, and impaired ex-
ecutive functioning. Other changes due to heavy alcohol con-
sumption or drug use across the life span have been linked
with atrophy of the frontal and parietal lobes, leading to sig-
nificant cognitive changes as individuals age.
Changes in emotional processing and behavior also occur
with substance abuse and include: irritability, hypo- or hy-
peractivity, verbal/physical outbursts, mood swings, episodes
of mania and/or depression, apathy, and personality changes.
Individuals with substance abuse disorders experience
changes in their ability to perform their usual daily routines
and activities, including difficulties in their work or school
performance and strained relationships with family, friends,
and significant others.
Pharmacological and Nonpharmacological
Interventions
Bartels and colleagues (2002) found little endorsement for
use of pharmacological interventions with older adults with
substance abuse disorders. More than in other mental health
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194 PART II ■ Aging: Body Structures and Body Functions
conditions, individuals with substance abuse disorders must
reach a point of willingness to seek treatment and readiness
to change their behaviors Once individuals are “willing” and
“ready,” nonpharmacological interventions provide promising
results in the treatment of substance abuse in older adults.
Some types of treatment include supportive therapy and
cognitive behavioral therapy in either a group or individually
(Bartels et al., 2010).
Understanding the Illness Experience
of Individuals With Cognitive
Conditions
Traditionally, researchers and clinicians have focused on as-
sessing and intervening on the cognitive, functional, and
behavioral symptoms of cognitive conditions. More recently,
researchers, clinicians, individuals, and their families have ad-
vocated for understanding and intervening to support indi-
viduals’ illness experience of living with cognitive impairment
(Clare, 2010; Clare, Roth, & Pratt, 2005; Harris, 2002; Judge,
Menne, & Whitlatch, 2010; Menne, Kinney, & Morhardt,
2002). This is an extremely important distinction and advance.
The cognitive, functional, and behavioral symptoms of a
cognitive condition are the direct result of the neuropathol-
ogy and specific brain areas affected by the illness. For example,
damage to neurons in the hippocampus results in difficulties
in short-term processing and consolidating and remembering
new information. How individuals make sense of these symp-
toms, how they manage and cope with them, and how they
perceive their impact is the “illness experience.”
Individuals may have the same cognitive and functional
symptoms, but may have different personal reactions to these
symptoms, resulting in very different illness experiences. For
example, one individual may be embarrassed about difficulty
with short-term memory, while another individual may not
be bothered by this symptom. What is important is the ac-
knowledgment and understanding that individuals with cog-
nitive conditions are not devoid of personal reaction and
experience, but rather personal factors or individual difference
variables can either positively or negatively affect an individ-
ual’s illness experience. More important, understanding the
illness experience can facilitate care planning and identify
areas amenable to intervention.
✺ PROMOTING BEST PRACTICE
Predictors of Well-Being Outcomes
Recent research has investigated key predictors of well-being
outcomes for individuals with dementia (Dawson, Powers,
Krestar, Yarry, & Judge, 2013). Using self-report data from
131 individuals with dementia, results found individuals who
reported more embarrassment about their memory loss had
higher symptoms of anxiety, whereas individuals with more
physical health strain and greater feelings of role captivity
had greater symptoms of depression. Higher quality of life
was uniquely predicted by lower perceived difficulty with
performing instrumental activities of daily living and higher
self-efficacy. These results underscore the importance of
understanding the illness experience and highlight the need
to develop interventions that address negative psychosocial
outcomes. For example, interventions aimed at reducing
embarrassment about memory loss or feelings of role captivity
also could reduce symptoms of anxiety and depression,
respectively. It is clear that viewing the individual as more
than his or her cognitive and functional symptoms is crucial
for developing and implementing a successful plan of care.
Studies also have been conducted to understand the illness
experience of stroke survivors. Relationships with health pro-
fessionals were identified as a key predictor in determining
various somatic and emotional dimensions following an acute
stroke (Kitson et al., 2013). This highlights the importance
of rapport building as well as including individuals in the re-
habilitation process to facilitate well-being and therapy out-
comes. Additionally, social isolation and lack of medical
insurance were predictive of higher rates of depression later
in the disease process (see Box 12-3) (Kreiter et al., 2013).
Ensuring that adequate support is received is essential to
maintaining good mental health following a stroke.
Translating Research Findings Into
Rehabilitation Treatment Plans for
Cognitive and Emotional Disorders
Rehabilitation professionals (i.e., occupational therapists,
physical therapists, and speech-language pathologists) are in
the unique position to integrate key research into their de-
livery of care and treatment planning. Using a strengths-
based approach and the Environmental Press Model, this
section reviews current research findings on interventions for
individuals with dementia. These interventions can be readily
applied to individuals with other types of cognitive impair-
ment because these strategies work by compensating for cog-
nitive processes that are impaired while facilitating current
cognitive abilities.
A common misconception in working with individuals
with dementia is that it follows a linear, decrement-based tra-
jectory across all cognitive processes and that this pattern is
the same for all types of dementia. Underestimating an indi-
vidual’s current cognitive abilities may contribute to excess
functional disability, symptoms of depression and anxiety,
and negative effects for family caregivers such as burden and
relationship strain. Research has found multiple trajectories
across and within different types of cognitive processes, in-
dicating that not all processes are affected at the same time,
rate, or severity (Chamberlain et al., 2011).
Research has investigated the beneficial effects of imple-
menting cognitive rehabilitation interventions for persons
with dementia (Camp, 1999; Camp, Foss, O’Hanlon, &
Stevens, 1996; Camp & Mattern, 1999; Clare et al., 2000;
Quayhagen & Quayhagen, 2001) including learning and
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CHAPTER 12
BOX 123 Case Example: Individual Experience of Cognitive Difficulty
Mary Jane and Anna both have mild symptoms of dementia and
thus have the same functional difficulties in completing their instru-
mental activities of daily living. It may be easy to assume that Mary
Jane and Anna should have the same reactions or experiences in
coping and managing with their dementia symptoms because they
have the same objective profile of cognitive and functional symp-
toms and should receive the same treatment plan. However, what
is missing is the way Mary Jane and Anna subjectively appraise and
experience their illness as well as an understanding of the formal
and informal resources available to them.
Would assessment change with the following information? Mary
Jane has always struggled with self-esteem and depression. Now
that she has dementia, she is even more critical of herself and very
apprehensive in participating in social activities. Mary Jane has been
married for 30 years and has four children. Although her husband
and children are supportive, Mary Jane does not want to be a bur-
den to them and rarely shares what she is feeling. She often chooses
remembering new information (Bird, 2001; Bourgeois, 1990;
Hoerster, Hickey, & Bourgeois, 2001); eliciting constructive
(or positive) engagement while participating in Montessori-
based activities (Camp, et al., 1997; Judge, Camp, & Orsulic-
Jeras, 2000); improved performance in instrumental and
personal activities of daily living (Josephsson, Bäckman,
Borell, Nygård, & Bernspäng, 1995; Zanetti, et al., 2001);
and improved communication skills (Bird, 2001; Bourgeois,
1990; Hoerster et al., 2001). These interventions use a variety
of cognitive rehabilitation techniques that draw on individu-
als’ remaining cognitive and functional abilities (i.e., proce-
dural memory, semantic and episodic long-term memory
systems, implicit processing, and reading ability) while cir-
cumventing losses in cognitive processing. The most widely
used cognitive rehabilitation techniques include cognitive
task analysis, errorless learning, external memory aids, cueing
and redirection, and spaced retrieval. With appropriate train-
ing and structure, persons with dementia can benefit from
cognitive rehabilitation skills training. Several cognitive
processes and techniques are discussed in more detail in what
follows.
Procedural memory, a part of long-term memory, is one
of the most powerful assets remaining through middle and
even severe stages of the illness (Beaunieux et al., 2011; Camp
et al., 1996; Cherry, Simmons, & Camp; 1999; Lezak,
Howieson, & Loring, 2004; Machado et al., 2009; Mahendra,
Scullion, & Hamerschlag, 2011). This type of memory stores
skills, procedures, habits, emotional associations, and condi-
tioned responses; learned over time through repetition, this
form of memory requires little or no conscious awareness or
effort. Thus, activities such as getting out of a chair, playing
an instrument, engaging in a long-time leisure activity, or
social graces (e.g., saying hello) may be more readily avail-
able to individuals until later in the disease process. This is
■ Cognitive and Emotional Function: Health Conditions 195
to sit home alone rather than join the family. Mary Jane has increas-
ingly felt socially isolated, embarrassed, and depressed.
Anna has always had a pleasant and calm demeanor. Throughout her
life, she has encountered her share of hardships but she has always
tried to look for the positive in life, takes one day at a time, and uses
humor whenever she can. Because of this, Anna makes friends easily
and is very sociable. She has been widow for 10 years and has two
children who live out of state. Despite her dementia, Anna has not
cut back on her regular activities, and in fact she believes maintaining
her normal schedule helps provide structure and cognitive stimula-
tion. She uses her sense of humor to cope with her symptoms and
relies on her children for emotional support. Despite having similar
objective cognitive and functional symptoms of dementia, Mary Jane
and Anna have very different subjective experiences in how they are
each living with and experiencing dementia. Understanding both the
objective and subjective experience of dementia is imperative in ad-
dressing the care needs and issues for individuals.
important for rehabilitation professionals because using func-
tional exercises, such as weighted sit to stand or walking on
an uneven surface, may be easier for individuals to complete
than open-chain exercises, such as a leg kicks or ankle circles,
which are unfamiliar and not readily available in long-term
memory as activities previously completed.
Another technique called spaced-retrieval (SR) capitalizes
on the remaining cognitive strength of implicit processing and
implicit memory (Camp, 1989). SR is a “method of learn-
ing and retaining information by recalling that information
over increasingly longer periods of time” (Camp et al., 1996,
p. 196). Researchers have documented successful learning in
individuals with dementia using this concept (Bourgeois et al.,
2003; Brush &Camp, 1998; Cherry, Simmons & Camp,
1999; Hopper et al., 2005; Lin et al., 2010). This technique
has been successfully used in the speech therapy setting (Brush
& Camp, 1998) and should be easily translated into other
rehabilitative settings.
Other cognitive domains that remain intact include read-
ing, emotional memory, simple attention, certain aspects of
language processing, and portions of episodic and semantic
long-term memory such as events from childhood or early
adulthood and well-preserved general world knowledge. Ex-
amples of episodic long-term memory include hobbies and
leisure activities while semantic long-term memory describes
general knowledge usually learned through formal education.
Incorporating these remaining strengths into an exercise in-
tervention, for example, would warrant focus on functional
and familiar activities while also being able to use strategies
that rely on intact processes, such as reading, to compensate
for declines and losses in short-term memory. Using a written
form of instruction as an external memory aid could assist
people with dementia in independent performance of a par-
ticular exercise because they may have forgotten the verbal
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196 PART II ■ Aging: Body Structures and Body Functions
instructions given earlier in a session due to difficulties with
short-term memory. Another example is keeping it short and
simple, which capitalizes on simple attention while addressing
difficulties with short-term and working memory (Judge et
al., 2010). Using activities that are familiar to the participant
will reduce the amount of verbal instructions required. Learn-
ing by model through visual demonstration and use of visual
feedback has been found much more effective than typical
trial-and-error learning in people with dementia (Dechamps
et al., 2011; Judge et al., 2010). The use of demonstration in-
stead of elaborate verbal instruction may improve perform-
ance with a new exercise for people with dementia. Adding
these techniques to a treatment session could improve imple-
mentation and goal attainment.
Other strengths to consider in a rehabilitation setting are
psychosocial domains such as social support and coping skills.
For example, does the individual have involved family mem-
bers or is the individual coping using humor and optimism?
After being identified, these strengths can be integrated into
a holistic, comprehensive care plan that emphasizes the in-
dividual’s care needs and preferences. This type of individu-
alized treatment plan development exemplifies the concept
of person-centered care, which has been associated with
higher levels of quality of life and lowered levels of boredom
and helplessness in individuals with dementia living in resi-
dential care facilities (Brownie & Nancarrow, 2013; Terada
et al., 2013).
A strengths-based approach and the Environmental Press
Model, as frameworks for implementing interventions, can
also be used to empower caregiving dyads by focusing and
building on their current strengths and abilities for managing
and coping with the symptoms of cognitive impairment. For
example, individuals with mild dementia experience difficul-
ties with instrumental activities of daily living, such as doing
the laundry or preparing dinner. Training caregiving dyads
to effectively problem-solve and simplify tasks based on their
current strengths and abilities not only enables individuals to
complete tasks but also addresses dyads’ psychosocial issues
(Pinquart & Sörensen, 2006).
In the dyadic intervention, Project ANSWERS, a strengths-
based approach, was used to train individuals with dementia
and their family caregivers on a core set of cognitive rehabil-
itation and educational counseling-based skills for managing
and coping with the symptoms of dementia (Judge, Yarry, &
Oruslic-Jeras, 2010; Yarry, Judge, & Orusulic-Jeras, 2010).
Key areas addressed were effective communication, managing
memory, staying physically, mentally, and social active, and
recognizing and managing emotions and behaviors. Positive
results were found for both care partners, with caregivers
reporting fewer symptoms of emotional health strain, less
dyadic relationship strain and role captivity, fewer symptoms
of depression and anxiety, and higher caregiving mastery
(Judge et al., 2013). Individuals with dementia reported de-
creased distress in completing personal activities of daily liv-
ing, less dyadic relationship strain, and fewer symptoms of
anxiety (Judge, Yarry, & Oruslic-Jeras, 2010). These results
underscore the benefits of using a strengths-based approach
for addressing the nonmedical or psychosocial care issues
faced by individuals with cognitive impairment and their
family caregivers.
SUMMARY
Older adults and their families coping with cognitive im-
pairment and mental health issues face unique challenges in
providing care and managing cognitive, functional, and be-
havioral symptoms. These challenges can result in negative
psychosocial outcomes for both individuals and their family
caregivers (Deimling, 1994; Deimling & Bass, 1986; Gurland,
1980; Kunik et al., 2003; Schulz, Visintainer, & Williamson,
1990). If an individual experiences cognitive changes that are
not explained by normal age-related changes (see Chapter 7
for in-depth review), it is imperative to determine the cause
to provide the appropriate diagnosis and treatment plan. In
most cases, an interdisciplinary approach is most effective as
multiple aspects of cognitive, functional, physical, social,
emotional, behavioral, and mental health domains may be in-
volved. For example, if during an initial evaluation, a physical
therapist notices confusion leading to atypical functional mo-
bility (i.e., shuffling during walking or not being able to se-
quence getting out of bed), a nurse practitioner or physician
should be involved to complete a medical evaluation to un-
cover possible explanations, such as medication interactions,
infection, metabolic disorder, or electrolyte imbalance. Ad-
ditionally, a social worker or psychologist may be asked for
consultation if psychosocial or mental health issues are con-
tributing to this presentation.
Once the etiology of the cognitive impairment has been
identified, a treatment plan can be developed. Principles of
a strengths-based approach and the Environmental Press
Model can be used to assist in the development of the care
plan. Identifying current strengths and understanding envi-
ronmental fit also clarifies treatment emphasis. Specifically,
should interventions be geared toward rehabilitation or de-
velopment of compensatory strategies? For example, if an
individual has been diagnosed with Alzheimer’s disease,
treatment should not attempt to improve short-term mem-
ory but rather to develop strategies to compensate for this
difficulty. On the other hand, if the cause of cognitive diffi-
culties has been attributed to an acute medication interac-
tion, cognitive rehabilitation should be implemented in an
attempt to return to baseline status because of the reversible
nature of the condition.
During implementation of the treatment plan, under-
standing how the individual is managing the illness experi-
ence can deepen the person-centered care approach allowing
for more successful outcomes. It is important to address both
the medical and nonmedical care issues associated with cog-
nitive conditions. Health-care providers must realize that
atypical changes in cognitive processes can be observed with
both interindividual (e.g., severity, personality, coping skills)
4605_Ch12_181-200 31/10/17 12:24 PM Page 197
CHAPTER 12
and intraindividual differences (e.g., time of day effects, fa-
tigue, affective fluctuations). These differences must be con-
sidered when developing and implementing any rehabilitative
service to ensure and facilitate treatment adherence and at-
tainment of goals.
As emphasized by Maslow (2013), one of the challenges
facing people with cognitive impairments, their families, re-
searchers, clinicians, and policy-makers is how to develop
and implement evidence-based nonpharmacological treat-
ment protocols. This is becoming an increasingly complex
and important issue due to the growing number of individ-
uals who will develop cognitive conditions and the fact that
there is not a cure or drug therapy that adequately mitigates
the cognitive and other symptoms. Furthermore, our health-
care system does not sufficiently address the nonmedical
care needs and issues of people with cognitive impairments
and their families (Judge et al., 2011). Too often, these in-
dividuals and their families are left on their own to navigate
these incredibly difficult and life-changing illnesses as
few of the evidence-based, nonpharmacological interven-
tions are readily available for the general public. It is impor-
tant that more translational research is funded so that study
findings can be rapidly disseminated and implemented
effectively.
CASE STUDY
Mrs. Ava Graber is an 87-year-old woman living with her
husband in a two-story townhome in a senior retirement
community. She is a retired schoolteacher and volunteers
regularly at the youth center where she tutors elementary
school students in reading. Although she is active in the
community, she does not participate in any formal exercise
program. Her two daughters live across the country and
come to town for major holidays. In general, Mrs. Graber’s
health is good; however, she was recently diagnosed with
hypothyroidism and hypertension, both being treated with
medication.
Over the past several weeks, Mrs. Graber has not felt
like going to the youth center as she “does not feel like
herself.” Her husband has noticed that she has left the
stove on after cooking and has made several errors in their
checkbook, which is unlike her. He also notices that she
is having difficulty paying attention during conversations
and while watching television. These changes in Mrs. Graber
are beginning to concern him.
Questions
1. What are possible causes of Mrs. Graber’s symptoms?
Why do you think so?
2. Identify the necessary steps in properly diagnosing
the cause of her symptoms.
3. Develop a comprehensive, interdisciplinary treatment
strategy to address her challenges.
■ Cognitive and Emotional Function: Health Conditions 197
Critical Thinking Questions
1. What are the central tenets to understanding atypical
cognitive changes in older adults?
2. Describe the principles of the strengths-based
approach.
3. Why is it important to determine the underlying
cause of cognitive changes in older adults?
4. Outline possible etiologies for a patient presenting
with cognitive changes that cannot be attributed to
normal aging.
5. What are common pharmacological interventions
for treatment of these various conditions? Are these
treatments efficacious?
6. Discuss the importance of the interdisciplinary
approach to rehabilitation and how it can be used
in situations with cognitive impairment.
7. What are some of the remaining cognitive strengths in
individuals with dementia, and how can these domains
be used to develop an effective treatment program?
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Cardiopulmonary and Cardiovascular
Function: Health Conditions
LEARNING OUTCOMES
By the end of this chapter, readers will be able to:
1. Describe the impact of health conditions on cardiopulmonary
and cardiovascular function.
2. Describe the impact of recumbency and inactivity
on changes in cardiopulmonary and cardiovascular
function.
3. Describe changes in cardiopulmonary and cardiovascular
function secondary to extrinsic factors, such as medical
interventions and medications.
4. Describe changes in cardiopulmonary and cardiovascular
function secondary to intrinsic factors, such as the individ-
ual’s characteristics, culture and lifestyle, long-term occupa-
tion, and coexistent morbidity.
5. Describe the factors one should consider in prioritizing the
goals of an intervention plan and provide the rationale for
an older adult with morbidity.
6. Outline the focus of the assessment and the measures that
would be most relevant to record for an older adult with
morbidity.
7. Outline the intervention plan vis-à-vis prescribing
training for functional performance (e.g., activities of
daily living, functional capacity) for an older adult with
morbidity.
Clinical Vignette
Lareina Jaramillo is a 73-year-old Hispanic woman who
works as a store attendant part time. She helps look after
her husband who has been on a disability pension for
12 years. In addition to having hypertension and borderline
diabetes, Mrs. Jaramillo has had a history of arthritis for
several years. She is a nonsmoker, but her husband smoked
for 42 years, quitting only a year ago. She is also signifi-
cantly overweight. Two of Mrs. Jaramillo’s siblings have
died of ischemic heart disease. Mrs. Jaramillo reports once
she gets going in the morning, she can do most things
CHAPTER 13
Elizabeth Dean
“Old—Bette
age ain’t no place for sissies.
Davis (1908–1989)
”
around the house. However, when walking to the bus stop
two blocks from her home, she experiences leg pain (inter-
mittent claudication), and getting on the bus is challenging
when her hips are sore. Work has become difficult for her
because she becomes quite fatigued when she must stand
for more than a few minutes.
1. In what ways are Mrs. Jaramillo’s health and well-being
compromised?
2. Of those issues, which are closely associated with her
cardiopulmonary function?
C hapter 8 described the typical changes to the cardiopul-
monary and cardiovascular systems that occur with
aging and how cardiopulmonary and cardiovascular function,
and in turn functional capacity including activities of daily
living (ADL), can be maximized with exercise training. In
Chapter 8, the essentials of exercise testing and prescription
were described for the healthy older individual. This chapter
extends this foundation to the needs of older people with one
or more comorbidities, especially those that are directly
associated with cardiopulmonary disorders. Four levels of
factors need to be considered when assessing an older person’s
needs in terms of exercise testing and prescription for training:
pathology that affects, directly or indirectly, oxygen transport
and muscle strength; recumbency and inactivity; extrinsic
factors related to an older adult’s health care; and intrinsic
factors related to the individual.
Today, older people are at risk of one or more lifestyle-
related noncommunicable diseases (NCDs; e.g., ischemic
heart disease, chronic lung disease, high blood pressure,
stroke, type 2 diabetes mellitus, obesity, and osteoporosis),
in addition to other chronic conditions such as osteoarthritis
and Parkinson’s syndrome. Lifestyle-related NCDs are lead-
ing contributors to disability and premature death world-
wide. Furthermore, in the presence of these conditions,
people are likely to be taking medication, which may augment
or limit physical capacity. Medications can have an impact
201
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202 PART II ■ Aging: Body Structures and Body Functions
on mental health, which, when negatively affected, can in
turn have an impact on exercise capacity. The effects of com-
mon lifestyle-related conditions on the cardiopulmonary and
cardiovascular systems are presented in this chapter. How
these pathologies need to be examined and considered in
exercise testing and prescription are described. Means of
assessing health behavior change and motivating older peo-
ple to be physically active and to exercise are emphasized.
Importantly, improving health-promoting behaviors such as
not smoking, eating healthily, maintaining a healthy body
weight, sleeping well, and avoiding undue unmanageable
stress are emphasized. The remediation of one or more of
these health behaviors could improve an older person’s func-
tional status independent of any formal intervention by a re-
habilitation professional. Minimally, attention to lifestyle
behaviors could augment the outcomes of such interventions
on health status and function.
With respect to exercise testing and training older people,
special consideration needs to be given to analyzing assessment
findings to guide decisions about exercise testing parameters
BOX 131 Factors Contributing to Cardiopulmonary and Cardiovascular Dysfunction and Impaired Oxygen Transport
in Older People
I. Age-Related Changes
II. Cardiopulmonary system
Cardiovascular system
Hematologic factors
III. Cardiopulmonary and Cardiovascular Disease
Acute
Chronic
Acute and chronic
IV. Restricted Mobility and Recumbency
Removal of gravitational stress
Removal of exercise stress
V. Extrinsic Factors (i.e., those imposed by medical or surgical care)
Hospitalization
Fever
Malaise
Reduced arousal
Surgery (e.g., type, positioning, type and depth of sedatives
and anesthesia, incisions, duration, blood and fluid
administration, use of bypass machine, intraoperative
complications)
Dressings and bindings
Casts or splinting devices, traction
Incisions
Invasive lines, catheter, or chest tubes
Monitoring equipment (invasive and noninvasive)
Medications
Portable equipment (e.g., intravenous lines, oxygen tanks)
Intubation
Mechanical ventilation
Suctioning
and to analyzing exercise test results to inform decisions about
exercise training parameters. Finally, a case study is used to
illustrate the main points in this chapter.
Factors Affecting Cardiopulmonary and
Cardiovascular Health in Older People
Numerous factors contribute to impaired oxygen transport in
older people; these are summarized in Box 13-1. Establishing
the relative contribution of these factors is central to defining
treatment goals and treatment. All too often, an older person
who is vulnerable and at risk of a lifestyle-related health condi-
tion is subjected to a downward spiral of poor health practices
that contribute to functional decline, illness, and disability,
which in turn contribute to poorer health practices (e.g., less
activity, increased body mass, more smoking, poor sleep, and
more stress) and further functional decline and increased dis-
ability. The goal is to break the cycle by maximizing health,
thereby increasing the threshold for the manifestation of
Pain
Multisystem complications
VI. Intrinsic Factors (i.e., those imposed by the individual’s charac-
teristics, lifestyle, and medical and surgical histories)
Sex
Ethnicity
Sociocultural background
Smoking history (present as well as past)
Occupation
Environment (e.g., humidity, temperature, oxygen concentration,
and air quality)
Quantity and quality of sleep
Overweight/obesity
Nutritional deficits
Sleep deprivation/disturbance
Stress, anxiety, and depression
Deformity
Congenital abnormalities
Walking aids and devices
Habitual activity and conditioning level
Reaction to medications
Adherence to medication schedules
Adherence to recommendations from health-care professionals
Immunity
Fluid and electrolyte balance
Anemia or polycythemia
Thyroid and other endocrine abnormalities
Previous medical and surgical histories
Data from Dean & Ross (1992).
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CHAPTER 13 ■ Cardiopulmonary and Cardiovascular Function: Health Conditions 203

chronic conditions, reducing their rates of progression, thereby hyperexcitability of bronchial smooth muscle, may occur
maximizing functional capacity and minimizing functional de- on its own or as a component of chronic airflow limitation.
cline. To break this vicious cycle, the International Classifica- Although total lung capacity is unchanged, these changes
tion of Functioning, Disability and Health (ICF) predicated on impair the efficiency of respiratory mechanics, resulting in
the World Health Organization’s (WHO’s) definition of health inefficient ventilation, impaired gas mixing, and impaired
(see Chapter 2) provides a comprehensive and rational means ventilation and perfusion matching (Dean & Butcher,
of clinical reasoning with respect to the complexity of functional 2012a). Although less common, restrictive lung disease is
decline in an older person with negative health practices who also prevalent in older age-groups and results from pro-
may be living in an environment that does not support health longed exposure to a variety of pulmonary irritants through
and well-being. The next sections describe the four levels of occupational or environmental exposure (Table 13-3). In-
analysis of oxygen transport capacity mentioned earlier (patho- dividuals with restrictive lung disease tend to have fibrotic,
physiology, recumbency and inactivity, extrinsic factors related stiff lungs that have reduced compliance and thus are more
to health care, and intrinsic factors related to the individual). difficult to expand and ventilate with normal ventilator ef-
forts. The work of breathing needed to inflate the lungs and
counter the greater proportion of dead space, particularly
Pathophysiology, Etiology, and Epidemiology
during exercise, is disproportionate. Both types of lung
NCDs have reached epidemic proportions in high-income pathology, airflow limitation and restriction, can lead to im-
countries and constitute the leading causes of premature death paired oxygen tension in the blood during exercise and in
(WHO, 2016; Table 13-1). Most of these conditions affect the severe cases even at rest. The additional metabolic cost of
cardiopulmonary and cardiovascular systems either directly or in- breathing in individuals with moderate to severe disease of
directly. Table 13-2 illustrates this point: Physical inactivity con- either type contributes significantly to the overall metabolic
tributes to NCD manifestations and increasing activity offsets cost of a given activity or exercise. These individuals are in
these manifestations. Cardiopulmonary and cardiovascular con- danger of significantly desaturating their blood during in-
ditions are prevalent in older age-groups, given that older people creased workloads; thus, monitoring vital signs, arterial sat-
typically have had prolonged exposure to one or more risk factors uration, and subjective response during prescribed activities
for lifestyle-related conditions, particularly in Western countries. or exercise is essential.
This section describes the predominant pathophysiological fea- Cardiovascular abnormalities common in older age-groups
tures of these conditions and their etiology and epidemiology. include atherosclerosis, blood pressure abnormalities, and the
vascular components associated with diabetes. Atherosclero-
NCDs and the Cardiopulmonary sis is a degenerative disease of the arterial vasculature, espe-
and Cardiovascular Systems cially the large arteries and can affect the coronary arteries
(i.e., coronary artery disease) or the leg arteries (peripheral
Chronic airflow limitation is most frequently manifested as
vascular disease). Coronary artery disease, the major cause of
bronchitis and emphysema and is most commonly associ-
morbidity and mortality in older persons in the Western in-
ated with a history of smoking. Asthma, characterized by
dustrialized countries, typically blocks the coronary vessels
(i.e., ischemic heart disease [IHD]) causing shortness of
breath and, in some cases, the classic left-sided anginal chest
TABLE 131 ■ Leading Causes of Death in the pain. Electrical abnormalities may accompany these symp-
United States, 2014 toms or may be signs of ischemia without immediate symp-
toms. Those at risk for or who have IHD need to be screened
TOTAL for exercise testing and training; they should be monitored
CAUSE OF DEATH RANK DEATHS DEATHS %
to assess how the person responds and to inform exercise
All causes 2,626,418 100% training parameters. When the leg arteries become stenosed,
Heart disease 1 614,348 23.4% or completely occluded or blocked, exercise may be limited
Malignant neoplasms 2 591,700 22.5% by leg pain. The mechanism of the pain is the same: The de-
Chronic lower respiratory 3 147,101 5.2%
disease mand for arterial oxygenated blood exceeds the supply.
Accidents 4 135,928 5.2% Hypertension, the blood pressure abnormality that occurs
Cerebrovascular disease 5 133,103 5.1% most frequently in the older adults (Egan, Zhao, & Axon,
Alzheimer’s disease 6 93,541 3.6% 2010; Khan et al., 2006), is not generally associated with un-
Diabetes mellitus 7 76,488 2.9% pleasant symptoms. Thus, the older adult may be unaware of
Influenza and pneumonia 8 55,227 2.1%
Nephritis, nephrotic 9 48,146 1.8% the condition and may not seek medical attention or be in-
syndrome, and nephrosis clined to take medication regularly. The consequences of high
Intentional self-harm (suicide) 10 42,826 1.6% blood pressure, stroke, and heart disease are dire, and its
control significantly reduces complications, cardiovascular
Source: Heron, M. (2016). Deaths: Leading causes for 2014. National Vital Statistics
Reports, 65(5), 1-95. Data on p. 9. Retrieved from https://www.cdc.gov/nchs/
death, congestive heart failure, and stroke (Khan et al., 2006).
data/nvsr/nvsr65/nvsr65_05.pdf Alternatively, some older people are prone to hypotension,
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204 PART II ■ Aging: Body Structures and Body Functions

TABLE 132 ■ Lifestyle-Related Noncommunicable Diseases That Are Associated With Poor Health Practices, Including
a Sedentary Lifestyle and Low Levels of Activity

RISK FACTOR CARDIOVASCULAR IHD AND HT AND PVD COPD STROKE TYPE 2 DM CANCER OSTEOPOROSIS
Smoking X X X X X* X
Physical inactivity X X X X X
Obesity X X X X X
Nutrition X X X X X X
High blood pressure X X X
Dietary fat†/blood lipids X X X X
Elevated glucose levels X X X X
Alcohol‡ X ? X X X

COPD = chronic obstructive pulmonary disease; DM, diabetes mellitus; HT = hypertension; IHD = ischemic heart disease; PVD = peripheral vascular disease.
*An increased risk of all-cause cancer. Smoking is related not only to cancer of the nose, mouth, airways, and lungs, but also increases the risk of all-cause cancer.
†Partially saturated, saturated, and trans fats are the most injurious to health.
‡Alcohol can be protective in moderate quantities, particularly red wine.
Sources: Goldstein et al. (2011); Siteman Cancer Center (n.d.).

TABLE 133 ■ Cardiopulmonary and Other Health Conditions and Cardiovascular Abnormalities

ANATOMICAL AND PHYSIOLOGICAL

TYPE PRESENTING SYMPTOMS AND SIGNS CHANGES IMPAIRMENTS
Chronic airflow Barrel chest Hyperinflation of chest wall Inefficient ventilation
limitation May have shortness of breath on exertion or rest Flattening of hemi-diaphragms Impaired gas mixing
Breathing pattern: prolonged expiration to help Air trapping Impaired ventilation
promote gas exchange in the lungs Increased metabolic costs of breathing
Restrictive lung Breathing pattern: rapid, shallow to reduce work Fibrotic stiff lungs Reduced compliance Increased
disease of breathing effort to inflate lungs
Atherosclerosis High blood pressure Fatty atheromatous plaques within Stenosed arteries Increased
Ischemic chest pain blood vessel walls peripheral resistance
Myocardial infarction Vessel wall rigidity
Diabetes Hypoglycemia with activity or exercise Similar to atherosclerosis Similar to atherosclerosis

particularly during positional changes. This can contribute to
increased risk of falls. A diminished responsiveness of auto-
nomic adjustments may be responsible.
Type 2 diabetes mellitus is increasingly prevalent in
young as well as older populations and is now very common
among older adults. It can be prevented, reversed, and also
managed with healthier lifestyle practices. Obesity itself is
both a cause and a contributing factor for diabetes. Diabetes
has serious multisystem and vascular consequences. Hyper-
metabolism associated with activity and exercise places in-
creased demand on energy stores and insulin requirements,
which is critical in regulating and blood glucose and insulin
levels. Another vascular consequence of diabetes is the ac-
celerated rate of atherosclerosis compared with the older
population without diabetes.
Lifestyle factors are well-established contributors to a
range of cancers. Even with a cancer diagnosis, healthy living
is possible. Healthy living including reduced sitting, regular
physical activity, and structured exercise can prevent some
cancers, as well as augment quality of life when living with
the diagnosis. Finally, any discussion of age and age-related
changes that affect cardiopulmonary and cardiovascular capacity
in older people needs to address the role of sarcopenia.
Sarcopenia refers to the degenerative loss of skeletal muscle
mass (approximately 0.5 to 1 percent loss per year from early
adulthood onward), quality, and strength associated with
aging (Faulkner, Larki, Claflin, & Brooks, 2007). Some
50 percent of muscle may be lost by age 80. It has been attrib-
uted in part to poor diet and inactivity. Thus, age-associated
atrophy, weakness, and fatigability can be slowed with health-
ier lifestyle practices. Frail older people tend to have advanced
sarcopenia and related osteoporosis.
Clustering of Unhealthy Lifestyle-Related Behaviors
and Risks
The clustering of commonalities among lifestyle-related
NCDs, including chronic systemic low-grade inflammation
(CSLGI; Dean & Gormsen Hansen, 2012) and contributing
factors, have become a focus in the literature (Buck & Frosini,
2012; Schuit, van Loon, Tijhuis, & Ocke, 2002; Spring,
Moller, & Coons, 2012). Common negative health behaviors
do not manifest predictably into the same lifestyle-related
conditions. On the basis of their phenotypic predispositions,
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CHAPTER 13 ■ Cardiopulmonary and Cardiovascular Function: Health Conditions
some people will manifest pathological changes in their coro-
nary blood vessels, some in their cerebral blood vessels, some
in their peripheral vasculature, and some in abnormal blood
sugars. Simply speaking, lifestyle-related conditions in high-
income countries are associated with CSLGI, which results
from the pro-inflammatory Western lifestyle practices. Mediter-
ranean and Asian cultures have lifestyles that traditionally have
been healthier and antiinflammatory. The lifestyle-related con-
ditions are typically associated with elevated systematic in-
flammatory markers indicative of CSLGI. Understanding
the role of the common pathways these conditions provides
valuable insight into best practices for their prevention, re-
versal, and management (Dean, Lomi, Bruno, Awad, &
O’Donoghue, 2011). Although this chapter focuses on lifestyle
determinants of health, rehabilitation therapists need to be
mindful of other determinants of health including social,
economic, and environmental factors (Egger & Dixon,
2014). Occupational and physical therapists can help address
these determinants by supporting the initiatives of their pro-
fessional associations.
✺ PROMOTING BEST PRACTICE
“Health First” in Every Patient/Client Interaction
Occupational and physical therapists are uniquely positioned
to practice interprofessionally with respect to health behavior
change competencies that need to be central in every health
professional–patient interaction (Dean et al., 2014).
Ischemic Heart Disease
The good news about cardiovascular disease, including is-
chemic heart disease IHD and stroke, is that incidence has
diminished over the past decades, especially in developed
countries (WHO, 2017). The bad news is that they remain
very common, with low and middle-income countries having
substantial excess mortality from these conditions. Although
incidence is declining in places like the United States, they
remain common conditions worldwide.
The risk factors for IHD and associated peripheral vascular
disease are well established (Fleg et al., 2013). Atherosclerotic
plaques are deposited not only throughout coronary vessels,
but throughout the systemic arterial vasculature, leading to a
range of pathological consequences (Smith, et al., 2011). Risk
factors are classified as nonmodifiable (e.g., age, sex, family his-
tory, and past history) and modifiable (e.g., elevated choles-
terol, increased homocysteine, smoking, inactivity, high blood
pressure, diabetes, weight, and stress) (Cordero et al., 2016;
Keller, Fleury, & Mujezinovic-Womack, 2003; Shapiro, 2000;
Twisk, Kemper, Van Mechelen, & Post, 2001). Other risk
factors include elevated C-reactive proteins, markers of inflam-
mation (Parrinello, et al., 2015); sharing a lifestyle with some-
one who has IHD (Macken, Yates, & Blancher, 2000); having
overweight parents (Paterno, 2003); and passive smoking,
education level, depression, anger and hostility, and social
isolation (Graves & Miller, 2003; Panagiotakos, Pitsavos,
205
Chrysohoou, Stefanadis, & Toutouzas, 2002; Varghese,
Hayek, Shekiladze, Schultz, & Wenker, 2016). Small im-
provements in lifestyle can significantly affect modifiable risk
factors and have a sizable impact on health. Given that
lifestyle risk factors are modifiable through behavior change,
an individual has significant control over his or her health risk
(Sebregts, Falger, & Bar, 2000), notwithstanding the role of
other determinants such as social, economic, and environmen-
tal (Egger & Dixon, 2014).
Risk factors for IHD are prevalent in the general popula-
tion across the age spectrum. In a cross-sectional study of
late-middle-aged people, two-thirds exhibited atherosclerosis
involving the femoral artery (Leng et al., 2000). A direct re-
lationship was found between the degree of atherosclerosis
and cardiovascular and general circulatory health. Peripheral
artery disease constitutes a marker of systemic atheroscle-
rosis given individuals with peripheral artery disease have a
several-fold increased risk of IHD. Optimal lifestyle health
choices could reduce cardiac events up to 80 percent. Regular
walking, as well as more vigorous activity, has a major effect
on reducing IHD risk (Bauman, 2004). Moderate physical
activity reduces the risk of stroke by 49 percent in men with
left ventricular hypertrophy compared with sedentary men
with no cardiac involvement (Pitsavos et al., 2004). Type 2
diabetes mellitus is a stronger IHD risk factor in women than
in men (Anand, et al., 2008; Juutilainen, Lehto, Rönnemaa,
Pyörälä, & Laakso, 2005). Self-reported fitness is independ-
ently related to fewer IHD risk factors and angiographic
evidence of IHD in women undergoing coronary angiography
for suspected ischemia (Wessel et al., 2004). Measures of
obesity are not independently associated with these outcomes.
Thus, fitness could be more important than body weight as a
cardiovascular risk factor for women. Assessment of physical
activity and fitness should be an integral part of the cardio-
vascular risk-factor stratification, and interventions should be
directed at sustaining physical activity and fitness over the
long term. Assessment of physical activity and prescription
of exercise programs should be included in the management
of all people, particularly those at risk for IHD.
Nutrition is a well-established determinant of health and
independent risk factor for lifestyle-related conditions, as well
as other chronic conditions. Plant-based diets such as the
Mediterranean diet have been increasingly shown to have
multiple health benefits and are superior to the North American
diet regarding its diversity and healthfulness (Estruch et al.,
2013). These diets are high in fish, fresh fruit and vegetables,
and multigrains. They are low in added sugar and salt, and
favor unsaturated vegetable oil over saturated animal fats.
When studies of dietary habits are evaluated, people who
consume fish twice a week have a 47 percent reduced risk
of cardiac mortality compared with those who eat fish less
than once a month (Mozaffarian, Fried, Burke, Fitzpatrick,
& Siscovick, 2004). Consumption of only two whole-grain
slices of bread daily is associated with a 14 percent reduced
risk of myocardial infarction or stroke. Even later in life,
healthy cereal fiber consumption is associated with a reduced
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206 PART II ■ Aging: Body Structures and Body Functions
incidence of cardiovascular disease (Mozaffarian et al., 2003).
Moderately and highly physically intense leisure-time activ-
ities predict 28 and 44 percent lower mortality rates, respec-
tively, compared with little activity. Low, moderate, and high
levels of exercise are associated with 30, 37, and 53 percent
more years of healthy life, respectively. Aerobic training can
alter serum lipids even in older individuals—specifically, in-
creasing high-density lipoproteins and decreasing low-density
lipoproteins (Park, Park, Kwon, Yoon, & Kim, 2003). Lifestyle
change is a powerful intervention in that atherosclerosis can
regress and associated cardiac events can be substantially
reduced (Jousilahti, et al., 2016; Stuart-Shor, Berra, Kamau,
& Kumanyika, 2012).
Psychosocial factors (Hamer, Molloy, & Stamatakis,
2004) and stress (Brotman, Golden, & Wittsteinhave, 2007)
have been identified as cardiovascular risk factors. Stress can
be classified as minor daily stresses or hassles and major neg-
ative life events. Cumulative daily hassles may be underesti-
mated in terms of their impact on health compared with
major life stressors. After an individual’s first coronary event,
avoidance strategies are inversely associated with healthy
lifestyles, whereas positive reappraisal and problem-solving
are directly associated (Henrichon & Robichaud-Ekstrand,
2002). Positive reappraisal and problem-solving, program
participation, and the avoidance of distancing and escape
strategies predict one’s capacity to change lifestyle after a
coronary episode. Stress management programs should con-
sider the type of stressor and help to modify the individual’s
coping strategies and interpretation of stressors.
A leading risk factor for a cardiac event is having had an
event already (Capewell et al., 2006). In a seminal study by
Ornish and colleagues (1998), 194 individuals with previous
revascularization procedures avoided repeat procedures for at
least 3 years (the duration of follow-up in the study) when
they participated in a comprehensive lifestyle behavior change
program. Compared with individuals who also had had a pre-
vious revascularization procedure but did not participate in
the lifestyle-change program, those who did participate re-
ported a level of angina comparable to that experienced with
revascularization.
The numerous benefits of optimal control of modifiable
risk factors for coronary atherosclerosis, including cigarette
smoking, dyslipidemia, hypertension, and sedentary
lifestyle are well known (Eckel et al., 2014). However, de-
spite considerable evidence supporting the link between
lifestyle and morbidity and mortality, efforts to change
people’s behavior over the long term outside a clinical trial
is abysmally unsuccessful.
Smoking-Related Conditions
Smoking is a leading cause of preventable death worldwide
(Lim et al., 2012). Although its multisystem health hazards
are well documented, smoking remains prevalent through-
out the world. It is estimated that for each cigarette smoked,
life shortens by 11 minutes (Shaw, Mitchell, & Dorling,
2000). Thus, smoking cessation needs to be a primary goal
in every smoker regardless of disease severity (Yohannes &
Hardy, 2003). Guidelines from the Agency for Health Care
Policy and Research (2011) identify the hazards and rec-
ommend smoking cessation strategies. The danger of smok-
ing extends beyond chronic obstructive lung disease (COPD)
and cancer. Morbidity and all-cause mortality including
cancer of organs other than the respiratory tract are higher
in smokers overall.
COPD is typically among the leading causes of premature
death worldwide (Pierson, 2004). Long-term smokers have
higher incidences of all-cause morbidity and mortality (see
Table 13-2) (Mozaffarian et al., 2004). Compared with life-
time nonsmokers, former and current smokers have 25 and
44 percent fewer healthy years of life, respectively. Compre-
hensive pulmonary rehabilitation programs have demon-
strated sustainability of smoking cessation and other health
benefits in people with COPD (Calverley & Walker, 2003),
thus their use is warranted as a preventive measure, as well as
for the remediation and management of disease (Eckel et al.,
2014). Rehabilitation programs have proven efficacy inde-
pendent of pharmacotherapy, so they need to be considered
primary interventions rather than priorities after conventional
expensive medical care has failed (Qaseem et al., 2001). Only
with health coaching and follow-up can individuals with
COPD be able to effect lifelong health behavior change to
reduce exacerbations, reduce doctor and hospital visits, con-
tinue working, and reduce overall morbidity.
✺ PROMOTING BEST PRACTICE
Smoking Cessation
Smoking cessation is the most cost-effective intervention for
smokers with heart disease in terms of health protection and
risk reduction, and older adults do benefit from smoking
cessation programs (Tait et al., 2007).
In addition to smoking cessation, treatment of hyperlipi-
demia and referral to cardiac rehabilitation are highly cost-
effective per quality-adjusted life-year and are relatively
cost-effective per year of life saved. Smoking is an established
risk factor for ischemic stroke, subarachnoid hemorrhage, and
intracerebral hemorrhage (Kurth et al., 2003) as well as IHD.
The risk is directly proportional to the amount smoked. Risk-
factor detection and management is the cornerstone of high-
impact and high-quality care of cardiovascular disease.
Hypertension and Stroke
Stroke is a leading cause of death and disability, as discussed
in Chapter 12. Hypertension is the most common risk factor
(Roger et al., 2012). Although lowering blood pressure below
130/85 mm Hg is well accepted across ages, the success
of blood pressure control has been reported to be less than
25 percent in the hypertensive population (Chalmers &
Chapman, 2001). Stroke risk is far from being well controlled
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CHAPTER 13 ■ Cardiopulmonary and Cardiovascular Function: Health Conditions
despite considerable understanding of its causes, and remains
a major health threat. Risk factors for stroke include previous
stroke, hypertension, IHD, atrial fibrillation, hyperlipidemia,
diabetes, abnormal ankle-to-brachial pressure index, reduced
exercise endurance, retinopathy, albuminuria, autonomic
neuropathy, smoking, alcohol consumption, and lack of
exercise (Cohen, Estacio, Lundgren, Esler, & Schrier, 2003;
Cucchiara & Kasner, 2002; Kurl, et al., 2003; Piravej &
Wiwatkul, 2003).
Risk factors for hypertension and stroke can be accentu-
ated by smoking, elevated cholesterol, glucose intolerance,
inactivity, and obesity (Roger et al., 2012). In addition to
stroke, serious consequences of hypertension include heart
disease and renal disease. Increased sympathetic reactivity is
also implicated as a cause of stroke (Everson et al., 2001). In
the adult population aged 60 to 74 years, hypertension is
more prevalent among African Americans (Chobanian et al.,
2003). As with IHD, risk factors for high blood pressure con-
sist of nonmodifiable and modifiable risk factors. Nonmod-
ifiable risk factors include age, sex, race, and other genetic
factors. Modifiable risk factors include diets high in sodium
and low in potassium, alcohol consumption, reduced physical
activity, and being overweight (Slama, Susic, & Frolich,
2002). Obesity is a strong predictor of hypertension (Corrêa,
Thumé, De Oliveira, & Tomasi, 2016). Although significant
reduction of hypertension has been attributed to low-dose
thiazide diuretics and beta blockers, the first line of defense
to prevent high blood pressure and normalize blood pressure
should be nutritional approaches, weight reduction, and reg-
ular physical activity and exercise (Roger et al., 2012). In in-
dividuals whose hypertension is controlled, the combination
of a Mediterranean diet and physical activity can reduce
health risk substantially (Pitsavos, Panagiotakos, Chrysohoou,
Stefanadis, & Toutouzas, 2002). With respect to nutrition,
high sodium and low potassium levels have been implicated
in hypertension and stroke, as have lipids. Low plasma vita-
min C is associated with a several-fold increased risk of
stroke, particularly in men who are overweight and hyperten-
sive (Kurl et al., 2002).
A reduction in blood pressure of 10 mm Hg systolic or
5 mm Hg diastolic reduces stroke by 41 percent (Law,
Morris, & Wald, 2009). Thus, weight control and healthy
diet, regular exercise, smoking cessation, and blood pressure
control are central to stroke prevention, as well as to the com-
prehensive management of stroke. Although weight reduction
is an essential component of hypertension prevention and
management, the protective effect of physical activity may be
unrelated to the degree of obesity (G. Hu et al., 2004). A
4 to 8 percent reduction in body weight can reduce blood
pressure by 3 mm Hg, and physical activity can reduce blood
pressure by 5 systolic/3 diastolic mm Hg (Costa, 2002).
For African American men who are normotensive, aerobic
exercise can attenuate an exaggerated blood pressure response
(Bond et al., 2002). Similarly, fit African American women
who are normotensive have blunted blood pressure responses
to experimental stressors (Jackson & Dishman, 2002). Physical
207
activity and optimal nutrition can reduce the risk of early ath-
erosclerosis, a precursor to stroke, in lifelong nonsmokers
(Luedemann et al., 2002). Smokers benefit less from this pro-
tective effect. Physical activity seems not only to reduce the
risk of stroke but can also provide a potent prophylactic strat-
egy for increasing blood flow and reducing brain injury during
cerebral ischemia (Endres et al., 2003). A possible mecha-
nism is augmented endothelium-dependent vasodilation via
up-regulation of endothelial nitric oxide synthase throughout
the vasculature. Aerobic exercise three times a week reduces
cerebral infarct size and functional deficits in a mouse
model and improves endothelium-dependent vasorelaxation
(Endres et al., 2003).
Assessment of risk for hypertension is an important com-
ponent of medical and physical therapy intervention planning.
Management strategy should be based on an analysis of the
overall risk assessment rather than on blood pressure alone.
The prevention of hypertension requires more than normaliz-
ing blood pressure if the deadly manifestations of high blood
pressure, including IHD, are to be avoided. Recommendations
by the American Heart Association concerning physical activ-
ity and exercise guidelines for people poststroke concur that
physical conditioning is a primary goal for these individuals,
who have to contend with both the pathologic effects of stroke
and the effects of deconditioning (Gordon et al., 2004). Walk-
ing as little as 2 hours a week can reduce the risk of stroke by
50 percent (Costa, 2002). Improved conditioning may help to
reduce activity limitations and participation restrictions, and
hence improve quality of life. The burden of disease and dis-
ability and their risk factors may be correspondingly reduced.
To impact the health of the population, stroke prevention
depends on the dissemination of these well-established and
widely available interventions to a large number of people
through public health policy. Advice given by a health provider
to individuals with stroke for the purpose of prevention of a
second stroke can have significant impact. In one study, indi-
viduals were simply advised to eat fewer high-fat and high-
cholesterol foods and to exercise more (Greenland, Giles,
Keenan, Croft, & Mensah, 2002). Compared with a control
group that received no advice, those receiving advice reported
fewer days with limited activity, fewer days that “were not good
physically,” and more “healthy” days. The results of this study
are compelling in that even simple advice by a health-care
provider can have a major impact on important health behav-
iors and on potential health outcomes.
Type 2 Diabetes Mellitus and Metabolic Syndrome
Type 2 diabetes mellitus is a serious multisystem condition
that has rapidly become pandemic in Western countries and
some other countries where, previously, its incidence was
minimal. In addition to its serious physical and functional
consequences, perceived health status and quality of life are
compromised (Gregg et al., 2002). According to the Inter-
national Diabetes Federation, diabetes affects 387 million
people worldwide and is expected to increase to 592 million
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208 PART II ■ Aging: Body Structures and Body Functions
by the year 2035, with 77 percent of all diabetes cases oc-
curring in low- to middle-income countries (International
Diabetes Federation, 2014). Formerly known as adult-onset
diabetes, type 2 diabetes mellitus is now being diagnosed in
children, predisposing them to blindness, IHD, stroke, renal
disease, peripheral neuropathies, vascular insufficiency, and
amputations (Abraham, 2004; Ten & MacLaren, 2004). Al-
though diabetes itself is an endocrine disorder, not a cardio-
vascular disease, the primary consequences include pathologic
changes to the macrovasculature and microvasculature and to
nerve endings. Impaired glucose tolerance is a marker of vas-
cular complications in the large and small blood vessels, in-
dependent of an individual’s progression to diabetes. Early
detection of glucose intolerance allows intensive dietary and
exercise modifications, which have been shown to be more
effective than drug therapy in normalizing postprandial glu-
cose and inhibiting progression to diabetes (Singleton, Smith,
Russell, & Feldman, 2003). Diabetic autonomic neuropathy,
as an independent risk factor for stroke, may reflect increased
vascular damage and effect on the regulation of cerebral blood
flow in individuals with diabetes (Cohen et al., 2003).
Individuals with type 2 diabetes mellitus have increased
risk for cardiovascular disease compared with individuals
without diabetes, so strict control is essential. Lifestyle has
been established as a leading contributor to developing dia-
betes; hence, lifestyle practices need to be targeted foremost
(Hivert et al., 2016), given that medications are not proving
sufficient (Brown, Sanderson, & Bittner, 2009). Moderate
physical activity, including a fast walking (F. B. Hu et al.,
2001), along with weight loss is a powerful combination to
reduce the risk of type 2 diabetes mellitus, as well as to reverse
it. These interventions combined with a balanced diet can re-
duce the risk of developing diabetes among those who are at
high risk by 50 to 60 percent (Bauman, 2004). Cigarette
smoking is an independent risk factor for type 2 diabetes mel-
litus (Kim et al., 2014) and is particularly dangerous for in-
dividuals with diabetes (Pan, Wang, Talaei, & Hu, 2015).
Metabolic syndrome refers to a virulent and lethal group
of atherosclerotic risk factors, including dyslipidemia, obesity,
hypertension, and insulin resistance. Nearly 35 percent of all
U.S. adults and 50 percent of those aged 60 years and older
have the metabolic syndrome (Aguilar, Bhuket, Torres, Liu,
& Wong, 2015). The incidence of the syndrome is increasing
and warrants aggressive noninvasive management. Insulin
sensitivity is predicted primarily by body mass index, smok-
ing, age, and daily physical activity. Weight reduction coun-
ters the effects of the metabolic syndrome and may counter
the associated hypertension and dyslipidemia as well. Diet
and exercise are primary components of a multifactorial ap-
proach to preventing and managing this lethal condition.
Obesity
Obesity is a worldwide problem, and developed and devel-
oping countries are experiencing increasing prevalence and
incidence (Samper-Ternent & Snih, 2012). In older adults,
obesity is associated with a higher prevalence of cardiovas-
cular disease, metabolic disease, several cancers, a variety of
other medical conditions, increased functional limitations,
disability, and poorer quality of life (Samper-Ternent &
Snih, 2012). The complications of and risks for each of the
following should be assessed: IHD, cardiac myopathy, and
chronic heart and lung dysfunction; hypertension and
stroke; some cancers; insulin insensitivity and type 2 dia-
betes mellitus; gall bladder disease; dyslipidemia; os-
teoarthritis and gout; and pulmonary conditions including
alveolar hypoventilation and sleep apnea (Grundy, 2002;
F. B. Hu, 2003; Kannel, Wilson, Nam, & D’Agostino,
2002; Samper-Ternent & Snih, 2012). With each kilogram
of weight above normal, the risk of hypertension, IHD, and
type 2 diabetes mellitus increase proportionately. Obesity is
often linked with insulin resistance and hypertension, which
may reflect reduced activity and exercise. Reduced physical
activity is a predictor of obesity (Wenche, Holmen, Kruger,
& Midthjell, 2004). Insulin resistance associated with lack
of exercise in people who are overweight may be further
compounded by insulin resistance associated with chronic
inflammation observed in fat cells (Xu et al., 2003).
Abdominal obesity, lipid metabolism, and insulin resistance
are interrelated markers for coronary artery disease (Frayne,
2002). Additional discussion of obesity can be found in
Chapter 17.
Cancer
Most cancers directly or indirectly affect the cardiopulmonary
and cardiovascular systems. The risk factors for cancer are well
documented and include genetic and physiological factors,
viral infections (e.g., hepatitis C), environmental and be-
havioral factors including inactivity, nutrition (fats and
refined foods), poor air quality and smoking, psychological
factors, and ingestion of and exposure to chemicals. Smok-
ing has been implicated as a risk factor for many cancers,
not only those involving the respiratory tract (American
Cancer Society, 2014). Cancer is discussed further in
Chapter 17.
Gravitational Stress and Exercise Stress
Oxygen transport and tissue oxygenation are dependent on
the body’s ability to provide an adequate cardiac output to the
peripheral tissues commensurate with tissue demand. Physical
factors that normally challenge the body’s ability to maintain
or increase cardiac output include position change, activity or
exercise, and emotional stress. The older adult may be limited
in ability to adjust to the gravitational and exercise stress
caused by normal activities if a greater proportion of time has
been spent recumbent or if activity has been limited. Reduc-
tion in gravitational stress and exercise stress contributes to
physiological deterioration and susceptibility to illness.
Orthostatism refers to the ability of the body to maintain
normal cardiac output, in particular, cerebral perfusion,
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CHAPTER 13 ■ Cardiopulmonary and Cardiovascular Function: Health Conditions
during assumption of the upright body position. On moving
from the recumbent to the upright position, blood volume
is displaced toward the abdominal cavity and the legs
(Blomqvist & Stone, 1983). This blood volume displace-
ment reduces venous return and, hence, cardiac output, re-
sulting in a compensatory increase in heart rate and peripheral
vascular resistance to increased blood pressure and cardiac
output. If this neurological compensation is ineffective,
cerebral perfusion is compromised, and a blackout or faint-
ing may ensue.
During recumbency, this sequence of events is reversed.
The blood volume is displaced centrally toward the heart
and lungs. Venous return is increased, resulting in a com-
pensatory decrease in heart rate and peripheral vascular re-
sistance to maintain cardiac output. The increased central
blood volume leads to a compensatory diuresis within hours
of assuming the recumbent position. Thus, overall blood
volume is reduced, and the person is prone to orthostatic
intolerance on assuming the upright position (Sandler,
1986). The loss of fluid-volume–regulating mechanisms,
rather than cardiovascular deconditioning, has long been
known to be the primary factor responsible for bedrest de-
conditioning (Convertino, 1992). The only means of pre-
venting orthostatic intolerance following recumbency is to
assume the upright position frequently. This adaptation is
further augmented if it is coupled with movement; however,
exercise in the absence of being upright fails to counter
orthostatic intolerance (Chase, Grave, & Rowell, 1966). In
addition to the primary beneficial adaptive responses that
being upright and moving have on oxygen transport, virtu-
ally every other organ system benefits when an individual is
upright and moving (Dean & Ross, 1992).
A public health priority is reducing sedentary living. Pro-
longed periods of sitting, including screen-based activities,
have been shown to be an independent risk factor for a range
of lifestyle-related conditions such as heart disease, high
blood pressure, cardiometabolic syndrome, and kidney dys-
function (Hawkins et al., 2015).
INTERPROFESSIONAL PRACTICE
Contributions of occupational and physical
therapists in treating cardiovascular and
pulmonary disease
Although occupational and physical therapists have unique
competencies, health assessment and health promotion
interventions are core shared competencies with other
professionals. Occupational and physical therapists practice
largely nonpharmacologically and thus are in a unique
position to shift focus of care from a predominantly “illness”
system to a “health” system. Through their professional
organizations, physical therapists and occupational therapists
can help make a difference in outcomes of cardiovascular
and pulmonary disease in older individuals, as well as in
other conditions.
209
As discussed in Chapter 8, exercise increases the meta-
bolic demand for oxygen and substrates. With aging, the
oxygen transport system is less capable of responding to ex-
ercise stress as a consequence of the diminished efficiency
of the various steps in the oxygen transport pathway, in-
cluding oxidative metabolism at the cellular level (Lesnefsky
& Hoppel, 2006; Vigorito & Giallauria, 2014). Despite the
reported age-related changes, the considerable reserve ca-
pacity of the cardiopulmonary and cardiovascular systems
tends to offset the potential functional consequences. The
degree of this compensation, however, is highly variable
among individual older persons. Although this variability
reflects genetic factors to a considerable extent, fitness and
lifestyle factors also have a significant role. That cardiopul-
monary and cardiovascular reserve capacity is maximized
with exercise irrespective of age has been known for several
decades. Furthermore, age is not a limiter for the capacity
to exhibit an exercise response (Sattelmair, et al., 2011;
Sattelmair, Pertman, & Forman, 2009).
Extrinsic Factors
Extrinsic factors that can affect cardiopulmonary and cardio-
vascular function in older persons include iatrogenic factors—
that is, secondary effects from the medical care that an
individual may be receiving (Dean & Ross, 1992). In the con-
text of function in the older, medically stable adult, the effects
of medication and routine medical procedures are likely to be
the most important extrinsic factors. It is not uncommon for
older persons to be taking one or more medications. Although
a medication may have a specific and beneficial effect, it may
have an untoward effect elsewhere. For example, beta blockers
are highly effective in improving the mechanical efficiency of
the heart; however, these drugs blunt the normal hemody-
namic responses to exercise, and some individuals report ex-
periencing undue fatigue when taking these medications.
Routine medical procedures adversely affect cardiopulmonary
and cardiovascular function secondary to confinement to a
body position (typically recumbent) for a prolonged time pe-
riod, restricted mobility, insertion of invasive lines and leads,
and associated medications and hospitalization. The morbidity
and mortality associated with these routine procedures are
accentuated in older persons.
Intrinsic Factors
Intrinsic factors that affect cardiopulmonary and cardiovascular
function are those that are posed by the general history, back-
ground, and characteristics of the individual (Dean & Perme,
2008). For example, the effects of nonprimary cardiopul-
monary and cardiovascular disease—that is, manifestations of
diseases of the renal, hepatic, neurological, endocrine, gastroin-
testinal, immune, hematological, and musculoskeletal systems—
can have significant consequences on cardiopulmonary and
cardiovascular function (Dean, 1997). In addition, connec-
tive tissue disorders can have significant cardiopulmonary and
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210 PART II ■ Aging: Body Structures and Body Functions
cardiovascular manifestations. Although the secondary man-
ifestations of diseases of these systems can be more obscure
than manifestations of primary disease of the heart and lungs,
their diagnosis is more difficult and their prognosis tends to
be poorer.
Like other dynamic functions of the human body, the
function of the heart and lungs is dependent on adequate nu-
trition and hydration. The appropriate energy sources must
be available to the metabolically active tissues. Older persons
may be uninformed or negligent about their nutritional and
fluid needs or incapable of meeting these needs because of
physical or economic limitations. On the other extreme is the
problem of obesity. With the age-related reduced muscle
mass and reduced cardiopulmonary and cardiovascular re-
serves, being overweight constitutes a significant additional
load that can further impair heart and lung and muscu-
loskeletal function, and hence threaten functional independ-
ence. In Western countries, there is a tendency for people to
gain weight with advancing years; however, this trend re-
verses in very old age.
Reduced cardiopulmonary and cardiovascular function can
result from factors other than dysfunction of the primary
organ systems that are directly responsible for effecting func-
tional activity. For example, sleep deprivation, nutritional
deficits, or impaired cognition have obvious ramifications on
function and independence.
✺
PROMOTING BEST PRACTICE
Multiple Determinants of Health
In addition to addressing lifestyle factors, rehabilitation
professionals need to appreciate the broader determinants
of health including social, political, economic, and
environmental. Most of the manmade determinants,
anthropogens, have a common physiological link through
chronic, systemic inflammatory (meta-inflammation)
processes (Egger & Dixon, 2014).
Other intrinsic factors that affect cardiopulmonary and
cardiovascular function include current and long-term
lifestyle practices such as level of physical activity and exercise,
nutritional status, smoking history, and effectiveness of stress
management strategies. Regular exercise, in which the heart
rate reflecting exercise intensity is within the training-sensitive
heart rate zone, is essential for aerobic conditioning. Such
conditioning ensures aerobic reserve capacity, which provides
a cardiopulmonary protective effect if the person becomes ill
or requires routine medical and surgical procedures. Also,
years of active and passive smoking are well-known risk
factors for chronic airflow limitation and cancer. Poor coping
strategies contribute to excessive levels of circulating cate-
cholamines, cardiac irregularities, coronary vasospasm, and
hypertension. Occupational environments over the long term
can have significant long-term consequences (e.g., the occur-
rence of interstitial lung disease in workers exposed to toxic
environmental agents and in farmers).
Exercise Testing and Training Older
People With Cardiopulmonary and
Cardiovascular Health Conditions
Assessment Findings and Implications
for Exercise Testing
Exercise training programs and their parameters are deter-
mined by the rehabilitation professional, most often the phys-
ical therapist, based on the determinants of oxygen transport
capacity and strength as described earlier (pathophysiology, re-
cumbency and inactivity, extrinsic factors and intrinsic factors).
In addition, measures are recorded before, at times during, as
well as immediately after exercise, and some minutes later after
recovery. Exercise testing can be complex and includes cardiac
output and blood gases, valid and reliable tests can be con-
ducted with basic measures (respiratory, cardiac, and subjec-
tive) (Table 13-4). An exercise test is only as good as the
quality of the measures. Thus, the techniques need to be well
standardized. Automated equipment that has been shown to
be valid and reliable can be used. However, heart rate and
blood pressure measures, particularly the latter, may be less re-
liable and valid unless appropriate equipment is used. Most au-
tomatic self-deflating blood pressure systems, for example, are
not suited to measurement in when a person is moving. Addi-
tionally, pulse oximetry is more valid when the person is at rest.
The assessment also includes the older adult’s goals in con-
junction with education of the benefits of increased physical
activity and exercise. The desired outcomes need to be iden-
tified beforehand to enable the rehabilitation professional and
the older adult know when they have been achieved, and if a
change is needed to the prescription. Selecting an appropriate
exercise test for an individual requires clinical judgment. This
is based on a comprehensive assessment, including an esti-
mation of the older adult’s goals and baseline functional ca-
pability. Specificity of training is a fundamental principle in
exercise physiology. This means that training will be most
effective if it closely approximates whatever activity or capac-
ity the older adult identifies as a goal.
TABLE 134 ■ Assessment Considerations for Exercise Testing
of Older People With Cardiopulmonary and
Cardiovascular Health Conditions
Heart rate
Blood pressure
Rate pressure product [(heart rate × systolic blood pressure)/1000]
Respiratory rate
SpO2 (arterial saturation monitored with a finger sensor using pulse
oximetry)
Electrocardiogram as indicated
Subjective ratings (Borg scale and its modifications, see Table 8.5)
Exertion
Breathlessness
Fatigue
Discomfort/pain
4605_Ch13_201-216 31/10/17 12:23 PM Page 211
CHAPTER 13
Exercise Test Findings and Implications
for Exercise Training
Exercise training includes a comprehensive program of which
the activity or exercise prescription is one component. Max-
imizing health alone or most often concurrently with an ex-
ercise program is needed to maximize functional capacity. On
the basis of the assessment of health, and lifestyle behaviors,
this could include smoking cessation, quality nutrition,
weight loss, reduced sedentary behavior, improved sleep, and
reduced stress and anxiety. Exercise training specifically is
based on a determination of the parameters of the exercise
prescription, including the type or types of activity or exercise,
its intensity, duration, frequency and course. Table 13-5 shows
levels of analysis of exercise responses during a test, namely,
baseline (resting), during the test, termination of the test, and
after recovery. Information at each level helps to prescribe
the exercise training parameters.
Essential to these decisions is the engagement of the older
adult. Enjoyment and what is realistic for that individual will
ensure that the exercise regime is adhered to and better is
achieved. Most effective programs need to include flexibility
exercise and strengthening as well as aerobic conditioning.
The types of exercise can be gym and equipment based, games
such as racket sports or bowling, and activities such as walk-
ing, cycling, tai chi, dancing, yoga, and qi gong. Many of
these sports and activities can be enjoyed with friends and
family, as well as alone. Gym- and equipment-based exercise
are easier to set a fixed intensity (e.g., based on heart rate).
Treadmills, for example, require an even cadence such
that a person only needs to balance with a couple of fingers
(not grasp) and the person has a minimal walking speed of
at least 0.5 mph. Most treadmills do not start from zero
speed. Self-paced tests, for example, time limited tests including
TABLE 135 ■ Potential Exercise Test Findings of Older
People With Cardiopulmonary and
Cardiovascular Health Conditions
AT REST
Are resting subjective and objective values stable?
Are resting values in the normal ranges?
Low? High? Explain
DURING EXERCISE
Do variables increase in predictable manner?
Do variables peak in a predictable manner?
Is there a heart rate or VO2 peak? Plateau?
Is rating of perceived exertion appropriate for workload changes?
COOL DOWN AND RECOVERY (short/long term)
Do variables decrease in predictable manner?
Do variables plateau at resting levels in predictable manner?
REASON WHY THE TEST WAS TERMINATED
A predetermined endpoint by the rehabilitation specialist
Exercise tolerance (usually perceived exertion reflecting the work of
breathing and/or the heart)
Fatigue
Discomfort/pain
Other specified by the patient/client
■ Cardiopulmonary and Cardiovascular Function: Health Conditions 211
the 3- or 6-minute walk test, are often preferable in older
people, particularly those with health conditions including
musculoskeletal limitations.
However, older adults can be taught to base their exercise
intensity on perceived exertion (Borg scale from 0 [nothing]
to 10 [maximal exertion]). Moderate exertion is typically
between 5 and 8, which can provide an internal guide to
the person for self-monitoring. Intermittent exercise sched-
ules allow for periodic rests or intervals of less intensity.
This is set to the person’s individual needs, for example,
3 to 5 minutes of moderately intense exercise, followed by
1 to 2 minutes of less intensity, for example, between 2 to 5
on the rating of perceived exertion scale. Exercising at
70 to 85 percent of age-predicted maximal heart rate is
more useful for older adults who have high functional ca-
pacity, but less useful for those who are deconditioned. The
Karvonen formula provides a heart rate–based guide for
exercise intensity for people with low functional capacity
or high resting heart rates. The formula is based on a max-
imal exercise test as maximal achievable heart rate is used
in the equation as follows:
Upper limit of the exercise heart rate range = 80 percent
[Heart rate maximum – Heart rate resting] + Heart
rate resting
Lower limit of the exercise heart rate range = 60 percent
[Heart rate maximum – Heart rate resting] + Heart
rate resting
The lower an older adult’s functional capacity, the higher
the frequency of exercise sessions. Older adults with very low
functional capacities may need to exercise for three 10- to
30-minute bouts daily because once daily would be inade-
quate to elicit a training effect. Most older people will benefit
from some form of structured exercise at least once a day, for
example, strengthening exercises one day and aerobic exercise
the next. However, the higher the functional capacity be-
comes, every other day may suffice. Exercise at these higher
intensities does not preclude the need for regular physical
activity at low metabolic equivalent of task (MET) levels
throughout the day. As well, the lower an older adult’s func-
tional capacity, the sooner the benefits of the exercise pro-
gram will be evident compared with those whose functional
capacities are higher. In the latter cohort, benefits may not
be apparent for 6 to 8 weeks, whereas in the cohort of older
adults with low functional capacity, benefits may be evident
within a couple of weeks. Thus, retests are needed more
frequently in the group starting from a lower capacity point
group because achievable maximal heart rate may have
changed. Finally, exercise needs to be integrated into an older
person’s life, rather than just exercising for a 6- to 8-week
period. This phase is known as the maintenance phase. Dis-
cussion with the older adult will help refine the prescriptive
parameters for long-term exercise at this stage in terms of
type(s), intensity, duration, and frequency. Adjustments may
be needed over time to accommodate changes in a person’s
health condition, setbacks, and effects of medications.
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212 PART II ■ Aging: Body Structures and Body Functions
SUMMARY
There are four levels at which the oxygen transport pathway
is affected in older people that may interfere with their ca-
pacity for functional activity and exercise: pathological fac-
tors, recumbency and inactivity, extrinsic factors related to an
older adult’s care, and intrinsic factors related to the individ-
ual. With respect to pathology, the cardiopulmonary and car-
diovascular impact of aging is mostly overshadowed by the
effects of chronic exposure to unhealthy lifestyle practices
such as smoking, unnutritious diets, overweight/obesity,
sedentary activity, low physical activity, poor sleep, and men-
tal health issues including anxiety and depression. These
unhealthy lifestyle practices contribute substantially to the
leading causes of premature death: cancer, cardiovascular dis-
ease (heart disease and hypertension), cerebrovascular disease,
type 2 diabetes mellitus, and obesity. Older people tend to
be recumbent more often than younger people and less active.
The impact on the cardiopulmonary and cardiovascular sys-
tems of being recumbent and inactivity are distinct. They
need to be examined to establish their contribution to im-
paired oxygen transport. The more medical and surgical care
an older adult needs, the greater likelihood the capability for
oxygen transport may be compromised (e.g., medications that
cause fatigue or other symptoms; surgeries that have pro-
longed recovery times). Intrinsic factors related to the indi-
vidual older adult may compromise oxygen transport capacity
and physical functioning (e.g., barriers to physical activity,
cultural beliefs about exercise, accessing appropriate care and
attention in a timely manner).
An assessment of the four levels of factors is needed to in-
form the test selection and its parameters. This information,
along with the findings of the exercise test, is then analyzed to
provide a basis for exercise prescription. Engaging the older
adult in decision-making is imperative if the exercise program
is to be sustained. An exercise program needs to be a compo-
nent of a comprehensive health program, including lifestyle be-
havior change as indicated. Attention to an older person’s health
overall when prescribing physical activity and exercise will aug-
ment its benefits and help ensure physical activity is sustained
over time. Active older adults will succumb to fewer health is-
sues than inactive older people, and, should they get sick or
experience some disability, their outcomes will be improved.
CASE STUDY
Paul Jenkins is a 68-year-old white man. He has been over-
weight since childhood. He has smoked occasionally since
his teens and is a social drinker. He separated from his wife
14 years ago and is estranged from his two adult children.
He is in a positive relationship with a 70-year-old widow
at this time. Mr. Jenkins has had three bouts of angina and
experiences claudication pain in his right calf when he goes
up hill. He is also classified as prediabetic. By occupation,
he drives a delivery truck part-time, which requires mostly
sitting and driving in dense urban traffic. He says he relaxes
with beer in front of the television when he gets home from
work until he goes to bed. Mr. Jenkins complains of sleep
disturbance. He has been diagnosed with sleep apnea.
Questions
1. What factors contribute to Mr. Jenkins’s decondi-
tioning and poor health?
2. Even without an exercise intervention, what benefit
do you think addressing each unhealthy lifestyle
behavior might have on his functional capacity?
3. Describe the benefits you would expect from an
exercise program intervention in combination with
lifestyle behavior change?
4. How might you go about involving his companion
into his exercise program?
Critical Thinking Questions
1. Some argue that health choices are personal
choices and are not the responsibility of
health-care professionals. Discuss.
2. Some argue that health-care professionals have a
moral responsibility to share the evidence base regard-
ing positive healthy lifestyle choices on short- and
long-term health and well-being outcomes. Discuss
what you believe is the role of occupational and physi-
cal therapists as health coaches and educators.
3. If the ICF is to serve as a guide, where does health
behavior change fit in this framework?
4. Given the clustering of unhealthy lifestyle behaviors
and their consequences, what are the implications for
management of an older adult with one or more of
these? Think about targeted interventions versus inter-
ventions that address the cluster of unhealthy lifestyles.
5. For the management of chronic, lifestyle-related
conditions, few, if any, medications have comparable
benefits to healthy living, including physical activity
and exercise, either in the short or long term. Given
the commitment of the health-care professions to
translate evidence-based knowledge, explain the
discordance between the strength of what is known
about healthy living practices and the prevalence of
lifestyle-related conditions. Note: These conditions
are the leading causes of disability and premature
death in industrialized countries such as Canada, the
United Kingdom, and the United States.
6. What is the role of health policy in helping to make
the healthy choice the easy one?
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CHAPTER 13 ■ Cardiopulmonary and Cardiovascular Function: Health Conditions
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Sensory Function, Function Related
to the Skin and Pain: Health Conditions
Linda A. Hunt
“There are children playingbecause
in the streets who could solve some of my top problems in physics,
they have modes of sensory perception that I lost long ago.
LEARNING OUTCOMES
By the end of this chapter, readers will be able to:
1. Describe major health conditions that affect sensory
systems functions, and cause pain in older adults.
2. Explore how health conditions may cause smell, taste,
and nutritional consequences.
3. Determine what aspects of sensory impairments due to
health conditions are barriers to performing activities of
daily living and instrumental activities of daily living.
4. Describe impairments in swallowing associated with health
conditions.
5. Identify the how interprofessional health-care teamwork
may help older adults improve functional performance
and lifestyle issues despite health conditions that affect the
sensory systems.
Clinical Vignette
Mr. Oscar Reyes, a 79-year-old retired long-haul truck
driver, lives at home with his wife. His two adult children
reside about 30 kilometers away and visit two to three times
a month. Mr. Reyes has had bilateral hip replacements at
age 70 and bilateral knee replacements at age 59. In addition,
Mr. Reyes has glaucoma and has been diagnosed with stress-
induced peripheral neuropathy secondary to his long hours
sitting in the truck and other postural demands from his job.
Mr. Reyes has fallen when participating in community activ-
ities. Fortunately, he has not experienced injuries from the
falls but now fears walking in new places. Mrs. Reyes reports
that Mr. Reyes constantly groans, even in his sleep, and can-
not divert his attention away from the pain. Mr. Reyes finds
the pain more distressing lately. The pain is affecting his ap-
petite, so he rarely wants to eat. His physician had been hes-
itant but has finally given him pain medication. However, the
medication makes Mr. Reyes want to sleep more, and con-
sequently, he is less active. Furthermore, the pain medication
CHAPTER 14
■ Bobby Nijjar ■ Amanda Stead
—J. Robert Oppenheimer
”
is making Mr. Reyes nauseated. Mr. Reyes is noticeably
weaker and has less endurance. In addition, glaucoma has
made Mr. Reyes fearful of moving, as he understands his en-
vironment less and less. His wife is thinking of assisted living.
However, this is not really affordable for the family.
1. What additional information do you need to gather?
What immediate next steps might you need to consider?
2. Considering the diagnosis of glaucoma, how might
Mr. Reyes present? What difficulties might Mr. Reyes
have in day-to-day function and occupational performance?
3. Considering Mr. Reyes’s age, would there be any point
to implementing therapy interventions to address the
pain?
T his chapter explores how some health conditions of
older adults affect the sensory systems and how these
affect functional performance, activity, and occupational de-
mands. Older adults, who have one or more health condi-
tions associated with aging or as the result of poor lifestyle
choices, may lead productive and satisfying lives with inter-
ventions of multiple health-care providers and motivation
(Massof, 2006).
Pathological Changes in the Visual
System
According to the 10th Revision of the International Classifi-
cation of Diseases (World Health Organization, 2017), there
are four levels of visual function: normal vision, moderate
visual impairment, severe visual impairment, and blindness.
The accuracy of vision is usually referred to as “Snellen acuity”
after Dutch ophthalmologist Hermann Snellen (1834–1908).
Snellen created the chart and letters now commonly used to
measure visual acuity. In some countries (e.g., Canada, the
United States), 20/20 vision indicates “normal” vision. This
217
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218 PART II ■ Aging: Body Structures and Body Functions
refers to the ability to see an object clearly when the indi-
vidual is 20 feet away from the object. In other countries,
6/6 may designate normal vision, where 6 refers to 6 meters
versus 20 feet. Therefore, 6/6 vision is the same concept as
20/20 vision. See Figure 14-1 for how someone would see
with “normal vision.”
Low vision (moderate or severe visual impairment) is
generally defined as an untreatable loss of sight that is not cor-
rectable with standard eyeglasses, interferes with the function-
ing of the individual, and leads to disability (see Chapter 9 for
information on normal changes in vision due to aging). When
ordinary eyeglasses, contact lenses, or intraocular lens implants
cannot provide sharp sight to an individual, they are said to
have low vision. Although reduced central or reading vision
is common, low vision may also result from decreased side
(peripheral) vision, the reduction or loss of color vision, or the
eye’s inability to properly adjust to light, contrast, or glare.
About 65% of all people who are visually impaired are aged 50
and older, representing about 20% of the world’s population
(World Health Organization, 2014). In the United States, an
estimated 3.5 million people have low vision; of this group,
approximately 2 million have mild low vision, which mainly
affects driving and reading ability, and about 1 million meet
the legal criteria for blindness. Across all age-groups, the inci-
dence of more severe forms of low vision is about 250,000 new
cases per year (Centers for Disease Control and Prevention
[CDC], 2016). By about 2035, with the aging of the popula-
tion, both the total number of low vision cases and the number
of new cases per year may double. Many of the services for peo-
ple with visual impairments target children and working-age
adults. There is an immediate and rapidly growing need for
services that target the older adult population.
The term low vision, along with visually impaired, visually
disabled, and partially sighted, implies that an individual has
some vision remaining. In other words, a person with low
FIGURE 141 A scene as it might be viewed by a person with normal
vision (20/20 or 6/6). Credit: National Eye Institute, National Institutes of
Health (Ref#:EDS01).
vision has some usable vision, but the visual loss is significant
enough to affect work, recreation, and the performance of
functional activities. In some countries, governments use a
separate term, typically legally blind, to define a person whose
degree of sight loss entitles them to special benefits. Legal
blindness is defined as (1) visual acuity of 20/200 or less in the
better eye after best possible standard correction or (2) a visual
field of no greater than 20 degrees in the better eye (U.S.
Social Security Administration, 1992). Visual acuity of 20/200
means that a person can see a letter or word at a distance of
20 feet that can be seen by a normally sighted person at a dis-
tance of 200 feet. It is important to note that legal blindness
is not necessarily the same as total blindness.
Cataracts
With advancing age, the lens of the eye may undergo protein
degeneration and aggregation. The resulting lenticular opac-
ity, a cataract, reduces light transmission to the retina and
causes the lens of the eye to appear cloudy and yellowish. The
most common cause of loss of useful vision worldwide is be-
cause of cataracts. According to the National Eye Institute
(n.d.), roughly 24.4 million people currently have cataracts.
They project that by 2050, that number will have doubled
to 50 million. Individuals with cataracts will experience the
following (Fig. 14-2):
■ Decreased acuity
■ Hazy or blurred vision
■ Altered color perception
■ Increased sensitivity to glare
■ Difficulty driving at night
■ Difficulty seeing low-contrast objects
■ Image distortion (straight lines appear wavy) (National
Health Service, 2016)
FIGURE 142 A scene as it might be viewed by a person with cataracts.
Credit: National Eye Institute, National Institutes of Health (Ref#: EDS03).
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CHAPTER 14 ■ Sensory Function, Function Related to the Skin and Pain: Health Conditions
When the cataract interferes with vision to such an ex-
tent that functional activities are affected, cataract extrac-
tion and lens prosthesis implantation surgery is performed
(Brodie, 2003). Although treatment for the removal of
cataract is widely available, access barriers, such as insur-
ance coverage, treatment costs, patient choice, or lack of
awareness, prevent many people from receiving the proper
treatment (CDC, 2016).
Age-Related Macular Degeneration
It has been projected that 196 million people will be affected
by age-related macular degeneration by 2020, increasing to
288 million by 2040 (Wong et al., 2014). Age-related macular
degeneration (AMD) is more common in whites, smokers,
those with a blue iris, hypertension, hypercholesteremia,
and a family history of the disease. AMD is characterized by
retinal atrophy and scarring, along with hemorrhages in the
macula, resulting in a gradual loss of the central field of vision
(Fig. 14-3).
There are two types of AMD:
1. Dry AMD (non-exudative). This type of AMD is
characterized by yellow deposits of extracellular mate-
rial (drusen) in the macula. Areas of retinal atrophy
may lead to vision loss over time. Dry AMD is the
most common type of AMD.
2. Wet AMD (exudative). This type of AMD progresses
more rapidly and is characterized by a proliferation of
abnormal blood vessels that leak blood and fluid into
the macula.
Medical treatment options for AMD are limited. Wet
AMD can sometimes be treated in the early stages of the dis-
ease with laser surgery (photocoagulation) to cauterize the
new blood vessels and stop their development (Brodie, 2003).
Other treatments include medications injected directly into
the eye and photodynamic therapy, which involves shining a
special laser into the eye to activate a medication that has
FIGURE 143 A scene as it might be viewed by a person with
age-related macular degeneration. Credit: National Eye Institute,
National Institutes of Health (Ref#: EDS05).
219
been administered intravenously. However, no known treat-
ment prevents macular degeneration or can reverse the visual
loss (Daniel et al., 2016). Central vision loss can have very
negative psychological and social effects. Because the macula
is responsible for fine-detail vision, reading, needlework,
writing, and recognizing faces become very difficult. Prob-
lems with distance and depth cues and color and contrast per-
ception are also evident. As a result, safe mobility may be
affected because of problems with distance and depth cues, a
reluctance to participate in social activities can appear, and
limitations with activities of daily living (ADL), work, and
leisure are common (Watson, 2001). Because people with
AMD cannot see items in their central visual field, they may
compensate by rotating the head or trunk to see the missing
information. Training in eccentric viewing, the process of
aligning the image into a new retinal viewing area, allows the
older adult to place the target outside of the blind spot so it
can be seen (Nilsson, Frennesson, & Nilsson, 2003).
Glaucoma
Glaucoma (Fig. 14-4) is a group of diseases characterized by
progressive optic nerve damage. Glaucoma is more common
in blacks and Hispanics in the United States (Minassian,
Reidy, Coffey, & Minassian, 2000). Among blacks, glaucoma
presents at a younger age with higher intraocular pressures,
is more difficult to control, and is the main irreversible cause
of blindness (Owsley et al., 2015). It is estimated that the
number of people with glaucoma worldwide will increase to
111.8 million in 2040, disproportionally affecting people
residing in Asia and Africa (Tham et al., 2014). There are
several types of glaucoma; however, the two most common
in older adults are as follows:
1. Primary open-angle glaucoma (POAG). POAG has a
slow and insidious onset. The major risk factor for de-
veloping POAG is raised intraocular pressure (IOP).
The increased IOP may cause permanent loss of pe-
ripheral vision before the individual notes a change in
FIGURE 144 A scene as it might be viewed by a person with
glaucoma. Credit: National Eye Institute, National Institutes of Health
(Ref#: EDS02).
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220 PART II ■ Aging: Body Structures and Body Functions
vision, and blindness occurs if left untreated (Glaucoma
Research Foundation, 2016).
2. Angle-closure glaucoma (ACG). ACG is an acute con-
dition resulting from a sudden blockage of aqueous fluid
outflow and acute elevation of IOP. Gradual increase
in lens size, with advancing age or because of cataracts,
predisposes the eye to ACG. Symptoms include severe
pain, blurry vision, and halos around lights. ACG is a
medical emergency (Brodie, 2003). Angle closure can
appear suddenly and is painful. Visual loss can progress
quickly; however, the pain and discomfort usually lead
patients to seek medical attention before permanent
damage occurs (CDC, 2016).
Glaucoma is treated medically or surgically, depending on
the type and stage of glaucoma. Medical treatment consists
of either focused topical medications such as eye drops or sys-
temic medications that will lower the intraocular pressure. If
pressure is not relieved enough or if medications are not
effective or tolerated, surgery (filtration surgery, laser tra-
beculectomy) is used to help remove the blockage and in-
crease fluid drainage (Brodie, 2003). The effect of the loss of
peripheral vision is great. The individual may not see objects
in a path and bump into objects in the periphery, making am-
bulation unsafe. Objects or people outside the person’s pe-
ripheral field of view may suddenly appear, startling the
individual. In addition, reading and writing may be problem-
atic because only a small portion of the page can be seen at
once (Watson, 2001). The adaptations used by persons with
visual field loss resulting from glaucoma are similar to those
used by individuals with AMD—one must increase head or
trunk rotation to gather missing sensory information. Regular
eye examinations are essential because early detection and
treatment can prevent the visual loss that occurs if glaucoma
is left untreated.
Diabetic Retinopathy
Diabetic retinopathy (DR) (Fig. 14-5) is the leading cause
of blindness among U.S. working-age adults aged 20 to
74 years. An estimated 4.1 million and 899,000 Americans
are affected by retinopathy and vision-threatening retinopa-
thy respectively (CDC, 2016). Although DR can affect in-
dividuals of all ages, damage to the blood vessels of the retina
due to diabetes is a common cause of retina changes in the
older adult.
Because diabetic neuropathy is a complication of dia-
betes, the incidence of diabetic neuropathy typically in-
creases with the length of time a person has diabetes. The
degree and rate of progression of the retinopathy strongly
correlate with the level and duration of elevated blood sug-
ars. Thus, good control of insulin levels is essential to pre-
vent diabetic retinopathy and delay its progression (CDC,
2016). Diabetic neuropathy occurs in stages. In the initial
stage (nonproliferative stage), microaneurysms form but are
reabsorbed by the retina. With time, the retinal capillaries
FIGURE 145 A scene as it might be viewed by a person with diabetic
retinopathy. Credit: National Eye Institute, National Institutes of Health
(Ref#: EDS04).
begin to leak fluid into the surrounding tissue, causing reti-
nal edema and producing exudate, which leads to decreased
visual acuity. In the later stage (proliferative stage), new
blood vessels grow in the retina. These blood vessels easily
rupture, bleeding into the eye. Scotomas in the central
vision field often occur (Brodie, 2003).
Symptoms of diabetic neuropathy include fluctuating and
blurred vision, decreased contrast sensitivity, problems with
driving at night, difficulty with color discrimination, “spotty”
visual field losses, and complete blindness.
The degree of activity limitations and participation restric-
tions resulting from diabetic retinopathy varies greatly and is
dependent on time of diagnosis and severity of the disease.
Medical management is dependent on the stage and may in-
clude laser surgery to treat the microaneurysms or vitrectomy,
a procedure used to remove blood and scar tissue from the
vitreous (Brodie, 2003). The risks of DR are reduced through
disease management that includes good control of insulin
levels, blood pressure, and lipid abnormalities. Early diagnosis
of DR and timely treatment reduce the risk of vision loss;
however, as many as 50% of people with diabetes are not get-
ting their eyes examined or are diagnosed too late for treat-
ment to be effective (CDC, 2016).
INTERPROFESSIONAL PRACTICE
Efforts to Promote Effective Interprofessional
Treatment of Low Vision
■ The American Optometric Association Low Vision
Rehabilitation (LVR) Section has played a major role in the
Medicare Low Vision Demonstration Project by examining
the impact of standardized national coverage for vision
rehabilitation services provided in the home by physicians,
occupational therapists, and certified low vision
rehabilitation professionals.
■ In the United States, several organizations have worked to
expand outreach efforts to bring LVR to more people,
including the U.S. Association of Blind Athletes, Indian Health
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CHAPTER 14 ■ Sensory Function, Function Related to the Skin and Pain: Health Conditions
Service, Seniors’ Coalition, American Occupational Therapy
Association, National Eye Institute National Eye Health
Education Project, AMD Alliance International, the American
Academy of Ophthalmology, and the American Association
of Retired Persons (Grover, 2008).
■ The multidisciplinary nature of LVR and collaboration
among ophthalmology, occupational therapy, and
opticianry were described in a case study. The
ophthalmologist referred a client to an optician, who then
provided and dispensed the devices prescribed to the
client, and an occupational therapist taught the client how
to use the devices. The occupational therapist conducted
a series of sessions to further enhance reading and writing
skills and a workplace assessment, aimed at optimizing
workplace conditions (Kaldenberg, Markowitz, Markowitz,
& Markowitz, 2011).
■ Alma, Groothoff, Melis-Dankers, Suurmeijer, and van der
Mei (2013) demonstrated that LVR centers could implement
multidisciplinary group rehabilitation programs to improve
the psychosocial functioning of older adults who are visually
impaired.
Functional and Behavioral Adaptations
What do vision changes mean for functional performance of
the older adult? Vision loss of any type is a significant event
in the life of the older adult—not only to the individuals
affected, but also to their families, their communities, and the
health-care system. Horowitz (2004), in her review of the
consequences of vision impairments in later life, found that
vision impairments have one of the greatest impacts on func-
tional ability in older adults. Relationships have been found
between vision impairment and diminished overall function,
decreased quality of life (e.g., Brown & Barrett, 2011; Klein,
Moss, Klein, Lee, & Cruickshanks, 2003), and decreased par-
ticipation in household activities, socializing, paid or voluntary
work, and leisure activities (Alma et al., 2011). Whether acute
or gradual in onset, whether partial or full loss, any vision
changes can threaten the functional independence older adults
strive to maintain. Safe mobility is jeopardized because of
visual problems. In addition to obvious acuity problems with
reading, practical day-to-day tasks—such as housekeeping,
shopping, and clothing selection—can be quite frustrat-
ing. Color discrimination of critical items—such as food and
medication—can be challenging. Common leisure activities—
such as card playing, sports requiring eye–hand coordination,
television viewing, and needlepoint—can become extremely
difficult for the older adult with age-related visual changes.
Glare and sudden illumination contrasts can compromise
vision because of slower adaptation. Night vision may be poor,
curtailing many activities, including driving. Dim lighting in
restaurants and other public places may contribute to trips and
falls. Several researchers have documented the relationship
between visual impairments and both falls and the fear of
falling, which may further limit social activities of older adults
221
(Ivers, Norton, Cumming, Butler, & Campbell, 2000; Klein
et al., 2003; Lotery, Xu, Zlatava, & Loftus, 2007).
Visual detail, distance, illumination, and facial acuity of a
partner are all important factors for successful communica-
tion (Legault, Gagné, Rhoualem, & Anderson-Gosselin,
2010). Lipreading also plays a vital role in communication
because it provides visual cues to assist in the perception of
speech (Tye-Murray, Spehar, Myerson, Hale, & Sommers,
2016). Older adults with vision loss will have difficulty seeing
their communication partner’s face, trouble compensating
for hearing loss by lipreading, and problems picking up
nonverbal cues such as gestures, facial expressions, and body
posture (Heine & Browning, 2002; Tye-Murray et al.,
2016). The psychological impact of loss of vision on older
adults varies and relates to personal factors, such as person-
ality characteristics and individual coping strategies; timing
and degree of loss; and the use of compensatory strategies.
One study found that 7% of older adults with vision impair-
ments had major depression and 26.9% had subthreshold
depression (Horowitz et al., 2005). Older adults with vision
loss may have to stop doing things they enjoy and may feel
more isolated and vulnerable (Alma et al., 2011; Renaud &
Bédard, 2013). It is important to note that the sensitivity
of others and environmental modifications can assist the
older adult in facing visual impairments without undue
despair. Adaptation to age-related visual changes is posi-
tively affected by support received from one’s social net-
work, the use of coping strategies, and knowledge of, as well
as access to, rehabilitation services (Brennan, 2002; Brennan
et al., 2001).
Many visual disability questionnaires can be used to
examine the impact of visual impairments on the older adult,
including: the Visual Activities Questionnaire (Sloane, Ball,
Owsley, Bruni, & Roenkar, 1992), the Activities of Daily
Vision Scale questionnaire (Mangione et al., 1992), the
VF-14 (Steinberg et al., 1994), the Visual Disability Assess-
ment (VDA) (Pesudovs & Coster, 1998), the National-Eye
Institute Visual Functioning Questionnaire—25 (VFQ-25)
(Mangione et al., 2001), and the Catquest questionnaire
(Lundström, Roos, Jensen, & Fregell, 1997). These ques-
tionnaires are used in different parts of the world. For
example, the VF-14 and VFQ-25 are used in North America,
the Catquest is widely used in Europe, and the VDA is used
in Australia.
Perlmutter and colleagues (2013) developed the Home
Environment Lighting Assessment (HELA), a scale which
has strong clinical utility, for clients with low vision, the
HELA provides a structured tool to describe the quantitative
and qualitative aspects of home lighting environments where
near tasks are performed. It can be used to plan lighting in-
terventions and has the potential to affect assessment and in-
tervention practices of rehabilitation professionals in the area
of low vision and improve near task performance of people
with low vision.
Some intervention strategies for older adults with low
vision depend on cognitive capabilities such as memory and
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222 PART II ■ Aging: Body Structures and Body Functions
sequencing a task. Therefore, it is important rehabilitation
therapists screen cognition with appropriate assessments (see
Chapters 7, 12, and 27). For example, the Mini Mental State
Exam (Folstein, Folstein, & McHugh, 1975) would not be
appropriate for cognitive testing because it requires intact
vision. Hunt and Bassi (2010) found the Trail Making Test
(Reitan, 1992), a neuropsychological test of visual attention
and attention or task switching that provides information
about visual search speed, scanning, speed of processing, and
mental flexibility, can be administered to those with vision
acuity of up to 20/100 without visual impairment affecting
performance.
Low-vision rehabilitation (LVR) is growing into a specialty
area for occupational therapists. Occupational therapists work-
ing in conjunction with other professionals, including ophthal-
mologists, neuro-ophthalmologists, optometrists, nurses, social
workers, physical therapists, orientation and mobility instruc-
tors, and psychologists, can assist older adults in managing and
adjusting to their visual impairments through the use of optic
devices (Table 14-1), compensation, and environmental strate-
gies (Chapter 9).
INTERPROFESSIONAL PRACTICE
Roles of Occupational and Physical Therapists
in Low Vision Treatment Teams
The role of the therapist, typically the occupational therapist,
in LVR may be to:
■ Educate the older adult, family members, and caregivers
about low vision.
■ Teach the older adult how to use his or her prescribed
optical and nonoptical devices in ADL.
■ Teach the older adult how to function more effectively
within the context of the vision loss.
■ Assist the older adult to develop appropriate adaptive
techniques to expand their visual and physical capabilities.
■ Educate the older adult about vision substitution techniques.
■ Educate the older adult and the family about general
compensation strategies and environmental modifications,
such as management of lighting, contrast, and glare.
■ Address any psychosocial issues.
■ Refer the older adult to community resources. (McCabe,
Nason, Demers Turco, Friedman, & Seddon, 2007)
■ In some countries (e.g., the United States), occupational
therapists can become certified as low-vision specialists
or undertake graduate-level training (certificate program)
in LVR.
■ Physical therapists are less often involved in direct care for
visual impairments. However, they must take the issues
described here into consideration when providing care for
the older adult. In addition, they may have strategies and
recommendations relevant to mobility issues.
Environmental modifications are easier to implement with
the availability of today’s technology. Older adults now make
up the fastest growing consumer segment of Internet users,
and computers have become an increasingly integral part of
the lives of older adults in both workplace and personal con-
texts (Wagner, Hassanein, & Head, 2010). With the use of
closed-circuit video units, mobile phones, tablets, or comput-
ers (including laptop computers for those who cannot sit at a
computer monitor), older adults can be quite creative in using
any residual vision. Devices can be adapted or modified to
interact with or effectively be used by the older adult. A large
computer screen can automatically increase word or picture
size. Many documents available online can be viewed in a
variety of text sizes. Voice-to-text software, keyboards that
produce sound or “speak” when touched, symbols or pictures
on computer screens that produce text or speak when
touched, and phones with photos or symbols instead of tele-
phone numbers are just some examples of adaptations (see
Chapter 9 for more information).
Other Diseases That May Affect Vision,
Visual Processing, and Functional
Performance
Two diseases, Parkinson disease (PD; see also Chapter 15)
and Alzheimer disease (AD; see also Chapter 12) also cause
visual impairments. Understanding how these health con-
ditions affect vision and visual processing may have diag-
nostic and therapeutic relevance for therapists addressing
functional performance. “Parkinsonian retinopathy” creates
visual problems including hallucinations, problems with
reading, attention, and diminished contrast sensitivity
(Antal, Terney, & Bodis-Wollner, 2008; Diederich, Stebbins,
Schiltz, & Goetz, 2014; Hunt, Sadun, & Bassi, 1995).
Retinal dopamine deficiency results from a progressive loss
of dopaminergic cells predominantly in the retina and pos-
sibly in other areas of the visual system. Selective spatial-
temporal abnormalities in retinal ganglion cell function,
probably arising from altered receptive field organization in
the retina of people with PD, result (Jackson & Owsley,
2003). Visual impairment in people with PD is not typically
evident on routine eye examination because the visual acuity
score, the most commonly used measure of vision, remains
unaffected in patients with PD if the impairment is well
corrected with glasses. Contrast sensitivity measure (see
Chapter 8), which is in fact more relevant to everyday tasks,
shows specific changes (Antal et al., 2008).
Saccades, continuous eye movements that occur in re-
sponse to a sudden change of fixation, are impaired by PD
(Hunt et al., 1995). Saccades occur when reading, looking
at a scene, or searching. Saccades also play a role in atten-
tion and information processing because eye movement
brings information to our focus from the periphery (Jackson
& Owsley, 2003). Because PD compromises saccadic move-
ments, it is essential to listen to clients when they report
losing their place while reading or a lost interest in reading.
In addition, people with PD may report being surprised
by a vehicle when driving or an object while walking.
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CHAPTER 14 ■ Sensory Function, Function Related to the Skin and Pain: Health Conditions 223

TABLE 141 ■ Common Optic Devices Used for Older Adults With Vision Loss

DEVICE DESCRIPTION AND CONSIDERATIONS

Strong prescription reading glasses
Magnifiers
■ Objects appear in focus only when held very close to the eyes
■ If older adults wear these glasses while walking, can lead to difficulty with mobility
■ Amount of magnification is determined by one’s visual acuity
■ Different magnification strengths used for different purposes
■ Enlarge objects held at a normal distance
■ Can be handheld (for spot reading), attached to a stand (for continuous reading), head-mounted, or
attached to glasses (for hands-free work)
■ Advantages:
■ Can be used at a greater distance from the eye

■ Disadvantages:
■ Handheld devices require good hand control, and one hand is always in use

Telescopes ■ Can be handheld or mounted onto a pair of glasses

■ Can be monocular or binocular
■ Used to view distant objects
■ Disadvantages:
■ Stronger telescopes allow only a small field of view—leads to the older adult getting “lost” trying to find

the object of interest

■ Less acceptable cosmetically

Electronic magnification ■ Can be achieved through closed-circuit television, video magnification, or computer software in which
images are enlarged and contrast is enhanced
■ Advantage:
■ Provide very high magnification

■ Disadvantage:
■ Expensive and not very portable

Note. Magnification devices can cause nausea and dizziness. Postural support and ergonomics are important aspects to consider.
Adapted from VisionAware, 2016; Watson, 2001.

Interventions may include referrals to a vision therapist for
eye movement exercises or covering the prior lines of text
while reading, as a visual cue to help keep one’s place read-
ing text. Moreover, a driving evaluation may be warranted
(Rizzo, Uc, Dawson, Anderson, & Rodnitzky (2010).
Chapter 22 provides additional information about these
evaluations. Education regarding loss of ability to scan
one’s environment may help with safer ambulation. Exer-
the VOSP (Lincoln, Radford, Lee, & Reay, 2006). Thera-
pists may want to explore its use; for example, occupational
therapists could use it as part of driver screening and physical
therapists as part of balance and gait assessment. Caregivers
and older adults with AD may find better understanding of
and solutions to performance issues when provided with in-
formation on visuospatial deficits.

✺ PROMOTING BEST PRACTICE

cises to improve neck range of motion may assist clients to
develop a habit of turning the head to scan the environ-
ment, which may prevent falls.
Alzheimer’s disease causes similar visual manifestations
to PD. The visuospatial deficits appear primarily as diffi-
culties with reading, problems in discriminating form and
color, an inability to perceive contrast, difficulties in visual
spatial orientation and motion detection, agnosia, and dif-
ficulty developing visual strategies, which may impair func-
tional performance of everyday activities (Jackson &
Owsley, 2003; Quental, Dozzi Brucki, & Bueno, 2013).
Visuospatial deficits associated with AD can cause drivers
to become lost, which may have fatal consequences (Hunt,
Brown, & Gilman, 2010).
The Visual Object and Space Perception (VOSP) battery
can be used to evaluate visuospatial function, with minimal
interference of other cognitive functions (Quental et al.,
2013). Studies have found that older adults with dementia
performed significantly worse than controls on portions of
Sensory Loss Due to Disease
Loss of homeostatic reserve puts the older adult in a
particularly vulnerable position in which acute health
events may lead to loss of function and independence and
reduction in quality of life. Disease of the sensory systems
causes loss of vision, hearing, balance, smell, taste, and
increased pain, which may contribute to poor nutrition,
less physical activity, limited cognitive stimulation, frailty,
and isolation. Health-care professionals must begin with
assessments and referrals for appropriate devices such
as optic/hearing aids to increase sensory abilities. The
rehabilitation process should incorporate adaptation to older
clients’ environments at home, in the community, and in
health-care settings to accommodate for sensory loss,
reduced appetite, chronic pain, and loss of balance (Kiely,
Anstey, & Luszcz, 2013).
4605_Ch14_217-230 31/10/17 12:23 PM Page 224
224 PART II ■ Aging: Body Structures and Body Functions
Pathology of the Auditory System
Hearing loss can occur from a variety of other nonpatholog-
ical and pathological factors including heredity, ear-wax
buildup, exposure to very loud noises over a long period of
time, viral or bacterial infections, circulatory and neurological
health conditions, tumors, and certain medications which are
toxic to these symptoms. Because of anatomical proximity
and functional interconnections, auditory and vestibular
symptoms can manifest simultaneously, making pathology
arising in this region challenging to address.
Researchers have suggested that hearing loss is a marker
for early-stage dementia or a modifiable risk factor for cogni-
tive decline (Frank et al., 2011). Hearing loss is often associ-
ated with accelerated cognitive decline (Lin et al., 2013), and
the presence of dementia may lead to a perception of increased
impairment when not managed correctly. Communication
impairments, including hearing loss, can lead to social isola-
tion, which has also been highly linked with the incidence
of dementia (Bennett, Schneider, Tang, Arnold, & Wilson,
2006; Strawbridge, Wallhagen, Shema, & Kaplan, 2000).
Skin
Aging causes a decrease in collagen, a connective tissue mak-
ing up a large part of the dermis that prevents tearing of the
skin when it is stretched. Health-care providers and caregivers
must take precautions when transferring, bathing, and dress-
ing older clients due to the possibility of skin tearing. As well,
skin tears in the older population may be slow to heal and
therefore cause infection. Neurosensory perception of super-
ficial pain is diminished both in intensity and speed of per-
ception (increasing the risk of thermal injury); deep tissue
pain, however, may be enhanced. A decline in lipid content
as the skin ages inhibits the permeability of nonlipophilic
compounds, reducing the efficacy of some topical medications.
Allergic and irritant reactions are blunted, as is the inflamma-
tory response, compromising the ability of the aged skin to
affect wound repair. These functional impairments (although
a predictable consequence of intrinsic structural changes) have
the potential to cause significant morbidity in the older adults
and may also be greatly exacerbated by extrinsic factors like
photodamage (Farage, Miller, Elsner, & Maibach, 2008).
These changes may lead to heightened risk of medical prob-
lems such as dermatitis (skin irritation) and pruritus (excessive
itching), xerosis (dry skin), pressure sores, and skin infections
and infestations (Voegeli, 2012). These skin disorders are
often compounded by comorbidities, for example, diabetes,
peripheral vascular disease, incontinence, polypharmacy, and
other consequences of the aging process such as reduced
mobility and dexterity, general frailty, and cognitive decline
(Voegeli, 2012). Poor healing of chronic wounds, largely seen
in the older population, is more often related to comorbid
conditions rather than age alone (D. R. Thomas & Burkemper,
2013). It is therefore, the responsibility of all health-care
professionals to assess clients’ skin integrity and be aware of
the chronic conditions that may compromise skin healing. In-
teraction with a client in a health-care setting may provide an
opportunity for a comprehensive assessment which includes
general skin health and inspection of the condition of the skin,
looking for signs of the common problems outlined here.
INTERPROFESSIONAL PRACTICE
Roles of Health Care Professionals in Assessing
Skin Related Issues
Finch (2003) recommends that all health-care professionals
assess an older adult for skin related issues:
■ Ask about medical history, previous skin problems, current
medications (prescribed, over-the-counter, herbal), usual
skin-care routine, psychological well-being, bowel and
bladder function, reported feelings about body image.
■ Observe general skin quality of the whole body for signs
of edema, variations in skin color, bruising, inflammation,
scratch marks, jaundice, swelling, breaks in skin integrity,
ulcers, and lesions; observe the condition of skinfolds in
obese individuals.
■ Touch to assess texture, moisture, swelling, and temperature.
■ Smell to assess for body odor: is the person is able to wash
effectively? Are there infections? Is there incontinence of
bowel and bladder?
Several tools exist to assess the skin. For example, the
Braden Scale for Predicting Pressure Sore Risk (Bergstrom,
Braden, Laguzza, & Holman 1987) assesses risk for devel-
oping pressure sores and comprises six indicators: sensory
perception, moisture, activity, mobility, nutrition, and fric-
tion or shear. The total score can range from 6 to 23 with a
lower score indicating a higher risk. Older adults with a
Braden Scale score below 18 (or any low subscale score) re-
quire intervention and the care team should be consulted.
The level of risk dictates the intervention strategies that
should be used.
✺ PROMOTING BEST PRACTICE
Education in Health-Care Programs and to Caregivers
Multimedia communication for older adults with sensory
impairments should be taught to all who work and care for this
population, and health-care and health professional curricula
should include experiential learning (e.g., having students
experience sensory loss by wearing goggles that blur vision,
earplugs that impair hearing, and gloves that impair touch
during activities). Likewise, health-care professionals need to
educate caregivers, including certified nursing assistants, about
sensory loss through experiential learning so that they better
understand the world as experienced by the person with
sensory impairments and how sensory loss affects everyday
occupational performance and quality of life (Gerontological
Society of America, 2012).
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CHAPTER 14 ■ Sensory Function, Function Related to the Skin and Pain: Health Conditions
Pain
Pain, an unpleasant sensory and emotional experience asso-
ciated with actual or potential tissue damage, may be de-
scribed in terms of such damage (International Association
for the Study of Pain, 2017). Unrelieved pain has significant
functional, cognitive, emotional, and societal consequences
(Hanks-Bell, Halvey, & Paice, 2004). For example, pain
from fall-related injuries may result in decreased functional
performance, activity, and ambulation, which in turn may
lead to deconditioning, fear of falling, and balance and gait
disturbances. Pain can lead to sleep deprivation, which may
decrease pain thresholds, limit daytime energy, increase the
incidence and severity of depression and mood disturbances,
and decrease overall sense of well-being in older adults.
AROUND THE GLOBE: Back Pain Prevalence in Older Adults
in China, Ghana, India, Mexico, the
Russian Federation, and South
Africa.
“Past-month back pain prevalence” was examined among adults
aged 50 years and older in six countries. Overall past-month back
pain prevalence was about 30%, and prevalence estimates varied
across the countries: 22% in China, 40.5% in Ghana, 39.1% in India,
35.5% Mexico, 56% in the Russian Federation, and 38.5% in South
Africa. Older age was associated with higher prevalence. As well,
prevalence was found to be higher in females, rural dwellers, and
for those older adults with high-risk waist circumference and two
or more chronic conditions. Higher wealth and higher education
were associated with lower prevalence (Stewart Williams et al.,
2015). Although not fully understood, rehabilitation professionals
need to be aware that sociocultural factors may influence
the perception and reporting of back pain by older adults in
developing countries.
The experience of pain is important for occupational and
physical therapists to consider because it may affect an older
person’s engagement in functional performance. All health-
care providers must be educated that pain in the absence of
disease is not a normal part of aging, yet pain may be experi-
enced daily by a majority of older adults. Older adults are at
high risk for undertreatment of pain due to a variety of bar-
riers, including lack of adequate education of health-care pro-
fessionals, cost concerns, and other obstacles related to the
health-care system, as well as individual factors such as re-
luctance to report pain or take analgesics. A variety of health
conditions can cause pain in older adults (Davis, Hiemenz,
& White, 2002; Hanks-Bell et al., 2004; Horgas, 2003),
including the following:
■ Fibromyalgia
■ Gout
■ Neuropathies (e.g., diabetic, postherpetic)
■ Vitamin B complex deficiencies
225
■ Osteoarthritis
■ Spinal disorders
■ Osteoporosis and fractures
■ Cancer
■ Polymyalgia rheumatica
Older adults’ attitudes, such as stoicism, and beliefs (e.g.,
“pain is a necessary part of aging”), and external barriers gen-
erated by health professionals are determinants of whether
an older adult decides to seek help for pain (Gammons &
Caswell, 2014). Personality and perceived importance of
independence were also found to influence help-seeking
behaviors (Gammons & Caswell, 2014). Lower rates of pain
treatment have been found for the oldest-old and for those
with cognitive and communicative disorders (Maxwell et al.,
2008). Identifying pain in the cognitively impaired older
adult depends heavily on knowing the individual and paying
attention to changes in behavior (Hanks-Bell et al., 2004).
Poorly treated pain not only negatively affects the older adult
directly, it also has significant consequences for health-care
professionals and institutions. In the United States, national
standards and guidelines for pain management that apply to
all health-care settings, including long-term care, have been
published, and failure to adequately comply with the stan-
dards in the assessment and treatment of pain can lead to loss
of accreditation for the institution. Important roles for the
occupational and physical therapists include adequately as-
sessing for pain, providing appropriate interventions, and re-
ferring older adults to pain specialists as needed. The issue of
pain and pain management for older adults is also discussed
in Chapter 17.
Assessment
A thorough pain assessment is critical to guiding the thera-
peutic process. Pain management among older adults is
complicated by multiple, concomitant causes and locations
of pain (Horgas, 2003), making it difficult to distinguish
acute pain caused by a new health condition from that of an
old condition. Knowing the older adult’s baseline level of
functioning and taking a focused history assists in making
this differentiation (Hanks-Bell et al., 2004). Communica-
tion skills are critical to effective pain assessment, which in
turn, is dependent on the health-care provider’s ability to
recognize sensory and cognitive impairments. Decreased
hearing and vision may limit verbal communication and use
of written pain assessment tools. Some older adults require
extra time to consider the posed question and formulate an
appropriate answer, so it is important to be patient. In turn,
the health-care provider may need to adapt the method of
communication, for example, by speaking more slowly or
ensuring a quiet setting.
Without any known biological markers or diagnostic
tests to detect pain, self-report remains the only reliable in-
dicator of the existence of pain and its intensity (Hanks-Bell
et al., 2004). Family members or caregivers may provide
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226 PART II ■ Aging: Body Structures and Body Functions
information about the older adult’s baseline cognitive and
physical functioning and validate history when cognition or
communication are barriers (Hanks-Bell et al., 2004). In-
dividuals who cannot provide a self-report of pain should
be directly observed for pain behaviors, and a proxy should
be used where appropriate. Pain behavior includes agitation,
confusion, social withdrawal, or apathy (Herr & Garand,
2001); facial expressions (grimacing, frowning); vocalization
(shouting, moaning); body movements (pacing, rocking);
changes in interpersonal interactions (eating alone, easily
annoyed); changes in activity (no longer exercising, protect-
ing a body part); and mental status changes (increased con-
fusion, new agitation). Several pain rating scales can be used
for older adults with mild to moderate cognitive impair-
ment. The Royal College of Physicians, British Geriatrics
Society and British Pain Society (2007) provide a complete
description of standardized pain assessments with copies for
clinicians to use. Some of these can be found in the online
ancillary materials.
Interventions
Occupational and physical therapists need to be aware of the
medications that have been prescribed to treat pain, as many
cause side effects. The goals of pharmacologic therapy in the
older adult include relief of pain, prevention and early man-
agement of adverse effects of analgesics, and enhanced quality
of life (American Pain Society, 2008). Pharmacologic thera-
pies useful for older adults include nonopioids, including
acetaminophen and nonsteroidal anti-inflammatory drugs;
opioids; and adjunct drugs. Ablative procedures, such as nerve
blocks and other invasive techniques, may be indicated in
select cases (Hanks-Bell et al., 2004).
Nonpharmacologic treatments (NPTs) include various
physical and emotional therapies for both acute and persist-
ent pain, such as physical movement, heat, cold, massage,
acupuncture or acupressure, and transcutaneous electrical
nerve stimulation. NPTs are most effective when paired
with analgesic medications and function as adjuvant pain
treatment. Selection of the appropriate NPT depends on
the individual and the family, the type of pain being expe-
rienced, and preexisting medical problems. Research of the
use of NPTs in older adults has been sparse and results are
inconclusive. Claims of dramatic pain relief from any NPT
must be viewed with caution, and an important role for
therapists includes educating seniors about the validity of
such claims.
Physical movement such as sports, dance, or tai chi decreases
pain from chronic pain syndromes such as osteoarthritis, fi-
bromyalgia, or peripheral vascular disease (Bunch, 2004). Ac-
tivity improves joint function and flexibility, increases muscle
strength for improved alignment and reduced muscle spasms,
and promotes collateral circulation, minimizing symptoms of
claudication. Exercise improves well-being and preserves func-
tion and therefore is highly recommended in older adults that
can participate safely.
Exercise therapy, supplemented with manual joint mo-
bilization, was found to be superior to either strength train-
ing or exercise therapy alone in people with medial knee
osteoarthritis (OA), although all three modalities improved
pain and physical function (Jansen, Viechtbauer, Lenssen,
Hendriks & de Bie, 2011). Debilitated adults with knee
OA, aged 60 years and older, who participated in the
Fitness Arthritis and Seniors Trial demonstrated modest
improvements in pain, function, and disability with either
resistance or aerobic exercise programs (Mangani et al.,
2006). Home-based exercises, supplemented with monthly
telephone calls offering advice and support, was found to
significantly decrease knee pain (K. S. Thomas et al., 2005).
It seems that the follow-up phone call provided psycholog-
ical support that helped the older adults continue prescribed
exercises for pain relief.
The application of heat or cold may be beneficial as well.
Care must be taken to avoid skin damage or burns in the sus-
ceptible older adult population. Cold is appropriate for acute
injuries, especially during the first 48 hours postinjury. Cold
therapy is also appropriate to decrease bleeding or hematoma
formation, edema, and chronic back pain. Heat works well
for relief of muscle aches and abdominal cramping. Massage
offers many therapeutic effects that reduce pain, including re-
lease of muscle tension, improved circulation, increased joint
mobility, and decreased anxiety. A recent systematic review
found acupuncture to be associated with significant reduc-
tions in pain intensity, improvement in functional mobility
and quality of life (Manyanga et al., 2014). Physical thera-
pists, in particular, should be aware of the potential for these
modalities to relieve pain and need to consider safety precau-
tions in the use of heat and massage with older adults whose
skin is delicate.
Cognitive-based NPTs, such as guided imagery and re-
laxation, can be effective but require the ability to learn new
skills and the motivation to practice these techniques (Kerns,
Otis, & Marcus, 2001). Once learned, guided imagery and
active relaxation can be practiced individually or with the aid
of a coach and are effective in reducing pain by relieving
anxiety and reducing muscle tension (Kwekkeboom, Kneip,
& Pearson, 2003). Use of distractions, including watching
television, playing cards, listening to music, or interacting
with friends, families, or pets, may also help reduce the
sensation of pain. Attending to personal fears or concerns
of family, finances, or spirituality can also help to decrease
pain levels (Weiss, Emanuel, Fairclough, & Emanuel,
2001). McCracken, Gauntlett-Gilbert, and Vowles (2007)
examined the role of mindfulness in relation to the func-
tioning of persons with chronic pain and found that when
people with pain are more realistically in contact with their
experiences and aware of these experiences in a way that
minimizes some of their otherwise automatic reactions, they
may function better and suffer less. The authors propose
that mindfulness leads to behavior patterns that are more
effective and less caught up in distressing thought content
or emotions.
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CHAPTER 14 ■ Sensory Function, Function Related to the Skin and Pain: Health Conditions
Gagliese and colleagues (2012) demonstrated that a brief
educational intervention is associated with gains in knowl-
edge about pain and aging among older community mem-
bers, suggesting that this is a promising method of pain
education that may reduce barriers to pain management in
older people. Combined cognitive behavior therapy–based
pain self-management and exercise programs has been
found to be more effective than exercises alone and usual
care in older adults with chronic pain (Nicholas et al.,
2013). The Internet may also be an efficient mode for de-
livering self-care education to older adults with chronic
pain, potentially complementing clinical care (Berman, Iris,
Bode, & Drengenberg, 2009).
SUMMARY
The impact of sensory abilities on an older adult’s functional
performance must be emphasized in all rehabilitation and clin-
ical settings. All senses are important sources of information
about one’s environment and play an important role in func-
tion, particularly in the social and cognitive domains. Sensory
deprivation may lead to confusion, disorientation, social isola-
tion, and the appearance of dementia. Most sensory impair-
ments may be approached with adaptive strategies or exercises
such as in the case of vertigo. If not addressed, an older adult
may become frail and this, potentially, will limit quality and
span of life. All health-care professionals must use their obser-
vation skills and assessments at their disposal to determine
whether clients require special referrals to, for example, audi-
ologists, eye care professionals, nutritionists, physical thera-
pists, occupational therapists, pain specialists, and neurologists.
Not surprisingly, given the many changes that occur in the
skin during the aging process, older people are vulnerable to
a wide variety of skin disorders. Health-care professionals
must assess skin integrity, check nutritional and water intake,
positioning and circulation, and incontinence and cleanliness
to avoid skin breakdown. Pain is not a natural part of aging
and often improves or remains stable over time, stoicism may
not lead to improved quality of life, and pain medications are
not highly addictive in older adults. Attention to protective
factors, including good mental health, self-efficacy, social
support, and greater activity, may enable older patients to
adapt better to any pain they experience.
CASE STUDY
Mrs. Aleka Spiros is an 81-year-old woman with vertigo
and congestive heart failure, who has been living in a skilled
nursing facility for the past 3 weeks. Before that, she lived
with her son and daughter-in-law until they could no
longer care for her at home. They were hoping that
Mrs. Spiros could receive rehabilitation and then return to
their home. Mrs. Spiros is from Greece, has only been in
the United States for 2 years since her husband died, and
speaks very little English. Mrs. Spiros has poor endurance
227
and needs assistance to walk and move from chair to bed.
On this particular day, she has been brought, along with
all the other residents who need assistance with feeding, to
the activity area for lunch. Mrs. Spiros is seated in a semi-
reclined position, at a table with a white tablecloth. Her
napkin is also white. She squints at her food tray. Today’s
lunch is mashed potatoes and chicken with canned pears,
all served on a white china plate. When Mrs. Spiros tries
to move or reach for her food, she grimaces. When the cer-
tified nursing assistant, Kathy Cartwright, tries to help
Mrs. Spiros feed herself, Mrs. Spiros turns her head away
grabbing her napkin to cover her face. Kathy, fearful that
Mrs. Spiros will starve without eating, tells her, “You have
to eat, your son will ask me about how much you have
eaten of your lunch, and I can’t lie to him.” Despite this,
Mrs. Spiros still does not eat, and her plate is sent back to
the kitchen basically untouched. Mrs. Spiros is now agi-
tated and groaning, as she tries to move in her chair. Kathy
reports this to the charge nurse, Mrs. JoAnn Jordon, who
knows that Mrs. Spiros’s refusal to eat has been an ongoing
situation. JoAnn wonders if she should talk to Mrs. Spiros’s
doctor about a feeding tube.
Questions
1. What evaluations/services should Mrs. Spiros receive?
2. What sensory problems would a clinician’s observa-
tions diagnose?
3. What might be contributing to diminished appetite
and inability to feed independently?
Critical Thinking Questions
1. Vision or hearing impairments often cause older
adults to disengage from activities that enhance their
quality of life. How can occupational or physical ther-
apy promote reengagement in functional activities?
2. Imagine you are hired as an occupational therapist/
physical therapist in an older adult pain clinic. What
key factors are important to consider when complet-
ing an assessment and what interventions might be
used and why?
3. What ethical dilemmas may emerge when older
adults are in too much pain to participate in the
rehabilitation process?
4. How would strategies for home modifications be the
same and different for clients who have cataracts,
macular degeneration, diabetic retinopathy, and
glaucoma?
5. How can family members support the occupational,
physical, and social functioning of older adults who
are frail and experiencing sensory lost due to disease?
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228 PART II ■ Aging: Body Structures and Body Functions
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Neuromuscular and Movement
Function: Health Conditions
Norma J. MacIntyre ■ Vanina Dal Bello-Haas
“To know how to grow old is the masterwork of wisdom and one of thein themostgreatdifficultart ofchapters
—Henri Frederic Amiel, 19th-century Swiss philosopher and poet
LEARNING OUTCOMES
By the end of this chapter, readers will be able to:
1. Describe the features (signs, symptoms, risk factors) of
some of the more common neuromusculoskeletal health
conditions that affect older adults.
2. Differentiate between osteoarthritis and osteoporosis.
3. Identify the tests that can be used in the objective
assessment of older adults with osteoporosis.
4. Describe the management of common musculoskeletal
causes of disability among older adults, specifically
osteoporosis and osteoarthritis.
5. Describe the management of an older adult after
amputation due to diabetes.
6. Describe the management of common neurological causes
of disability among older adults, specifically stroke and
Parkinson’s disease.
7. Discuss some of the literature that describes evidence-
based interventions for older adults with osteoporosis,
osteoarthritis, amputation, stroke, and Parkinson’s disease.
Clinical Vignette
Mr. Bruno Tadesco is a 69-year-old man who recently retired
from his position as a construction manager after 40 years.
Mr. Tadesco tells you he has deep aching pain and stiffness
in both of his knees, especially after getting out of bed in the
morning, progressive stiffness, and difficulty walking and
going down stairs. The pain and stiffness began approxi-
mately 2 months earlier and has gotten progressively worse
to the point where he is no longer able to walk his dog.
Mr. Tadesco’s medical history includes diabetes, hyperlipi-
demia, obesity, and asthma. His medication includes met-
formin 500 mg twice daily, glyburide 10 mg daily, simvastatin
10 mg daily, albuterol 2 puffs as needed, and acetaminophen
325 mg daily for the past 3 months for pain. Mr. Tadesco’s
face is expressionless when he is speaking. He reports that he
CHAPTER 15
■ Sirirat Seng-Iad
living.
”
nipped a piece of skin around his big toe when he was clip-
ping his toenails. Mr. Tadesco thought the skin would have
healed by now as he has been applying antibiotic ointment,
but the edges haven’t closed. In fact, the edges of the cut seem
to be increasing.
1. On the basis of the information in the clinical vignette,
what might be causing Mr. Tadesco’s knee pain and
stiffness?
2. What concerns are most important about Mr. Tadesco’s
past and medical history? Why?
3. What else might be going on with Mr. Tadesco? What
facts contribute to this assessment? What additional
information or assessments might be useful?
T his chapter focuses on some of the more common
health conditions that affect the neuromusculoskeletal
system in older adults. The two most prevalent musculoskele-
tal health conditions in older adults, osteoarthritis (OA) and
osteoporosis, are described. Because lower limb amputation
may occur in older adults, often due to diabetes and vascular
disease–related complications (see Chapters 13 and 17), limb
amputation in the context of the age-related changes is de-
scribed. Last, two neurological health conditions, stroke and
Parkinson’s disease, are discussed.
Osteoarthritis
Musculoskeletal health conditions that cause loss of mobility
and physical independence can be particularly devastating for
older adults, not just physically and psychologically but also
in terms of increased mortality rates (Nüesch et al., 2011).
In recognition of the burden of musculoskeletal conditions,
the Bone and Joint Decade (http://bjdonline.org), a global
alliance, was formed to prevent or better manage these dis-
eases to reduce pain and disability in the aging population.
231
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232 PART II ■ Aging: Body Structures and Body Functions
OA is the most common form of joint disease and one of
the leading causes of disability in older adults. It is estimated
that 1 in 10 adults aged 60 years and older have significant
clinical problems attributable to OA. The incidence rises
sharply after the age 50 and peaks in the 70- to 79-year-old
age-group (Busija et al., 2010). The significant prevalence of
OA brings a high cost to society through the loss of self-care
abilities and productivity, and major economic costs. For ex-
ample, an Austrian study (published in German and summa-
rized by Woolf, Erwin, & March, 2012) reported that total
direct healthcare costs for individuals with hip or knee OA
in the year before joint replacement was 2,747 Euros with
just over half spent on personal care and household assistance
required due to loss of function. Hip and knee OA ranked as
the 11th highest contributor to global disability and as the
38th highest in disability-adjusted life years of 291 conditions
investigated (Cross et al., 2014). Clearly, with the aging of
the world’s population and the increasing incidence of obesity
globally, occupational and physical therapists need to prepare
for a large increase in the health service demands for older
adults with hip and knee OA.
Risk Factors and Signs and Symptoms
The precise cause of OA is unknown but is related to mechan-
ical wear and tear of articular cartilage. There also is a complex
genetic component to developing the disease (Fernandez-
Moreno, Rego, Carrerira-Garcia, & Blanco, 2008). Risk fac-
tors for OA include nonmodifiable factors such as increased
age and family history; modifiable factors include obesity, high
physical workload occupations, and participation in contact
sports. OA can occur in any joint, but most often affects the
hip, knee, spine, metatarsalphalangeal joint of the big toe, car-
pometacarpal joint of the thumb, and interphalangeal joints of
the fingers. For interested readers, the American College of
Rheumatology has published clinical classification guidelines
for OA of the hand, hip, and knee (see the online Ancillaries).
Osteoarthritis is characterized by the degradation and loss of
articular cartilage, active bone remodeling, loss of active and
passive joint range of motion, pain, and deformities. With OA,
the cartilage becomes thinner, tears, and disrupts the joint cap-
sule. As the cartilage wears, eburnation (ulceration), spur for-
mation (osteophytes), synovitis, and thickening of the capsule
occur, all resulting in less joint integrity. Individuals with OA
commonly report pain and stiffness, and frequent signs include
joint pain and swelling, decreased range of motion, and crepi-
tus (grating, grinding, cracking sensation) with movement.
Pain is usually relieved by rest, however, paradoxically most
individuals with OA report a period of morning stiffness.
Management of Osteoarthritis
Interventions are typically directed at multiple levels. One of
the most important aspects of management is the reduction
or modification of risk factors, especially obesity. Exercise
to address pain and increase function, and joint protection
education are also key elements to an overall management
plan. Strength training and physical fitness exercise have been
found to improve function, decrease pain and disability, in-
crease endurance, and decrease risk of falls in older adults
with OA (American Geriatrics Society Panel on Exercise and
Osteoarthritis, 2001). Pharmacologic management consists
of analgesics, nonsteroidal anti-inflammatory medications,
topical agents, and glucosamine. Intraarticular injection of
corticosteroids and arthroscopic surgery to remove loose car-
tilage or large osteophytes may be useful. For individuals with
advanced disease, intractable pain, or severely compromised
function, a joint replacement is performed. Surgery is the only
effective intervention for advanced disease, and replacement
(total hip arthroplasty or total knee arthroplasty) have been
shown to restore function and quality of life (Mariconda,
Galasso, Costa, Recano, & Cerbasi, 2011; Pivec et al., 2015).
Clinical practice guidelines have been developed that make
evidence-based recommendations relevant to rehabilitation
therapists. These recommendations include the following:
■ Self-management through education about the condition,
modifiable personal factors, and recommended treatments;
■ Pain management strategies including medications, joint
protection, environmental adaptations, and exercise; and
■ Restoration of biomechanics through surgical and/or non-
surgical interventions) (Fernandes et al., 2014; Hochberg
et al., 2012; McAlindon et al., 2014).
In persons with OA of the lower extremities, fall risk
factors including lower limb weakness, slower reactions to
perturbations of balance, and impaired functional ability
(e.g., gait, ability to rise from a chair) are observed. Addition-
ally, the risk of falls and fractures is elevated in older adults
prescribed narcotics to control OA pain (Rolita, Spegman,
Tang, & Cronstein, 2013). A synthesis of the literature sug-
gests that individuals whose mobility is not severely restricted,
but have mild to moderate arthritis have elevated rates of
falls and fractures (Arnold & Gyurcsik, 2012). Arnold and
Gyurcsik (2012) developed a conceptual integrated framework
for fall-risk screening and assessment of people with OA
based on the American Geriatrics Society/British Geriatrics
Society 2011 clinical practice guideline for prevention of falls
in older persons (Panel on Prevention of Falls in Older
Persons, 2011). Adapted guidelines for persons with hip and
knee OA, such as those developed by Arnold and Gyurcsik
(2012), are important tools for occupational and physical ther-
apists providing community fall-prevention interventions and
underline the need to include fall prevention in integrated care
of older adults with musculoskeletal health conditions.
✺ PROMOTING BEST PRACTICE
Activity Pacing and Land- and Water-based Therapeutic
Exercise Programs Are Beneficial for People With OA
Education about activity pacing has been found to reduce
joint stiffness, fatigue, and pain in people with hip and knee
OA; individualized interventions (e.g., tailored to the individual
4605_Ch15_231-248 31/10/17 12:21 PM Page 233
CHAPTER 15
person with OA) were also found to be effective (Smith, Davies,
Jepson, Hosny, & Hing, 2013)
Therapeutic exercise programs, consisting of traditional
muscle strengthening, functional training, and aerobic fitness
exercise, have been found to reduce pain and improve physical
function among people with symptomatic hip OA and in people
with knee OA (Fransen et al., 2014, 2015).
Aquatic exercise decreases pain and disability and improves
quality of life in people with knee and hip OA (Bartels et al., 2016).
Osteoporosis
Osteoporosis, which manifests as a fragility fracture, is a
growing public health problem throughout the world, in part
because of the increasing numbers of people living beyond
age 65 years. Osteoporosis is defined as a skeletal disorder
characterized by compromised bone strength, predisposing a
person to increased risk of fracture (NIH Consensus Devel-
opment Panel on Osteoporosis Prevention, 2001). Low bone
mass and microarchitectural deterioration in bone tissue lead
to bone fragility and a consequent increase in fracture risk
(NIH Consensus Development Panel on Osteoporosis Pre-
vention, 2001). A fragility fracture is defined as a fracture oc-
curring spontaneously or following minor trauma, such as a
fall from a standing height or less, or other injury that would
not cause a normal bone to break and results from reduced
compressive and/or torsional strength of bone (Bessette et al.,
2008). The most common skeletal sites for osteoporotic frac-
tures are the vertebral body, distal radius, proximal femur,
and proximal humerus; therefore, these are called major
osteoporotic fractures.
Clinical Diagnosis
In 2002, the World Health Organization (WHO) endorsed
the clinical diagnosis of osteoporosis on the basis of bone
mineral density (BMD) assessed at the hip or spine using
dual energy x-ray absorptiometry (DXA). For the total pro-
jected area of the bone under investigation, areal BMD is cal-
culated as the ratio of bone mineral content (BMC, or mass
of mineral) per unit of projected area (g/cm2). A t-score is
determined by subtracting the measured BMD from the
mean value for gender-matched young adults at peak bone
mass and dividing by 1 standard deviation of the young adult
mean. The clinical diagnosis of osteoporosis is made when
the t-score less than or equal to –2.5, whereas osteopenia
exists when the t-score is between –1.0 and –2.5. A t-score
greater than or equal to –1.0 is classified as normal. For each
SD decrease in BMD in men and postmenopausal women
over age 50 years, the risk of osteoporotic fracture increases
by 1.5 to 2.5 times (Marshall, Johnell, & Wedel, 1996). In
addition to BMD, bone strength is also dependent upon
bone quality, which considers bone architecture, bone min-
eralization, accumulated damage (e.g., microfractures), and
■ Neuromuscular and Movement Function: Health Conditions 233
bone turnover (NIH Consensus Development Panel on Os-
teoporosis Prevention, 2001). Whereas the fracture rate is
higher in postmenopausal women with a clinical diagnosis of
osteoporosis, the absolute number of fragility fractures is
higher among those who are classified as osteopenic (Cranney,
Jamal, Tsang, Josse, & Leslie, 2007). It is clear that factors
other than BMD need to be considered to predict absolute
risk. To address this need, WHO developed an online Frac-
ture Risk Assessment (FRAX) tool that considers age, sex,
body mass index (BMI), presence of clinical risk factors, and
BMD in the estimation of an individual’s 10-year absolute
fracture risk (www.sheffield.ac.uk/FRAX). This tool has now
been validated for use in many countries around the world
and performs well even when BMD values are not included.
Functional risk for fracture is not incorporated into the
FRAX tool, and few studies have evaluated the association
between physical performance and fractures. Data are emerg-
ing that underline the importance of incorporating physical
performance into the assessment of fracture risk in older
adults. For example, cross-sectional data show that the qual-
ity of observed performance on typical activities of daily living
measured using the Safe Functional Motion test (SFM) are
associated with fragility fractures at the spine and hip and
with injurious falls, after adjusting for known risk factors
(Recknor, Grant, Recknor, & MacIntyre, 2013). Scores on
the SFM predicted incident morphometric vertebral fractures
at one and three years after adjusting for known risk factors
(MacIntyre, Recknor, Grant, & Recknor, 2014). A 10-year
longitudinal study reported taking 10.2 seconds or longer
to complete the Timed Up and Go test was associated with
incident nonvertebral fractures (Zhu, 2011). In addition,
standing balance and gait speed have been found to be in-
dependent predictors of incident hip fracture at 10 years
(Wihlborg, Englund, Åkesson, & Gerdhem, 2015).
Fractures
Future fragility fractures are strongly associated with the pres-
ence and number of fragility fractures sustained independent
of BMD (Klotzbuecher, Ross, Landsman, Abbott, & Berger,
2010). Osteoporotic fractures are more common in women
than men at a rate of approximately 3:1 (Ismail et al., 2002).
Data from the Global Longitudinal Study of Osteoporosis
in Women (GLOW), including 60,393 postmenopausal
women aged 55 years and older from the United States,
Canada, Australia, and seven European countries were ana-
lyzed to determine when, where, and how fractures occur
(Costa et al., 2013). Fragility fractures of long bones occurred
in 68% to 86% of falls (with the proportion increasing with
increasing age). Only 45% of vertebral fragility fractures were
associated with falls except in women aged 85 years and older,
when only 24% occurred after falling (Costa et al., 2013).
It is estimated that osteoporotic fractures, and particularly
refracture, are associated with elevated mortality rates among
community-dwelling women and men 60 years of age and
older (Bliuc, Nguyen, Nguyen, Eisman, & Center, 2013).
4605_Ch15_231-248 31/10/17 12:21 PM Page 234
234 PART II ■ Aging: Body Structures and Body Functions
The subjective assessment of individuals with osteoporosis
addresses the risk for fracture and falls in addition to the pre-
senting complaint. The WHO has proposed an assessment
core set for individuals with osteoporosis specific for body
structure, body function, and activity and participation (Cieza
et al., 2004). Table 15-1 describes tests that can be used in
a physical or occupational therapy objective assessment.
Figure 15-1 summarizes hypothetical assessment findings
in the context of the International Classification of Func-
tioning, Disability and Health (WHO, 2001) framework.
Management of Osteoporosis
Management of osteoporosis involves a multidisciplinary
team approach. Pharmacologic interventions target bone
loss by decreasing bone resorption, increasing bone forma-
tion, or a combination of both these processes. Nonpharma-
cologic interventions mainly address nutritional management
with consideration of dietary sources of calcium and ade-
quate protein/caloric intake given that BMI may be too low.
Fall prevention, posture reeducation, education about body
mechanics, and exercise also are important. Adaptive de-
vices and thoracolumbar bracing may be required to improve
biomechanics, reduce fracture risk, and increase functional in-
dependence. Exercise plays an important role in management;
TABLE 151 ■ Objective Tests That Can Be Included in the Assessment of Older Adults With Osteoporosis
CONSTRUCT
Anthropometrics (height, weight)
Posture
Ergonomics and body mechanics
Mobility
Gait speed
Balance (static and dynamic)
Physical performance
Muscle performance
Range of motion
Pain
Dizziness
Self-care, home management, community engagement
Specific assessment of system capacity as indicated
however, few research studies have included participants
with a history of osteoporotic fracture. An international
panel of experts in osteoporosis and exercise used the Grad-
ing of Recommendations, Assessment, Development and
Evaluation (GRADE) approach to translate the available
evidence into practice (Giangregorio et al., 2014). The lit-
erature describing the effect of exercise on various outcomes
deemed important by the panel, such as balance, and by in-
dividuals with osteoporosis, such as BMD were reviewed.
The quality of evidence related to the effect of exercise was
low or very low for the outcomes of interest, with the excep-
tion of the falls outcome (Gillespie, Robertson, Gillespie,
Lamb, & Gates, 2009; Sherrington, Tiedemann, Fairhall,
Close, & Lord, 2011). On the basis of the GRADE approach,
it was strongly recommended that individuals with osteo-
porosis engage in a multicomponent exercise program that
includes resistance training in combination with balance
training. Furthermore, it was recommended that individuals
with osteoporosis not engage in aerobic training to the ex-
clusion of resistance or balance training. For older adults
with osteoporotic vertebral fracture, consultation with a
physical therapist was recommended to ensure safe and ap-
propriate exercise (Giangregorio et al., 2014). Exercise
can address some of the factors that contribute to risk of
spinal injury, such as body weight and posture, spine
TEST
Stadiometer—used for measuring height
Wall–Occiput Distance (WOD, consider spine radiograph if >4 cm; Siminoski,
Warshawski, Jen, & Lee 2011)
Flexicurve ruler (a malleable ruler that can be bent in only one plane and that retains
the shape to which it is bent) or digital inclinometer (an electronic device that
measures the slope or tilt of an object) to measure kyphosis and lordosis
Observation during tasks
2-minute stepping test
8-m Timed Up and Go test
Timed 20-m walk test
Timed single leg stance test
Four square step test
Mini balance evaluation systems test (mini-BESTest)
The Physical Performance Test (PPT)
The Senior Fitness Test (SFT)
Six-repetition maximum testing
Endurance
Handheld dynamometer
Goniometer
Numeric rating scale (e.g., visual analog scale)
Numeric rating scale
Self-reported Mini-Osteoporosis Quality of Life questionnaire
Vestibular, cardiovascular, pulmonary, urinary, etc.; exercise response
4605_Ch15_231-248 31/10/17 12:21 PM Page 235

CHAPTER 15 ■ Neuromuscular and Movement Function: Health Conditions 235

Health Condition
Osteoporosis with VCF at T8

Body Structure/Function
Activity (Tasks) Participation
(Impairments)
• Pain—neck, pelvis • Bed mobility • Bed mobility • Watches TV • Shorter, less
• Hyperkyphosis Able to roll and Unable to bridge • Takes dog for walk frequent dog walks
come to sitting • Standing balance • Difficulty lifting and
• Difficulty sleeping • Babysits 10 yo
• Standing balance SLS test 5s grandson 1 night/ carrying (e.g., meal
• Difficulty breathing with
Static double • Uses arms to stand week prep, laundry)
brisk walking
stance okay from sitting • Enjoys “happy hour”
• postural control
• Ambulation • Ambulation get-togethers with
• trunk and hip ROM Independent— Turns toward railing friends
• mm strength—trunk shorter steps, and 2 feet per step
extensors (endurance) and guarded, uses to descend stairs
abs and quads (power) railing on stairs
• Urinary incontinence

Personal and Environmental Factors

Internal +/– External +/–

• Previously • 67 yo female, • Family healthy • Laundry in

active 11y post and supportive basement
• Takes Reclast menopause • Bungalow

FIGURE 151 Hypothetical assessment findings in the context of the International Classification of Functioning,
Disability and Health (World Health Organization, 2001) framework. ROM = range of motion; SLS = single leg
stance test; yo = years old.

curvatures, muscle forces, and neuromuscular control.
However, not all risk factors (e.g., height and disc degen-
eration) can be addressed through exercise. Exercise pre-
scription can also address impairments to improve body
mechanics during daily activities. It is “unsafe” for people
with or at risk for osteoporotic fracture to repeatedly flex
the spine forward without using a hip-knee-ankle strategy,
rotate the upper spine with respect to the pelvis (or vice
versa) past midline, hold loads unevenly or away from the
midline of the body, and perform activities or movements
in a way that puts the body off balance (MacIntyre et al.,
2014; Recknor et al., 2013). The main goals of therapeutic
exercise for individuals with osteoporosis include fall pre-
vention, safe movement, reduced rate of bone loss, and pain
control as required. Common across all these goals is the
aim maintaining or increasing muscle strength, power and
endurance, and preventing future fragility fracture. A tai-
lored multimodal treatment program, which includes edu-
cation, movement training, and appropriate referrals to
other health-care professionals may be beneficial in restor-
2009). Meta-analysis determined that at least 2 hours per week
of exercise that includes challenging balance exercises was
most effective for fall prevention (Sherrington et al., 2009).
Thus, the Too-Fit-to-Fracture Initiative (www.osteoporosis.
ca/osteoporosis-and-you/too-fit-to-fracture) guidelines
recommend a minimum of 150 min per week of exercise
(Giangregorio et al., 2014). In the event that time is limited,
resistance and balance training should take priority over aer-
obic exercise. See Box 15-1 for guideline recommendations
for people with osteoporosis and no fragility fracture.
BOX 151 Too-Fit-to-Fracture Initiative Exercise
Recommendations for People with
Osteoporosis and No Fragility Fracture
■ Weight-bearing aerobic activity preferable
■ Progressive resistance training designed to increase muscle
strength
■ 8–12 repetitions

ing function and maximizing optimal health. ■ Intensity rating of 5 to 8 on a 0 to 10 scale for perceived

Physical activity guidelines for older adults (i.e., Canadian exertion

Society for Exercise Physiology, Centers for Disease Control ■ Balance training strongly recommended
and Prevention, American College of Sports Medicine—see ■ 2 hours per week or 20 minutes per day

Ancillaries for web links) recommend 150 minutes of moderate ■ Daily exercise to increase muscular endurance in spinal
to vigorous intensity aerobic physical activity per week for gen- extensors.
eral health benefits (Chodzko-Zajko, Schwingel, & Park,
4605_Ch15_231-248 31/10/17 12:21 PM Page 236
236 PART II ■ Aging: Body Structures and Body Functions
For people with osteoporosis and one or more vertebral
fractures, with or without pain, and hyperkyphosis, consensus
was that the guidelines in Box 15-1 are not appropriate. The
following is recommended instead:
■ 150 minutes per week of moderate-intensity aerobic activity
in bouts of 10 minutes or more;
■ vigorous aerobic activity may not be appropriate;
■ progressive resistance training designed to increase muscle
strength, with emphasis on form and alignment instead of
intensity;
■ balance training strongly recommended—2 hours per week
or 20 minutes per day;
■ daily exercises to increase muscular endurance of spinal
extensors, in positions in which the spine is least loaded,
when possible (supine < standing < seated);
■ education by physical and/or occupational therapists about
appropriate positioning and alignment, transitions, use of
assistive aids, and pain control.
It is recognized that when applying this information in
the rehabilitation setting, practitioners should consider im-
portant factors such as the prevalence of osteoporosis within
each clinic, therapeutic goals, and client-specific factors, such
as history of and time since fracture, length of time on bone-
sparing medication, comorbid conditions that affect bone
biology, medication use, and physical performance, and the
client’s individual motivation to participate in a program.
Amputation in Older Adults
Determining an accurate estimation of the precise number of
persons with limb amputation worldwide is challenging be-
cause the causes of amputation vary greatly from region to
region around the world (WHO, 2004), and the number
worldwide is not currently tracked by any organization. How-
ever, the incidence of dysvascularity (poor circulation) in-
creases with age, as does the presence of comorbidities such
as diabetes (Chapters 13 and 17). Nearly 75% of all lower
limb amputations occur in persons over age 65 years (Fleury,
Salih, & Peel, 2013). Huang and colleagues found that the
incidence (events per 1000 person-years) of amputation in
older adults with short-duration diabetes (0–9 years) was 1.01
for those aged 60 to 69, 1.28 for those aged 70 to 79, and 1.72
for those aged 80 years or older. For those with long-duration
diabetes (10 or more years), incidence increased to 3.94
for those aged 60 to 69 years old, 4.26 for those aged 70 to
79 years, and 3.92 for those 80 years and older (Huang et al.,
2014). In older adults, the most common causes of lower limb
amputation include vascular disease associated with diabetes
and peripheral vascular disease (PVD), followed by trauma
(20%), and tumors or cancer (5%) (Renzi, Unwin, Jubelirer,
& Haag, 2006). Unlike older adults undergoing trauma- or
cancer-related amputations, those with diabetes and PVD are
more likely to require additional amputation surgery (e.g.,
amputation at a higher level of the same limb or amputation
of contralateral limb) because of vascular compromise from
the progression of the underlying disease (P. Clarke, Gray,
Legood, Briggs, & Holman, 2003; Dillingham, Pezzin, &
MacKenzie, 2002). Additionally, older adults with limb
amputations secondary to vascular-related causes have higher
mortality after a lower limb amputation: 20% within the
first year and 40% within 5 years (Carmona et al., 2005).
Physical and Psychosocial Challenges
of Limb Amputation
Limb amputation causes a variety of physical and psychosocial
challenges, such as difficulties with physical functioning, de-
creased independence, pain, changes in employment status,
and alterations in emotional and psychological well-being and
social functioning (Boulton, Vileikyte, Ragnarsson-Tennvall,
& Apelqvist, 2005; Geertzen, Martina, & Rietman, 2001;
Horgan & MacLachlan, 2004). It is common for older adults
to have negative emotions and thoughts after an amputation.
Denial, depression, anxiety, and suicidal thoughts may be
present. Not only does the older adult have to cope with the
loss of a limb and resultant loss of function, but she or her also
has to cope with body image changes. Other people’s reactions
to the amputation or amputated limb may also lead to grief
and bereavement, similar to what is experienced with the loss
of a loved one.
Management of Limb Amputation
in Older Adults
It is critical that postamputation management begins imme-
diately after surgery. Successful rehabilitation for older adults
after amputation is multifaceted because of “normal” age-
related changes and the multimorbidity that accompanies
aging. Thus, a variety of health professionals, with medical,
surgical, nursing, rehabilitation, prosthetic, nutrition, psy-
chological and vocational expertise, and a team approach are
essential (Giangarra, & Manske, 2017). Positive effects on
functional outcome have been found when appropriate med-
ical, surgical, and rehabilitative care are provided (Giangarra
& Manske, 2017). It is particularly important to comprehen-
sively evaluate rehabilitation potential of the older adult pre-
operatively and estimate functional prognosis estimation to
establish realistic rehabilitation goals (Schoppen et al., 2003).
Depending on rehabilitation potential, goals may vary
from patient to patient, including the comfort of returning
to independence in daily living, physical, vocational, and
recreational and leisure activities. Cognitive impairment may
influence not only the ability to regain functioning but may
also interfere with residual and remaining limb care (e.g.,
checking for signs of ulceration or infection). Thus those
with cognitive impairments are at higher risk of future am-
putation (Fleury et al., 2013). Chronic health conditions in-
cluding congestive heart failure, coronary artery disease,
diabetes, hypertension, osteoarthritis, PVD, and stroke can
reduce the potential for prosthetic wear and use, resulting in
4605_Ch15_231-248 31/10/17 12:21 PM Page 237
CHAPTER 15
compounded adjustment problems. Although rehabilitation
outcomes can be poorer in adults aged 80 years, comorbidi-
ties, general health status, and level of amputation are more
significant factors associated with outcomes than age (Fleury
et al., 2013).
INTERPROFESSIONAL PRACTICE
Occupational and Physical Therapy Interventions
Occupational and physical therapist interventions for the older
adult postamputation will include a variety of intervention
strategies. However, each professions’ scope of practice and
practice environment will delineate how and to what extent
the intervention strategies are implemented:
■ Exercise
■ Range of motion (e.g., for residual limb, other joints)
■ Strengthening (e.g., for residual limb and other muscles
as required; upper extremity strengthening exercises
for those with lower extremity amputation; core
strengthening for balance and postural control)
■ Aerobic exercise for endurance
■ Interventions to prevent soft tissue contractures in the
residual limb
■ Flexibility and stretching exercises
■ Positioning
■ Interventions to reduce edema
■ Residual limb wrapping, use of elastic shrinker
■ Positioning
■ Pain management
■ Electrotherapeutic modalities, relaxation
■ Mirror therapy (Weeks, Anderson-Barnes, & Tsao, 2010)
■ A mirror is placed at groin or chest level (dependent
on amputation level). The residual limb is placed
behind the mirror, so that the view of this limb is
obstructed. The intact limb is placed in front of the
mirror, such that the client can see the reflection. The
client is asked to position the intact limb in the position
of the residual limb. This progresses to the client
moving the residual limb to “mirror” the intact limb.
■ Energy conservation and work simplification
■ Bed mobility, transfer, wheelchair mobility training
■ Activities of daily living training (e.g., self-care skills,
educating the older adult regarding positioning for sex)
■ Balance and postural control training
■ Mobility and gait training
■ Prescription and education regarding use of assistive devices
and training
■ Prescription and education regarding use of adaptive
devices and training
■ Prosthesis prescription and training
■ Maintenance of skin integrity, wound care, prevention of scar
adhesions
■ Desensitization interventions
■ Residual limb wrapping, use of elastic shrinker
■ Percussion, rubbing, or vibration over residual limb
■ Massage to prevent or release adhesions, soften scar tissue
■ Neuromuscular and Movement Function: Health Conditions 237
■ Weight bearing on end of residual limb, if not
contraindicated; use various surfaces (e.g., soft,
resilient to textured, resistant)
■ Residual limb wrapping, use of elastic shrinker to shrink and
shape the limb for optimal prosthetic fit
■ Interventions for addressing emotional and psychosocial
health issues
■ Develop a supportive and trusting client–therapist
relationships; encourage open discussion; provide
information and resources; peer mentors and support
groups; individual or group cognitive behavioral therapy
■ Planning for an appropriate level(s) of care postrehabilitation
■ Environmental and home modifications; safety training
■ Interventions to address community mobility and driving
■ Interventions to address work and productive activities,
leisure activities (e.g., home management, vocational
activities, age-appropriate leisure activities)
■ Educating the older adult and family (e.g., proper skin
hygiene, care of insensate skin, prosthesis components and
prescription, care of prosthesis, falls prevention, safety)
■ Referral to community resources, other health-care
professionals
Complications of Limb Amputation
Common complications of postamputation include residual
limb pain; phantom limb sensation—sensation in the ampu-
tated limb, as if it were still intact; phantom limb pain—pain
in the amputated limb, typically described as a cramping or
squeezing sensation or a shooting or burning pain; surgical
wounds and skin breakdown; infection; edema; and joint
contractures (Giangarra & Manske, 2017). If the amputation
is a result of vascular disease, wound healing can be severely
compromised by the underlying disease or because of skin
closure under tension (American Diabetes Association, 2003).
Prescription of assistive devices is common, and therapists
should prioritize safety over progression because older adults
with amputations are particularly vulnerable to falls. Al-
though all older adults are affected by similar modifiable and
nonmodifiable risks factors for falls (e.g., age, chronic disease,
gait and balance instability, neuromuscular weakness, med-
ication side effects, postural blood pressure changes, cognitive
disorders, loss of vision, and changes in sensation and propri-
oception), older adults with an amputation are particularly more
vulnerable to falling (Ülger, Topuz, Bayramlar, Erbahçeci, &
Șener, 2010).
Prevention of amputation is one of the primary public
health goals globally, in particular through diabetes preven-
tion, management, and care. A large majority of lower limb
amputations are preceded by a foot ulcer and persons with
diabetes have a 30 times greater lifetime risk of having an
amputation than those without diabetes (Tentolouris, Al-
Sabbagh, Walker, Boulton, & Jude, 2004). A comprehensive
foot care program comprising diabetes self-management
education, foot screening, and referral to specialists has been
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238 PART II ■ Aging: Body Structures and Body Functions

shown to be effective in reducing the risk of foot ulcers and
subsequent amputation (Mayfield et al., 2000; Rith-Najarian
& Reiber, 2000; World Health Organization, 2004) and can
reduce amputation rates by 45% to 85% (National Center for
Chronic Disease Prevention and Health Promotion, 2009).
Parkinson’s Disease
Parkinson’s disease (PD), a slowly progressive movement
disorder, is one of the most common age-related neurode-
generative disorders, second in prevalence only to Alzheimer’s
disease. With the aging global population, PD is consid-
ered a world health problem and health-care priority
(Global Parkinson’s Disease Survey Steering Committee,
2002). Although many theories exist as to why an individ-
ual develops PD, there is no single identified mechanism, and
it is generally thought that multiple factors are responsible.
PD affects 7 to 10 million people globally (Parkinson’s
Disease Foundation, 2017). The average age of PD onset
is 60 years, and prevalence increases steadily with age, with
1 in 20 persons over age 80 years affected (Van Den Eeden
et al., 2003). The disease affects the dopamine system of
the basal ganglia, a collection of subcortical nuclei. The
pathological hallmark of PD is cell loss within the substan-
tia nigra particularly the ventral component of the pars
compacta. Medical diagnosis of PD remains essentially a
clinical one (Kalia & Lang, 2015).
PD is characterized by voluntary and involuntary move-
ment dysfunction, including resting tremor and rigidity, es-
pecially exhibited as difficulty in initiating motion. Nonmotor
symptoms, including pain, depression, anxiety, apathy, fa-
tigue, memory impairments, sleep disturbances, and auto-
nomic dysfunction, can also occur and have a significant
impact on the day-to-day life and function of the individual
with PD. Neuropsychiatric symptoms sometimes present be-
fore the motor symptoms of PD. These symptoms contribute
to increased disability and decreased quality of life and be-
come more prominent and increasingly challenging to man-
age as the disease progresses (Olanow, Schapira, & Obeso,
2015). Autonomic dysfunction is extremely common in
people with PD and affects the cardiovascular, gastrointesti-
nal, urogenital, and thermoregulatory systems. For example,
orthostatic hypotension, defined as a decrease in systolic
blood pressure of at least 20 mm Hg or a decrease in diastolic
blood pressure of at least 10 mm Hg within 3 minutes of erect
standing (Consensus Committee of the American Auto-
nomic Society and the American Academy of Neurology,
1996), is both a safety concern and fall risk. Additionally,
both nocturia (i.e., the need to awaken at night to urinate)
and constipation can significantly and negatively affect quality
of life. Signs and symptoms associated with PD gradually
progress over time; however, the rate of progression varies
greatly among individuals. Progression of common manifes-
tations of PD are found in Table 15-2.
Management of Parkinson’s Disease
Currently there is no known cure for PD; rather, a combi-
nation of pharmacological interventions and rehabilitation
is essential in the management of the disease (Kalia &
Lang, 2015). Pharmacological interventions aim to increase
the level of dopamine, reaching the brain and to stimulate
the parts of the brain where dopamine works. Levodopa is
one of the main medications used to treat PD signs and
symptoms and remains the most effective medication for
the management of motor symptoms. Levodopa can be
used in all stages of PD and is typically prescribed in com-
bination with carbidopa or benserazide. When a PD med-
ication is working well, signs and symptoms are well
controlled (defined as “on time”). As the effectiveness of
the medication decreases, there is end of dose deterioration
or “wearing off” (“off time”). Sometimes the effects of
“wearing off” can occur quickly, and there is a sudden
change in the individual with PD between the “on time”
and “off time.” As the disease progresses, some individuals
report that a levodopa dose does not last as long before
the “off time.” A side effect of levodopa, particularly long-
term use, is motor complications, such as dyskinesias,

TABLE 152 ■ Common Motor Symptoms, Nonmotor Symptoms, Impairments, and Activity Limitations in People
With Parkinson’s Disease (PD)

Rigidity ■ Characteristic feature of PD

■ Increased resistance to passive movement
■ Cogwheel rigidity, jerky, fluctuating resistance to passive movement

■ Lead pipe rigidity, sustained resistance to passive movement

■ Typically asymmetrical in the early stages

■ Typically affects proximal muscles first
Bradykinesia ■ Characteristic feature of PD
■ Slowness of movement
■ Results from insufficient recruitment of muscle force during initiation of movement

■ Hypomimia, decreased facial expressions

■ Micrographia, writing becomes smaller and smaller

■ Hypokinesia, slowed and reduced movement

■ Akinesia, decreased spontaneous movement

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CHAPTER 15 ■ Neuromuscular and Movement Function: Health Conditions 239

TABLE 152 ■ Common Motor Symptoms, Nonmotor Symptoms, Impairments, and Activity Limitations in People
With Parkinson’s Disease (PD)—cont’d

Tremor ■ Characteristic feature of PD

■ A rhythmical, involuntary movement that affects a part of the body when at rest
■ Pill-rolling tremor, a low-frequency, resting tremor
■ On observation, it appears the individual is trying to roll a pill between thumb and index finger

■ Action tremor, a tremor that continues with movement

Postural Instability
Gait Problems
■ Postural tremor, seen in antigravity muscles
■ Rare in the early stage
■ Abnormal and inflexible postural responses to destabilizing events
■ Increased difficulty with dynamic destabilizing events
■ Difficulty with regulating feed-forward, anticipatory adjustments of postural muscles during voluntary
movements
■ Increased falls
■ More common in the later stages
■ Decreased arm swing with asymmetry common
■ Festinating gait, a progressive increase in speed with stride shortening
■ Can be anteropulsive, forward festinating gait or retropulsive, backward festinating gait

Fatigue ■ Difficulty sustaining activity

■ Increased lethargy and weakness as the day progresses
Muscle Performance ■ Decreased strength
■ May be dopamine related, e.g., people on dopamine replacement medication demonstrate increased

strength
■ Antigravity muscle weakness leads to flexed, stooped posture (kyphosis)

Motor Function ■ Difficulty with motor planning

■ Paucity of movement
■ Decreased movement accuracy
■ Difficulty with dual tasks
■ Difficulty with motor skill learning
Sensory System Symptoms ■ Primary sensory loss is rare
and Impairments ■ Paresthesias, numbness, tingling, cold
■ Pain—aching, burning
■ Symptoms are usually intermittent
■ Symptoms usually vary in intensity and location
■ Decreased proprioceptive regulation of voluntary movement
■ Decreased sense of smell or loss of sense of smell (anosmia)
■ Sensorimotor integration impairments
■ Visuospatial impairments
Dysphagia ■ Related to rigidity
■ Often an early symptom
■ Difficulty in all four phases of swallowing
■ Can lead to choking, aspiration pneumonia, nutritional deficiencies

■ Decreased spontaneous swallowing

■ May lead to sialorrhea, excessive drooling

Speech Impairments ■ Hypokinetic dysarthria

■ Characterized by decreased volume (hypophonia), monotonic or monopitch speech, imprecise/distorted

articulation, uncontrolled speech rate

Cognitive and Psychological
Impairments
Autonomic System Signs
and Symptoms
■ Late disease stage, mutism (no speech), may occur
■ May include memory impairments, bradyphemia (slowed thinking), confusion, mood fluctuations, PD
dementia, hallucinations (usually visual accompanied by delusions, agitation or aggression), delusions,
paranoia, psychosis
■ Depression
■ Anxiety
■ Problems with thermoregulation
■ Orthostatic hypotension
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240 PART II ■ Aging: Body Structures and Body Functions
which are involuntary, jerky movements affecting the
trunk, limbs or head, and motor fluctuations. Nonmotor
side effects of PD medications include impulsive or com-
pulsive behavior, hallucinations, and delusions. Surgery
may be considered for individuals with advanced PD or
when pharmacological management has not been effective,
but there are strict criteria and guidelines for appropriate
surgical candidates (Kalia & Lang, 2015). Three common
surgeries for PD include the following:
■ thalamotomy, a thalamic lesion to alleviate some forms of
tremor;
■ pallidotomy, a pallidum (one of the basal ganglia) lesion to
alleviate dyskinesias; and
■ deep brain stimulation, surgical placement of a deep brain
stimulator to control tremor.
Although PD is progressive and degenerative in nature,
occupational and physical therapists have much to offer the
older adult with this health condition. Interventions vary de-
pending on the stage of PD, similar to other neurodegener-
ative diseases (Dal Bello-Haas, 2002) and are directed at
maximizing function, independence, and participation; min-
imizing secondary complications; and assisting the older
adult to engage in meaningful activities including work and
family roles, social activities, and leisure. Incorporating motor
learning (Chapter 25) early in the PD disease process is im-
portant (Hirsch & Farley, 2009). People with PD require
extended time and high repetition practice for learning, in
particular for focused task or skill automatization (e.g.,
Behrman, Cauraugh, & Light, 2000; Onla-or & Winstein,
2008). Occupational therapy and physical therapy interven-
tions have been found to beneficial for people with PD
(Foster, Bedekar, & Tickle-Degnen, 2014; Keus, Bloem,
Hendriks, Bredero-Cohen, & Munneke, 2007; Tomlinson
et al., 2012); however, therapy intensity is an important fac-
tor related to effectiveness. C. E. Clarke and colleagues
(2016) found that low-dosage therapy (e.g., average “dose”
of combined occupational and physical therapy was four ses-
sions of 58 minutes over 8 weeks—about 4 hours) was no
more effective than no therapy for people with mild to mod-
erate PD. The research findings related to time, practice, and
intensity have important implications for therapeutic inter-
vention dosing for occupational and physical therapists and
for health system policies.
Individualized interventions focused on health and well-
ness self-management and cognitive-behavioral strategies
focused on lifestyle modifications and personal control
positively effect quality of life (Foster, Bedekar, & Tickle-
Degnen, 2014). Exercise and physical activity improve im-
pairments, such as muscle strength, motor performance
and skills, mobility, balance, gait, aerobic fitness, and oc-
cupational performance (see Interprofessional Practice
Box). Speech language pathologists (SLPs) also play an im-
portant rehabilitation role with individuals with PD
through interventions that address improvement of vocal
loudness and pitch range; speech therapy programs, such
as Lee Silverman Voice Treatment (www.lsvtglobal.com)
to optimize speech intelligibility; and interventions that
improve the safety and efficiency of swallowing to mini-
mize the risk of aspiration. SLP practitioners also work to
ensure an effective means of communication is maintained
throughout the disease course, which may include prescrib-
ing assistive technologies.
INTERPROFESSIONAL PRACTICE
Occupational and Physical Therapy Interventions
Occupational and physical therapist interventions for older
adults with PD focus on a variety of intervention strategies.
However, each professions’ scope of practice and practice
environment will delineate how and to what extent the
intervention strategies are implemented:
■ Motor learning strategies
■ for example, task-based practice interventions that
comprise goal-directed, individualized tasks; frequent
repetitions of task-related or task-specific movements
(Foster et al., 2014)
■ Motor initiation strategies
■ use of external cues (e.g., auditory, visual such as tape line
on the floor, cue cards) during functional mobility or other
movement activities (Lim et al., 2005)
■ Cognitive performance strategies
■ complex automated movements are broken down
into a series of relatively simple submovements
that are executed in a fixed order (e.g., Keus et al.,
2007)
■ Exercise and physical activity
■ Range of motion, flexibility, resistance, aerobic,
relaxation, and breathing exercise; see, for example,
Dibble, Addison, & Papa (2009); Dibble, Hale, Marcus,
Gerber, & LaStayo (2009); Goodwin, Richards, Taylor,
Taylor, & Campbell, (2008); Lamotte et al. (2015); Shu
et al. (2014); Stewart & Crosbie (2009); Uhrbrand,
Stenager, Pedersen, & Dalgas (2015)
■ Exercises for oral motor function and facial muscles;
manual dexterity
■ Tai chi (Toh, 2013), dancing (e.g., tango, ballroom;
Fernández-Argüelles et al., 2014; Hackney & Earhart,
2009)
■ Energy conservation and work simplification
■ Environmental and home modifications; safety training
■ Functional and activities of daily living training, e.g., bed
mobility, transfers, self-care, grooming
■ Balance and postural control training (e.g., Conradsson,
et al., 2015; Tomlinson et al., 2012)
■ Mobility and gait training (e.g., Mehrholz et al., 2015)
■ Prescription and education regarding use of adaptive
devices and training (e.g., for handwriting, feeding,
self-care)
■ Prescription and education regarding use of assistive devices
and training
■ Wheelchair prescription
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CHAPTER 15 ■ Neuromuscular and Movement Function: Health Conditions 241

■ Interventions for addressing emotional and psychosocial

health issues
■ Develop a supportive and trusting client–therapist
relationship; encourage open discussion; provide
information and resources; peer mentors and support groups
■ Cognitive-behavioral intervention that includes education,
goal setting, performance skill training, practice, and
feedback related to incorporating habits into daily life
(Foster et al., 2014)
■ Interventions to address community mobility and driving
■ Interventions to address work and productive activities,
leisure activities (e.g., home management, vocational
activities, age-appropriate leisure activities)
■ Educating the older adult with PD regarding positioning
for sex
■ Educating the older adult and family (e.g., fall preventions,
safety, effects of autonomic manifestations, use of
communication aids, positioning to enhance
communication and swallowing)
■ Referral to community resources, other health-care
professionals
Stroke
Every year, about 15 million people worldwide have a stroke.
Globally stroke is the second leading cause of death in people
older than 60 years. Although nearly six million die from
stroke, many survive, making stroke the second leading cause
of disability (World Heart Federation, 2017). Stroke is also
discussed in Chapters 12 and 13 because it is a complex con-
dition with multiple precursors and consequences.
AROUND THE GLOBE: Increasing Incidence of Stroke
in Developing Countries
In many developed countries, stroke incidence is decreasing, even
though the actual number of strokes is increasing because of the
aging population. However, in developing countries, the incidence
of stroke continues to increase.
■ In China, 1.3 million people have a stroke each year, and
75% live with varying degrees of disability due to of stroke.
■ In the next 2 decades, it is predicted that stroke mortality and
morbidity will triple in Latin America, the Middle East, and
sub-Saharan Africa.
From www.world-heart-federation.org/cardiovascular-health/
stroke
Each cerebral hemisphere is responsible for contralateral
motor activity initiation and sensory information reception,
and there is integrated function of both hemispheres. How-
ever, each hemisphere also has a large degree of specializa-
tion. Stroke signs and symptoms will vary depending on the
site of the stroke lesion; hemispheric dominance; whether the
stroke occurs in the hemispheres, brain stem, or cerebellum;
and the extent of the stroke (see Table 15-3). Considering
the anatomical regions(s) of the brain affected by the stroke
is a simplistic view to be taken by rehabilitation therapists—
function occurs in an integrated fashion. Although the stroke
may affect mainly one brain area, multiple areas of the nerv-
ous system must now function with a loss of input and output
from the affected area.
Because many older adults survive the initial stroke,
long-term impairments, activity limitations, and decreased

TABLE 153 ■ Stroke Signs and Symptoms by Vascular Territory/Distribution

VASCULAR TERRITORY/DISTRIBUTION SIGNS AND SYMPTOMS

Anterior Cerebral Artery
■ Less common type of stroke
Middle Cerebral Artery (MCA)
■ Most common type of stroke
■ Laterality (e.g., dominance) and
■ Contralateral weakness, affecting the distal lower extremity more than upper extremity and
face
■ Contralateral sensory loss
■ Abulia (lack of initiative)—bilateral occlusion
■ Incontinence—bilateral occlusion
■ Apraxia
■ Contralateral hemiparesis/hemiplegia, affecting the lower part of the face, upper extremity and
hand, largely sparing the lower extremity
■ Contralateral sensory loss, same distribution as above

division of a MCA stroke determines Superior Division

signs and symptoms ■ Broca’s aphasia (left hemisphere dominance)—motor/expressive aphasia, problem with output,

e.g., speech is nonfluent, but comprehension is good

■ Visual perceptual impairments (right hemisphere dominance)

Inferior Division
■ Homonymous hemianopsia—visual-field deficits affecting the same half of the visual field in

both eyes; affects same visual field as the side of motor and sensory impairment, e.g., left
hemiparesis occurs with left visual field deficit
■ Wernicke’s aphasia (left hemisphere dominance)—sensory/receptive aphasia, problem with

input, e.g., comprehension

■ Visual neglect (typically more profound in right CVA due to right hemisphere dominance)

Continued
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242 PART II ■ Aging: Body Structures and Body Functions
TABLE 153 ■ Stroke Signs and Symptoms by Vascular Territory/Distribution—cont’d
VASCULAR TERRITORY/DISTRIBUTION
Posterior Cerebral Artery
■ Laterality (e.g., dominance) determines
signs and symptoms
■ PCA stroke can affect the inferolateral
and medial temporal lobe; lateral and
medial occipital lobe, upper brainstem
(e.g., midbrain, visual cortex, cerebral
peduncles, thalamus, and splenium
of the corpus callosum
Posterior Inferior Cerebellar Artery (PICA)
■ Can affect the inferior cerebellum and
lateral medulla
Vertebral Basilar Artery
■ Can affect the cerebellum, brain stem,
or both
■ Signs and symptoms dependent on
what part of the medulla, midbrain
pons is affected or if cerebellum is
affected, e.g., if lateral medulla is
affected, this results in Wallenberg’s
syndrome (see PICA above)
Small arteries penetrating the medial
and basal portions of the brain and
brainstem (lacunar syndromes)
CVA = cerebral vascular accident.
SIGNS AND SYMPTOMS
■ Involuntary movements
■ Hemiataxia, ataxia
■ Intention tremor
■ Ipsilateral oculomotor palsy
■ Contralateral hemiparesis
■ Contralateral sensory loss
■ Intense, persistent, burning pain
■ Visual agnosia
■ Memory loss
■ Contralateral homonymous hemianopsia (e.g., right CVA has left visual field deficit)
■ Anomia, especially for naming colors (dominant hemisphere)
■ Topographic disorientation (nondominant hemisphere)
■ Prosopagnosia—difficulty recognizing faces
Lateral Medullary Syndrome (Wallenberg’s Syndrome)
■ Vertigo
■ Nausea, vomiting
■ Sensory loss—ipsilateral face, contralateral limb
■ Ipsilateral limbs ataxia
■ Nystagmus—rotatory or horizontal gaze
■ Hoarseness, dysphonia
Ipsilateral Medulla
■ Ptosis, anhydrosis, miosis (Horner’s syndrome)
■ Decrease in pain and temperature, ipsilateral face
■ Ataxia
Contralateral Medulla
■ Contralateral decreased pain and temperature
■ Dysphagia, dysarthria, hoarseness, vocal cord paralysis
■ Vertigo, nausea, vomiting
■ Hiccups
■ Nystagmus, diplopia
Cerebellum
■ Ataxia
■ Dyssynergia—impaired coordination
■ Dysmetria—impaired measure, extent and speed of intended movement
■ Intention tremor
■ Dysdiadochokinesis—difficulty with alternating movements
■ Nystagmus
■ Dysarthria
Cranial Nerves
■ Bilateral visual and cranial nerve impairments
■ Vertigo
■ Dysarthria/dysphagia
■ Diplopia
■ Facial paralysis, numbness, paresthesia
Motor
■ Hemiparesis, quadriparesis
■ Ataxia—unilateral limb, truncal
Sensory
■ Hemilateral or bilateral sensory loss
Other
■ Alterations of consciousness
■ Respiratory irregularities
■ Cardiac arrhythmias, erratic blood pressure (“drop attacks”)
Posterior limb of internal capsule/lower pons
■ Contralateral weakness of face, arm and leg
Sensory nucleus of the thalamus
■ Sensory signs and/or symptoms involving contralateral half of the body
4605_Ch15_231-248 31/10/17 12:22 PM Page 243
CHAPTER 15
participation greatly affect not only the stroke survivor but
the family as well. Therapists play critical roles in the reha-
bilitation of the older adult poststroke. A variety of reha-
bilitation approaches may be used to facilitate recovery from
stroke, but to date, research has not found that any one re-
habilitation approach is “best” (Pollock et al., 2014). What
the research does indicate is that repetition and intensity
are important to drive neuroplastic change and improve
function (e.g., Birkenmeier, Prager, & Lang, 2010; Luft
et al., 2004).
✺ PROMOTING BEST PRACTICE
Individuals Poststroke Have Negative Inpatient
Rehabilitation Experiences
A thematic synthesis provides new insights into inpatient
rehabilitation experiences of individuals poststroke. Negative
experiences, including disempowerment, boredom, and
frustration, were reported in all studies. The authors suggest
rehabilitation could be improved by increasing the amount
and type of activities within formal therapy, and in free
time, fostering clients’ autonomy through genuinely
client-centered care and more effective communication
and information provision (Luker, Lynch, Bernhardsson,
Bennett, & Bernhardt, 2015).
Research related to interventions poststroke often does
not focus solely on interventions for a specific age-group,
such as the older adult. In fact, older age is often an ex-
clusion criterion for research studies assessing interven-
tions poststroke. The reader is referred to the Promoting
Best Practice Box, found in the Ancillaries, which sum-
marizes some of the research published since the mid-
2000s related to poststroke rehabilitation interventions.
Chapter 32 also describes specific considerations for
occupational and physical therapists engaged in older adult
rehabilitation.
AROUND THE GLOBE: Occupational Therapy Practice
Guidelines
The College of Occupational Therapists in the United Kingdom
have several evidence-based clinical practice guidelines available
for download at https://www.rcot.co.uk/practice-resources/
rcot-practice-guidelines
■ Occupational therapy for adults undergoing total hip
replacement: practice guideline
■ Occupational therapy for people with Parkinson’s disease
■ Occupational therapy with people who have had lower limb
amputations: evidence-based guidelines
■ Splinting for the prevention and correction of contractures in
adults with neurological dysfunction: practice guideline for
occupational therapists and physiotherapists
■ Neuromuscular and Movement Function: Health Conditions 243
SUMMARY
Many health conditions affect the neuromusculoskeletal sys-
tem and movement function as adults age. It is important for
therapists to have an understanding of the pathology, risk fac-
tors, and signs and symptoms of these health conditions to
effectively function in all environments within the health-care
systems continuum. Osteoarthritis and osteoporosis are common
in older adulthood and can lead to severe impairments and nu-
merous disabilities. With the increasing incidence of chronic
diseases, such as diabetes and vascular conditions, resultant com-
plications can lead to limb amputation in older adults. The
prevalence of neurological conditions also increases with age,
typically causing a variety of signs and symptoms that affect
movement function and quality of life. Management of older
adults with neuromusculoskeletal system health conditions re-
quires a team approach to effectively address the myriad resultant
impairments, activity limitations, and participation restrictions.
CASE STUDY
Ms. Hamilton is a 71-year-old woman living in Toronto,
Canada, who is 2-days postop open reduction, internal
fixation for a right proximal femur fracture. Ms. Hamilton
states she was putting dishes away from her dishwasher
when her right leg gave way. She felt immediate, intense
pain. Ms. Hamilton dragged herself to her purse and
called the emergency medical system using her cell phone.
Ms. Hamilton is a professor emerita at a local university and
continues to be involved in conducting research. In addition,
she enjoys swimming in the local community pool 5 days
per week, participates in a monthly book club, and takes
what she describes as a “major trip to an exotic land” once
a year. Ms. Hamilton never married and lives alone in a two-
story house. There are five steps with no railings to get into
the home, and Ms. Hamilton’s bedroom and bathroom are
on the second level. Ms. Hamilton’s only family members
are a niece and nephew who live in Australia.
Ms. Hamilton’s medical history includes Parkinson’s
disease (PD), diagnosed 1 year ago. Her main complaint
related to the PD is the bilateral hand tremor that was ini-
tially only present at rest. Ms. Hamilton indicates that the
tremor has worsened over the past 3 years and now occurs
at rest and when she uses her hands for activities such as
slicing vegetables, sewing, putting on her lipstick, or typing
at her computer. Her handwriting has become messy and
sprawling and difficult to read. Physician’s orders for
Mrs. Hamilton are “Occupational therapy for discharge
home” and “ambulation feather-weight bearing, as tolerated.”
Questions
1. What might be the reasons for Ms. Hamilton
sustaining a fracture of the right femur?
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244 PART II ■ Aging: Body Structures and Body Functions

2. What precautions are necessary when engaging 3.
Ms. Hamilton in therapy and gait training?
3. What is the significance of Ms. Hamilton’s PD
diagnosis on her therapy while in the hospital? 4.
Once discharged?
4. What are the impairments, activity limitations
and participation restrictions that need to be 5.
addressed with in-hospital therapy and postdis-
charge therapy?
6.
What are the tests and measures that can be included
in an objective assessment of an older adult with
osteoporosis?
What are effective management strategies and
interventions for older adults with osteoarthritis
and osteoporosis?
What are the risk factors for and complications
of limb amputation in older adults?
Name five priority interventions for older adults after
limb amputation.

CASE STUDY
Mrs. Ada Castillo, is a left-handed, 67-year-old woman
admitted to the hospital. A computed tomography (CT)
scan shows a hyperdense middle cerebral artery sign.
Mrs. Castillo is retired, having served in the military for
25 years. When her husband died 2 years ago, she moved
into an assisted living facility. Mrs. Castillo was previ-
ously independent with basic and instrumental ADL and
walked and functioned without assistive or adaptive
equipment. Her room is on the third floor, and the din-
ing room is on the first floor. The walking distance to
the elevator from Mrs. Castillo’s room is 10 meters
(about 30 feet), and the distance from the first floor el-
evator to the dining room is 30 meters (about 90 feet).
Mrs. Castillo does not participate in the group activities
offered in the assisted living facility but she prefers to
stay in her room to watch television and play solitaire
and Sudoku on the computer. She is an avid watercolor
painter and sells her work to other residents, their fam-
ilies, and the assisted living staff. Mrs. Castillo has a his-
tory of cardiovascular disease, depression, and delusional
disorder.
Questions
1. What signs and symptoms might Mrs. Castillo
present with based on the CT scan?
2. What is the significance of Mrs. Castillo’s psycholog-
ical health conditions on her rehabilitation while in
the hospital? Once discharged?
3. What are some of the impairments, activity limita-
tions, and participation restrictions that likely
need to be addressed with in-hospital therapy and
postdischarge therapy?
Critical Thinking Questions
1. What is the difference between osteoarthritis and
osteoporosis in terms of risk factors, epidemiology,
signs and symptoms, pathology?
2. What is the significance of a fragility fracture?
7. Compare and contrast the motor and nonmotor
impairments and activity limitations found in people
with Parkinson’s disease.
8. Compare and contrast the signs and symptoms
of a middle cerebral artery, anterior cerebral artery,
posterior cerebral artery, posterior inferior cerebral
artery, and vertebral basilar artery strokes.
9. What are interventions that would be implemented
in older adults poststroke? In older adults with
Parkinson’s disease?
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Neuromuscular and Movement Function: Falls
Vanina Dal Bello-Haas
“Every—Michelangelo
block of stone has a statue inside it.... It is the task of the sculptor to discover it.
Buonarroti, Italian sculptor, painter, architect, poet (1475–1564)
LEARNING OUTCOMES
By the end of this chapter, readers will be able to:
1. Define falls and near falls.
2. Discuss the epidemiology of falls.
3. Identify the clinical implications and consequences of falls
for older adults.
4. Identify older adults who are at greatest risk of falling.
5. Distinguish between modifiable and nonmodifiable, intrin-
sic and extrinsic, age-related/biological, lifestyle/behavior,
environmental, and community fall risk factors.
6. Describe the components of an assessment for falls and fall
risk in the older adult.
7. Describe evidence-based, best practice falls and fall risk
assessment and intervention strategies.
8. Describe intervention strategies aimed at fall prevention.
Clinical Vignette
Mr. Aban Najjar is an 80-year-old man who lives alone inde-
pendently in a large, old house with several steps to the front en-
trance. Mr. Najjar has two supportive daughters and seven adult
grandchildren who live nearby. Mr. Najjar is a retired lawyer.
He has two cats and has an active social life with many friends.
He goes out every day to meet up with friends or run errands.
Mr. Najjar has recently been experiencing symptoms of
dizziness, particularly when getting out of bed or out of a
chair, and reports feeling unsteady on his feet. His daughters
report that Mr. Najjar is exhibiting some anxiety about going
out of the house because of the unsteadiness. Past medical
history includes hypertension, type 2 diabetes, osteoarthritis,
bilateral total hip replacement, L3–5 spinal stenosis and leg
numbness/paresthesia, cataracts, benign prostatic hypertro-
phy, with 3–4 times per night nocturia and occasional incon-
tinence. Medications include metformin 500 mg daily,
Flomax 0.8 mg at bedtime, gabapentin two 300-mg tablets
three times daily, Advil 500 mg one to two four times daily
as needed, Tribenzor 25 mg daily.
1. Is Mr. Najjar at risk for falls? Why?
2. What risk factors for falls does Mr. Najjar have? Can
anything be done about the risk factors?
CHAPTER 16
■ Norma J. MacIntyre
”
F alls in older adults are a significant health concern, and
an extensively researched topic. Conducting a literature
search of “older adult” and “falls” as key words, restricted to
the English language and to the past 10 years yields more
than 900,000 hits in just one database! This chapter focuses
on some of the essential concepts and elements related to falls
in older adults for the occupational and physical therapist.
However, as an entire book could be devoted to the topic of
falls in older adults, the interested reader should refer to
the reference list and the Web resources in the ancillaries for
additional information.
Definition of Fall and Near-Fall
The World Health Organization’s (2007) Global Report on
Falls Prevention in Older Age notes that the rapid growth in
the aging population makes falls prevention an important
objective worldwide. A fall has been defined as an event that
results in a person inadvertently coming to rest on the
ground, floor, or other lower level (e.g., bed, chair), with or
without injury (Tinetti et al., 1997). Falls may or may not be
witnessed. Because balance problems may be precursors to
serious falls, there has been increasing interest in the concept
of “near fall,” a slip, trip, stumble, or loss of balance such that
the older adult starts to fall but is able to recover and remains
upright (Ryan, Dinkel, & Petrucci, 1993).
Fall Facts
It is important for occupational therapists (OTs) and physical
therapists (PTs) to remember that falling is not necessarily a
“normal part” of getting older. Falling is a symptom and not
a diagnosis, and for most older adults, falls are multifactorial
in nature. Older adult falls are costly; for example, in the
United States, the direct medical costs for fall injuries are
$34 billion annually (adjusted for inflation), with hospital
costs accounting for two-thirds of the total (Stevens, Corso,
Finkelstein, & Miller, 2006). In Scotland, fall-associated
costs were reported to be more than £470 million, with 60%
of those expenses incurred by social services, mainly through
249
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250 PART II ■ Aging: Body Structures and Body Functions
the provision of long-term care (LTC). Cost per person
falling was more than £1,720, rising to more than £8,600 for
those seeking medical assistance (Craig et al., 2013). Because
of the personal, family, financial, health-care, and societal
impacts, older adult falls, fall-related injuries, and fall pre-
vention strategies and interventions are considered global
health priorities.
The older we get, the more likely we are to fall, and there
are direct positive associations between frailty, age, and the
frequency of falls. Statistics demonstrate that fall incidence
is fairly similar worldwide and fairly consistent over the years
of research—about one third of community-dwelling older
adults aged 65 years and older fall, and of these, 40% to 50%
have multiple falls (Medical Advisory Secretariat, 2008;
Public Health Agency of Canada, 2014). For people over
age 75 the fall rate is 40%, and for those 85 years and older,
the fall rate is about 50% (Stalenhoef, Diederiks, Knottnerus,
Kester, & Crebolder, 2002; Public Health Agency of Canada,
2014). Falls have been reported to be more common in
women than in men, and among older adults who are not
married. However, according to Canadian and U.S. data, the
rates of injurious falls among males is increasing (Kramarow,
Chen, Hedegaard, & Warner, 2015; Public Health Agency
of Canada, 2014).
Where and When Do Older Adults Fall?
Research has found that falls often take place in the home
(or place of residence) (Kochera, 2002), in the bedroom or
bathroom (Stevens, Mahoney, & Ehrenreich, 2014). Al-
though some researchers have found fall rates increase during
the winter months (Yeung et al., 2011), falls do occur in all
seasons (Public Health Agency of Canada, 2014). Fall rates
are higher for ambulatory older persons living in LTC facil-
ities than for community-dwelling older adults. About 50%
to 60% of LTC residents will experience at least one fall each
year, and falls in LTC settings tend to result in more serious
complications (Becker & Rapp, 2010; Panel on Prevention
of Falls in Older Persons, American Geriatrics Society and
British Geriatrics Society, 2011). Older adults in the hospital
also fall frequently. Inpatient fall rates are variable and de-
pend on care area investigated; in a Swiss university hospital
of 800 beds, the inpatient fall rate was 22 falls per 1,000 pa-
tient days (Halfon, Eggli, Van Melle, & Vagnair, 2001).
Environmental factors affect the incidence of falls. Safety
in a particular environment has much to do with the unique
characteristics of the individual and the specific nature of the
setting. For example, a home that “works well” for a very ac-
tive 70-year-old with few chronic health conditions may be
considered safe, but the same situation would not be consid-
ered safe for a 65-year-old with multiple morbidity, muscle
weakness, and mobility problems due to a stroke. Because
falls also occur in public areas, community policy issues are
important considerations for the occupational and physical
therapist. The safer the public environment, the better for the
older adult. Similarly, it would be expected that health-care
institutions, such as hospitals and LTC facilities, have a high
percentage of older adults with mobility problems—again,
the safer these institutions, the better for the older adult.
Consequences and Sequelae of Falls
Falls are a major cause of hospitalization, premature death,
physical injury, immobility, psychosocial problems, and
transition into LTC. Data over several years suggest that
the number (and rates) of older adults experiencing an
injurious fall is increasing (Public Health Agency of Canada,
2014). About one-quarter to one-third of falls cause mod-
erate to severe injuries (“injurious fall”), and unfortunately,
in some cases, they result in death. Injuries from falls include
the following:
■ Bruises, contusions, lacerations
■ Sprains
■ Fractures of the pelvis, hip, upper extremity, distal radius,
spine, skull, ankle. Hip fractures due to falling account for
more than a third of fall-related hospitalizations (Public
Health Agency of Canada, 2014; Stevens, Corso, Finkelstein,
& Miller, 2006).
■ After a hip fracture, many older people never regain
their premorbid level of mobility and autonomy, and
rates of institutionalization and mortality are high
(Cree, Carriere, Soskolne, & Suarez-Almazor, 2001;
Magaziner et al., 2003).
■ Head trauma and brain injuries
■ Falls are the leading cause of traumatic brain injury in
people older than 60 years of age (Public Health Agency
of Canada, 2014).
In addition to pain and suffering, limited mobility and im-
mobilization, functional decline, increased dependence and
greater isolation, decreased quality of life, fear of falling, and
depression, and increased caregiver burden are common
sequelae. Thus, falls, particularly those resulting in hospital-
ization, can be a catalyst for the transition to LTC.
Fall-related mortality rates differ depending on availability
of information regarding whether a fall eventually led to
death versus being the immediate cause of death. Moreover,
variation in mortality rates depends on the country and the
population studied. For example, in the United States, age-
adjusted death rates from unintentional falls increased
steadily between 2000 and 2013 for men and women aged 65
and older, with consistently higher rates observed among
men. During this period, death rates from falls increased
from 38.2 per 100,000 in 2000 to 67.9 in 2013 among men,
and from 24.6 to 49.1 among women (Kramarow et al.,
2015). There is a high incidence of coexisting chronic diseases
in older adults who fall to this increased mortality rate (Vu,
Finch, & Day, 2011). The actual number of fall-related
deaths is probably much higher because falls are not listed
consistently as the cause of death through the use of interna-
tional statistical classification of diseases and related health
problems developed by the World Health Organization.
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CHAPTER 16
The financial burden of falls is 3.7 times higher for adults
older than 65 years compared with younger adults. An av-
erage hospital stay for fall injury is 50% longer than other
reasons, and injuries from falls are one of the leading causes
of admittance into nursing homes (Public Health Agency
of Canada, 2014). Repeated falls and their consequences
often lead to the initial institutionalization of an older adult;
for example, in Canada, about 40% of LTC admissions are
a result of falls (Public Health Agency of Canada, 2014).
Thus, in addition to the injury, one of the major conse-
quences of fall-related injuries is the loss of independence
for the older adult.
Risk Factors for Falls
Interaction among risk factors can increase risk of falls, and
the more risk factors the more likely an older adult is to fall.
Identifying risk factors and determining fall etiology in older
adults who have fallen require a multidisciplinary approach.
A traditional framework for thinking about fall risk factors
divides up the risks into two categories: intrinsic factors and
extrinsic factors (Fig. 16-1). Intrinsic risk factors are those
things that are internal to the older adults such as medical
conditions. Extrinsic factors are external, such as the envi-
ronment and would include slippery floors. Both intrinsic and
extrinsic factors include factors that could be potentially af-
fected by intervention.
A different way to think about the falls risk factors is in
terms of which factors can be changed (modifiable risk fac-
tors) and which are much more difficult to change or cannot
be changed (nonmodifiable risk factors). For instance, the
slippery floor in the environment can be changed, but hav-
ing a condition that affects vision, such as macular degen-
eration, cannot be changed. Alternative fall risk factors
categories have been proposed: age related and biological,
behavioral and cognitive, environmental, and community
and policy (Scott, Dukeshire, Gallagher, & Scanlan, 2001).
See Figure 16-2.
This framework is useful because there are fall risk factors
(modifiable) that can be addressed within each of the cate-
gories, and the framework reminds the OT and PT to consider
Intrinsic Extrinsic
Medical and Medications
neuropsychiatric
conditions Improper
prescription and/or
Impaired vision use of assistive
and hearing Falls devices for
ambulation
Age-related
changes in Environmental
neuromuscular hazards
function, gait, and
postural reflexes
FIGURE 161 Intrinsic and extrinsic risk factors for falls. (Adapted from
Scott, Dukeshire, Gallagher, &, Scanlan, 2001.)
■ Neuromuscular and Movement Function: Falls 251
multiple levels of risk factors. The age-related or biological fac-
tors, such as medical conditions, can usually be best addressed
with the older adult and the appropriate health-care profes-
sional working together. Behavioral and cognitive problems
that affect falls can be addressed with the older adult making
changes in his or her lifestyle, such as wearing safer shoes or
paying more attention and becoming more mentally engaged
when walking. The environmental risk factors tend to some-
times be the easiest to address, for example, putting a railing
on a staircase or eliminating scatter rugs. Community policy
factors include things we can all support to make the environ-
ment and the health and social services system more responsive
to older adults’ needs.
Risk Factors—Age-Related and Biological
In general, poor health is related to increased fall risk, and
an older adult who has had an acute or recent illness is more
likely to fall. Various medical conditions may put a person
at higher risk for falls, including diabetes, which can cause
foot and sensory problems, both of which affect an older
adult’s mobility; arthritis, which causes joint stiffness and
mobility problems; neurologic conditions, such as stroke and
Parkinson’s disease, which affect balance (see Chapters 15
and 17); osteoporosis (see Chapter 15); urinary problems;
incontinence; and muscle weakness (see Chapter 10). In ad-
dition, older adults with a history of falls or a history of
dizziness, syncope, or blackouts are at increased risk of falls
(Pothula, Chew, Lesser, & Sharma, 2004). The prevalence
of dizziness among older adults is significant. For example,
a cross-sectional population study of the Network for the
Study of Frailty in Brazilian Elderly Adults found the preva-
lence to be 45% (deMoraes, Soares, Ferriolli, & Perracini,
2013). Vertigo, a feeling that the world is spinning around
an individual, may be caused by viral or bacterial infections
in the ear, head trauma, or blood circulation disorders that
affect the inner ear or brain. Vestibular problems are com-
mon in the elderly but are rarely the only cause for fall risk
or balance problems. Older adults with vestibular problems
often have comorbid health conditions such as decreased
hearing, vision, hypertension, anxiety/depression, and mus-
culoskeletal impairments (Marchetti, Whitney, Redfern, &
Furman, 2011).
In addition to medical conditions themselves, often the
medications prescribed to treat the medical condition causes
dizziness, vertigo, and balance problems. For instance, many
of the medications prescribed for depression, hypertension,
and pain can cause dizziness as a side effect. Taking four or
more medications has been found to be related to increased
fall risk, as can certain combinations of medications. See
Table 16-1 for a summary of common medications and their
potential fall-inducing side effects. It is important to note
that alcohol intake and/or use of illicit drugs can also increase
fall risk. Older adults may experience dizziness or intoxication
at much lower levels of intake as their kidney and liver func-
tion decreases.
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252 PART II ■ Aging: Body Structures and Body Functions

Age-Related and Biological Environmental

• Medical Conditions • Clutter
e.g., chronic disease • Poor lighting
e.g., acute illness
• Lack of handrails, grab bars
• Medication use
• Floors—wet, slick, throw rugs,
• Sensory changes uneven surfaces
e.g., vision,
proprioception • Stairs—lack of adequate
handrail, light switch
• Balance and gait impairments
• Lack of handrails, grab bars
• Muscle weakness
• Items that are hard to reach
• Problems with mobility
• Obstacles in
• Cognitive/psychological health paths...carelessness
Cognitive impairment dementia,
depressions, fear of falling

Falls

Behavioral and Cognitive Community Policy

• Cognitive • Buildings
Focus and distraction— Safe public access
divided attention Sidewalks in front of buildings
Cognitive impairment Handrails, grab bars
• Lack of exercise • Laws
• Unsafe footwear • Social policies FIGURE 162 Fall risk factors: age-related
• Alcohol use • Referral system and resource and biological, behavioral and cognitive,
• Nutrition, hydration networks environmental, and community and
• Taking risks policy. (Adapted from Scott, Dukeshire,
Gallagher, &, Scanlan, 2001.)

deficits, executive dysfunction, or visual field loss and can

TABLE 161 ■ Medications and Potential Fall-Inducing Side contribute to a higher propensity to fall. Studies have found
Effects that cognitive decline is a risk factor for falls, and older
MEDICATION CLASS SIDE EFFECTS adults in LTC who have cognitive problems experience
more severe falls and resultant injuries. Divided attention
Analgesics, especially narcotics Decreased alertness, central and dual tasking has also been examined as a contributor
processing to falls in older adults. Researchers have found that older
Psychotropics, especially Negatively affects dynamic balance,
tricyclics, benzodiazepines, attention, dual-task abilities
adults who perform poorly under dual-task conditions are
phenothiazines at increased risk for balance problems and falls (Brauer,
Antihypertensives, especially Decreased cerebral perfusion Woollacott, & Shumway-Cook, 2001; Muir-Hunter &
vasodilators; antiarrhythmics; Wittner, 2016), and recommend dual-task gait testing pro-
diuretics, especially when cedures should be incorporated into clinical practice to
dehydration occurs
Aminoglycosides; high loop Vestibular toxicity
identify and stratify fall risk in older adults (Muir-Hunter
diuretics & Wittner, 2016).
Phenothiazines Cause extra-pyramidal signs and The concept and cycle of fear of falling (FOF; see
symptoms Fig. 16-3) has also been studied in older adults. Older adults
with a history of falls may be afraid of falling; however, even
older adults who have never previously fallen may also have
a FOF. Avoidance of walking because of FOF is likely re-
Risk Factors—Behavioral and Cognitive inforced when multiple sensory difficulties hinder reception
As described in this and other chapters in this section, an of accurate information about the environment (Viljanen et
older adult may present with “normal” and/or pathological al., 2012). Fear of falling can dramatically affect quality of
age-related changes. Health conditions including dementia, life as individuals may begin to avoid participation in valued
depression, stroke, and Parkinson’s disease may cause attention activities.
4605_Ch16_249-262 31/10/17 12:20 PM Page 253
CHAPTER 16
Fear of falling
Restricts activity
Physical capabilities reduced
• Moves slower
• Avoids movement
Restricts more activities
More impaired
physical capabilities
• Becomes deconditioned
• Decreased strength and
endurance
FIGURE 163 The cycle of fear of falling.
INTERPROFESSIONAL PRACTICE
Fear of Falling Clues for the Occupational
and Physical Therapist and Other Health Care
Professionals
■ Older adult touches or holds onto objects (e.g., furniture
or people during mobility)*
■ Older adult walks very slowly*
■ Older adult takes small steps*
■ Older adult limits movement or does not want to move
■ Older adult expresses anxiety or demonstrates signs and
symptoms of anxiety
■ Expresses a fear of falling
*May be protective, but does not assist with maintenance
of balance or prevent falls
Physically active older adults have fewer and less severe
falls than those who are not as active (Sherrington, Lord, &
Finch, 2004). Similarly, older adults who are stronger and
more flexible are better able to respond to challenges to bal-
ance. Adequate nutrition and water intake is important as
well because dehydration can cause dizziness. Calcium and
vitamin D are important for improving bone density and re-
ducing the chances of fractures. Footwear is also important;
the best shoe in terms of balance and fall prevention is one
that is flat or has a very low heel, has a relatively thin sole,
and offers support. On the other hand, shoes with thick soles,
such as some of the sneakers, may hinder an older person’s
ability to sense the ground through the shoe.
Risk Factors—Environmental and Community
To date, there is a dearth of convincing scientific evidence
related to home and community building environmental fac-
tors, architecture, and environment and community-related
■ Neuromuscular and Movement Function: Falls 253
policies that contribute to or prevent older adult falls and fall-
related injuries. However, many building standards have been
adopted to reduce environmental hazards, for example, by
designing barrier-free or accessible rooms. Interestingly, re-
search has found the risk of fracture was greatest for older
adults during the immediate period after admission to a LTC
facility. The most likely reasons were physical deconditioning
associated with the condition requiring an LTC stay and the
transition from a familiar to unfamiliar environment. The role
and importance of extrinsic risk factors in LTC facilities have
been debated by many health-care professionals over the
years because of the complex interaction between a particular
older adult and the social and physical environment of a par-
ticular LTC facility (International Classification of Function;
World Health Organization, 2001).
Many aspects of the community and community policies
relate to older adults and fall prevention. For example, typi-
cally many community elements, such as sidewalks, pedes-
trian crossings, public building ramps, and handrails are
publicly funded and maintained. In some jurisdictions, traffic-
light timing has been changed to provide older adults ade-
quate time to cross the street. On a community level, in
addition to creating safe public spaces, it is important to have
an adequate network of health professionals who understand
the roles various professionals can play in preventing and
addressing older adult falls. A well-established community
network and referral system can also improve services for the
older adult. Without knowledge of adequate identification,
a particular older adult’s fall risk cannot be realized. For ex-
ample, if a family doctor is not aware that an OT can adapt
an older adult’s home environment to increase safety and a
PT can assist an older adult with gait and balance training,
then his or her patients are less likely to receive a referral.
Fall Risk and Fall Prevention
Assessment
The approaches to the assessment of fall risk and prevention
are similar, and whether at an individual, program, or insti-
tutional level, the assessment is focused on modifiable risk
factors.
✺ PROMOTING BEST PRACTICE
Screening and Assessment Recommendations
■ All older adults should be asked whether they have had a fall
in the past year.
■ Older adults who report a fall should be asked about the
frequency and circumstances of the fall(s).
■ Older adults should be asked whether they experience
difficulties with walking or balance.
■ Older adults who report a single fall in the past year should
be evaluated for gait and balance.
■ Older adults who present because of a fall or who report
recurrent falls in the past year or difficulties in walking or
4605_Ch16_249-262 31/10/17 12:20 PM Page 254
254 PART II ■ Aging: Body Structures and Body Functions
balance (with or without activity curtailment) should
undergo a multifactorial fall risk assessment.
■ Older adults who cannot perform or perform poorly on a
standardized gait and balance test (see Chapter 9), should
undergo a multifactorial fall risk assessment.
■ Older adults who have fallen should have an assessment
of gait and balance using an available evaluation.
■ Older adults who have difficulty or demonstrate
unsteadiness during the evaluation require a multifactorial
fall risk assessment.
■ Older adults who report only a single fall in the past year and
report or demonstrate no difficulty or unsteadiness during
the evaluation do not require a fall risk assessment.
■ Clinician(s) with appropriate skills and training should
perform the multifactorial fall risk assessment.
Summarized from Panel on Prevention of Falls in Older Persons,
American Geriatrics Society and British Geriatrics Society (2011).
The assessment elements that would be included are de-
pendent on the context of the OT’s or PT’s work environment
and the number and mix of other health-care professionals in-
volved. A complete assessment of an older adults’ risk for falls
or an older adult postfall includes many elements; see Pro-
moting Best Practice: Screening and Assessment Recommen-
dations and Chapters 7–11 and 27 for more information
regarding system-specific assessment tools and measures. At
an institutional or program level (e.g., LTC), it is important
to have mechanisms for benchmarking and documentation
that allows tracking and analysis of falls and fall injuries, in-
cluding time, location, activities associated with and conse-
quences of falls. These data can then be discussed (e.g., fall
huddle for all major fall events that occur), and summarized
and analyzed on a regular basis (e.g., quarterly) and timely
feedback provided to staff.
INTERPROFESSIONAL PRACTICE
Subjective and Objective Assessment Components
for the Occupational and Physical Therapist
and Other Health-Care Professionals
Subjective Assessment Objective Assessment
■ Health and medical ■ Mental status (e.g.,
history cognition, memory)
■ Medications—prescription, ■ Psychological health
over the counter (when (e.g., anxiety,
medication was started, depression)
when stopped, dosage ■ Range of motion,
changes, adherence) flexibility
■ Psychosocial history ■ Muscle strength
■ Fall history, fall injuries ■ Sensation
■ Near fall history ■ Balance, postural
■ Medications, side effects control elements
■ Social history ■ Movement strategies
■ Living arrangements (e.g., ankle, hip,
■ Home environment stepping)
■ Health behaviors (e.g., ■ Mobility
alcohol use, nutrition, ■ Gait
lifestyle, physical activity) ■ Endurance
■ Functional abilities ■ Screening tools
■ Fear of falling ■ Outcome measures
■ Pain
Some older people underreport falls because they view
them as a normal part of aging or may not recognize the sig-
nificance of a fall or multiple falls. If possible, family members
or caregivers living with the person may participate in the
subjective assessment, with the older adult’s consent. In the
institutional setting, documentation of circumstances should
be a part of the incident report. Staff members who have the
opportunity to observe the resident should be questioned, in-
cluding nursing staff, therapists, and dietary and housekeep-
ing staff.
The older adult should be asked not only about completed
falls but also about near falls, as well as gait and balance prob-
lems. If the older adult has fallen, it is important to obtain a
fall history, including the number of falls and near falls and
the circumstances for each episode, including location (in-
door, outdoor, kitchen, bathroom), activity (walking, getting
up from the bed or toilet), time of day or night, symptoms
(dizziness, weakness, vertigo), and type of footwear (shoes,
boots, slippers). Having the older adult complete a fall diary
for a period of time may provide the therapist with important
information about the circumstances of falls and assist with
identifying possible causes. For example, falls associated with
rising from a lying or seated position and experiencing symp-
toms of dizziness suggests orthostatic hypotension. If no
symptoms are present when rising from a chair, the design
of furniture may be a causative factor. If an older adult fre-
quently trips or slips, gait and balance should be thoroughly
assessed, and potential environmental hazards need to be
evaluated. It is important to keep in mind that some older
adults may not have the cognitive capacity to keep good
records. Some older adults may intentionally mask difficulties
out of fear they will be required (by concerned family) to
move from their preferred place of residence. If a family
member or other care provider has an opportunity to observe
the individual, reports of these caregivers may be helpful.
The physical assessment of the older adult includes a mo-
bility evaluation and an assessment of gait, balance, and abil-
ity to transition between positions, for example, standing up
from sitting. This is particularly helpful in providing clues to
underlying causes of falling, localizing the systems involved,
isolating potential environmental problems, and design-
ing interventions (Figure 16-4). The best method to assess
mobility is to observe the older adult in his or her living
environment. A number of simple mobility evaluations are
available that require little time, special expertise, space, or
equipment. An expert panel tasked with identifying the core
outcome set to use in the assessment of standing balance and
fall risk in adult populations selected five measures for in
depth discussion (Berg Balance Scale [BBS], Mini Balance
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CHAPTER 16
FIGURE 164 Careful assessment of balance and gait is important in
designing falls prevention intervention. (Courtesy of the Menorah Park
Nursing Home, Cleveland, Ohio, with permission.)
Evaluation Systems test [mini-BESTest], Short Physical
Performance Battery, Timed Up and Go [TUG] test, and
the Unified Balance Scale) from among 56 potential meas-
ures identified in the literature published recently on the basis
of measurement properties, feasibility, and components of
balance assessed according to the Systems Framework for Pos-
tural Control (Sibley et al., 2015). Although the panel agreed
that a single measure could not address the full spectrum of
balance abilities in adult populations, it recommended that,
at a minimum, performance on the BBS and mini-BESTest
be assessed. See Table 4 in Sibley et al. (2015) for a summary
of the characteristics of these measures, including equipment
required and time to administer. Comparison between differ-
ent fall-risk assessment methods such as fall history or assess-
ment tools did not demonstrate a clear superiority of one
method for residents living in institutions (Jensen, Nyberg,
Gustafson, & Lundin-Olsson, 2003).
Information gathered from the fall history and mobility
evaluation serves as a guide to elements of the physical ex-
amination that warrant additional evaluation. For example,
if the fall history reveals that falls occur in association with
dizziness, orthostatic hypotension and vestibular system dys-
function should be further assessed. If the physical examina-
tion confirms the presence of orthostatic hypotension, the
therapist can then refer the older adult to his or her physician
for additional medical tests such as blood work to evaluate
volume depletion and a comprehensive medication review.
In an ideal world, all older adults at risk for falls or who have
falls should have their living environment evaluated. The goal
of the environmental assessment is to identify environmental
areas or design features that increase fall risk and the need
for environmental modification and adaptive equipment. The
■ Neuromuscular and Movement Function: Falls 255
older adult should be observed walking through every room;
transferring on and off beds, chairs, and toilet; getting in and
out of the bathtub or shower; reaching to obtain objects from
kitchen and closet shelves; bending to retrieve objects from
the ground or low heights such as coffee tables; and negoti-
ating stairs. The assessment of the older adult living in an in-
stitution is similar, with the omission of activities usually not
performed independently. Environmental obstacles that in-
terfere with safe mobility should be noted and modifications
recommended.
Fall Risk and Fall Prevention
Intervention
The goals and processes of fall risk and fall prevention inter-
vention in both community-dwelling older adults and older
adults in institutions are similar: identification, assessment,
management, implementation, monitor, and review (Accred-
itation Canada, Canadian Institute for Health Information,
& Canadian Patient Safety Institute, 2014). First, older adults
at risk must be identified and assessed; for those at risk, pre-
vention interventions should be implemented. For those who
are falling, the etiology must be determined through assess-
ment, so that an implementation plan can be developed. Sec-
ond, the risk of falling or experiencing additional falls must
also be reduced by implementing interventions. After imple-
mentation, the effectiveness of the intervention(s) should be
monitored and reviewed. OTs and PTs play critical interven-
tion roles at the individual, organization (e.g., facility where
the OT and PT are employed), community, and societal lev-
els. At an institutional and program level, it is important for
OTs and PTs to discuss and prioritize possible interventions.
An institution’s or program’s specific case mix and legally
mandated requirements should be considered to develop
goals. Essential components for successful institutional and
program level interventions include organizational commit-
ment, leadership, and staff empowerment facilitated via effec-
tive knowledge exchange and translation, attitudinal change,
and organizational efforts. It is important to remember that
changes may take months, if not years, to become entrenched.
✺ PROMOTING BEST PRACTICE
Education for Fall Prevention: Is Education Alone
Sufficient for Fall Prevention?
A systematic review investigated patient education as a single
intervention or as part of a multifactorial falls prevention
program in the hospital and postdischarge community
settings. Falls prevention programs that contained patient
education were found to be effective in reducing fall rates
among hospital inpatients and postdischarge populations.
Patient education generally increased knowledge about
falls and awareness of prevention strategies. The uptake of
strategies may be dependent on the activities being targeted
(Den-Ching, Pritchard, McDermott, & Haines, 2014).
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256 PART II ■ Aging: Body Structures and Body Functions

Major roles, many of which overlap between the OT and fall occurrences. However, the trials suggest tai chi may only be
PT and other health-care professionals such as nurses, include effective in a more robust older population and may not
identifying risks for falls, educating about fall risk factors, de- benefit frail participants.
veloping fall risk and prevention plans, implementing inter-
ventions after an older adult has fallen to decrease an older
A systematic review of the Otago Exercise Programme
adult’s risk of falls, and consultation regarding environmental
(OEP), a home-exercise program combining strength and bal-
modifications. There is consistent evidence that exercise and
ance retraining exercises to prevent falls in older, community-
individually tailored multifactorial interventions are effective
dwelling people, determined that the OEP significantly reduced
in reducing falls in community-dwelling older adults (e.g.,
the risk of death over 12 months (risk ratio = 0.45, 95% confi-
El-Khoury, Cassau, Charles, & Dargent-Molina, 2015).
dence interval [CI] = 0.25–0.80] and significantly reduced fall

✺
rates (incidence rate ratio = 0.68, 95% CI = 0.56–0.79). How-
PROMOTING BEST PRACTICE ever, no significant difference in the risk of a serious or moderate
Multifactorial Fall Programs Are Most Effective injury occurring as the result of a fall was found (Thomas,
A systematic review examined and analyzed 33 articles. The Mackintosh, & Halbert, 2010).
strongest evidence was found for multifactorial programs that
included home evaluations and home modifications, physical
Resistance Exercise
activity or exercise, education, vision and medication checks,
or assistive technology to prevent falls. Positive outcomes Moreland and colleagues (2004) found lower extremity
included a decreased rate of functional decline, a decrease weakness (ankle dorsiflexors, quadriceps, hip extensors) to
in fear of falling, and an increase in physical factors such as be associated with falling. The odds ratio was 1.76 for any
balance and strength. The strength of the evidence for physical fall and 3.06 for recurrent falls. It was not possible to draw
activity and home modification programs provided individually conclusions about the relative contribution of different mus-
was moderate (Chase, Mann, Waske, & Arbesman, 2012). cle groups, and the role of the core (abdominals) muscles was
A systematic review and meta-analysis of randomized
not examined. The association between muscle weakness and
controlled trials found evidence that multiple component
falling was consistently higher for institutionalized than
interventions are effective at reducing both the number of
people that fall and the fall rate. This approach should be
considered as a service delivery option (Goodwin, et al., 2014).

Interventions for older adults postfall or to decrease fall

risk can include but are not limited to exercise (resistance,
aerobic, balance, combination exercise modes), prescription
of assistive and adaptive devices, ADL and gait training, and
fear of falling, environmental, and other interventions.

Exercise
Exercise interventions targeting gait, balance, coordination,
and functional exercises; muscle strengthening; and multiple
exercise types have been found to significantly improve vari-
ous measures of balance (Figure 16-5). Chapters 8, 10, and 11
provide more information on exercise and exercise prescrip-
tion for older adults. Exercise is effective at reducing falls,
and various forms of exercise have been examined including
resistance, balance, aerobic, and a combination of exercise.
Exercise tends to be most effective if tailored to the older
adult’s individual needs.

✺ PROMOTING BEST PRACTICE

Are Tai Chi and the Otago Exercise Programme
Beneficial?
The evidence from six randomized trials of 1857 older adults
(mainly female) participating in tai chi ranging from 15 weeks
to 2 years determined that tai chi may be beneficial in reducing
FIGURE 165 Participating in exercises designed to improve balance
can be fun as well as therapeutic. (Courtesy of the Geriatric Day
Hospital, Specialized Geriatric Services, Saskatoon Health Region,
Saskatoon, Saskatchewan, with permission.)
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CHAPTER 16 ■ Neuromuscular and Movement Function: Falls 257

community-dwelling, older adults (Moreland, et al., 2004). Fear of Falling Interventions

Research has consistently found muscle weakness to be a fall
risk factor, more so than other risk factors (see Table 16-2).
Research has yet to identify which muscle groups are most
important to target via exercise and what the thresholds of
muscle strength are to prevent falls.
Balance Exercise
Any balance exercise program needs to be based on an older
adult’s individual assessment findings. Elements of postural
control, such as adaptive mechanisms, anticipatory mechanisms,
and responses to perturbations (strategies; see Chapter 9) need
to be considered. A wide variety of challenging tasks, activities,
and exercises, progressing from simple to complex, are recom-
mended, including functional tasks, exercises, and activities with
varying stability, orientation, task, and environmental demands.
The focus of intervention for fear of falling is to assist the older
adult in regaining confidence in his or her ability to achieve
safe, independent mobility. An important first step is to
identify fall risk factors. Specific interventions are directed
at addressing the fall risk factors, such as improving balance,
improving muscle strength, and eliminating environmental
hazards using a room-by-room checklist, outside the home or
facility (sidewalks, public areas), education and counseling,
and behavioral modification that includes
■ progressively increasing involvement in the feared activity,
with close supervision,
■ ensuring physical safety and providing verbal reassurance
to build confidence, and
■ proceeding at a pace that is comfortable and not anxiety
provoking.

Prescription of Assistive and Adaptive Additional strategies are summarized in Box 16-1.
Devices and Activities of Daily Living,
Mobility, and Gait Training Environment/Community: Prevention
and Intervention
It seems reasonable to provide older adults with training in
appropriate use of new assistive or adaptive devices. For ex- The focus of environmental interventions is to make modifica-
ample, for older adults who have difficulty reaching a top tions to promote safety (see Table 16-3). Person–environment
shelf, the use a “reacher” may be beneficial. Canes and walk- mismatches on an individual level in private space are reduced
ers may be useful for older adults with gait and balance prob- through modifications, and compromises in the public areas are
lems; however, these devices come with their own problems. negotiated. For high-risk older adults, shock-absorbing floor
Particular user problems related to use of assistive devices surfaces in areas with very high-risk injury rates such as bed area
occur during sit-to-stand transfer (often due to improper use) and bathroom can be recommended.
and use of the device during nighttime walking, for example, An emerging and important role for OTs and PTs includes
when getting up to urinate. Therapists also need to critically social action and advocacy to address inadequate community
evaluate the dual-task costs of assistive and adaptive devices, standards through petitioning government and businesses to
particularly in those older adults with cognitive impairment. remove potential hazards and ensure safe public places, public
Additional information about considerations for use of assis- education, reporting public hazards, partnering with like-
tive technology can be found in Chapter 21. minded partners with priorities that include older adult wellness
and fall prevention, and ensuring an adequate health profes-
sional network and referral system. In LTC institutions, the
staff has the most important role in implementing change and
TABLE 162 ■ Contribution of Risk Factors to Falls adherence. Thus, the OT and PT are key collaborators in en-
suring that good practice standards are in place and that all staff
RISK SIGNIFICANT/ MEAN members are educated about and understand the specific fall
FACTOR TOTAL* RR/OR patterns and dynamics of falls and injuries in LTC facilities. A
Muscle 10/11 4.4
➪ Muscle weakness is the multidisciplinary/interdisciplinary approach and communica-
weakness most significant risk factor tion are critical. This includes initial assessments, shared treat-
History of falls 12/13 3.0 for falls across studies ment plans, and monthly team sessions to optimize approaches
Gait deficit 10/12 2.9 including exercise, medications, environment adjustments, and
Balance deficit 8/11 2.9 review of functional status of LTC residents, which can rapidly
Assistive device 8/8 2.6
Visual deficit 6/12 2.5
change. “Hot” precipitating risk factors should be identified and
Arthritis 3/7 2.4 adaptive strategies implemented immediately (e.g., acute illness
Impaired ADL 8/9 2.3 or a new fall resulting in change of mobility).
Depression 3/6 2.2
Cognitive 4/11 1.8
impairment Other Interventions
Age >80 years 5/8 1.7 Urinary incontinence, urge, and nocturia (the awakening from
ADL = activities of daily living; OR = odds ratio; RR= relative risk.
sleep at night to pass urine) are well-established problems
*Number of studies (significant/total). associated with falls in older adults (Brown et al., 2000;
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258 PART II ■ Aging: Body Structures and Body Functions

BOX 161 Cognitive and Behavioral Strategies Aimed at Reducing Fear of Falling

Cognitive Strategies older adult should make sure the doctor knows about all the
medications being taken (prescription and over the counter) to
■ Explain that falling is not a normal part of aging and that risk of
prevent harmful combinations of drugs.
falling can be reduced.
■ Limit the amount of alcohol use.
■ Explain that falls can be due to certain medical problems, med-
■ All falls and near falls or changes in balance should be reported
ications, and environmental hazards.
to the doctor, occupational therapist, physical therapists, and
■ Discuss possible home hazards and explain the need to correct
other health-care professionals.
any existing hazards (provide a home-hazard checklist that can
■ Vision should be tested regularly. If glasses are needed, they
be used by the individual or a family member to help identify
need to be worn.
fall hazards and to suggest corrective action).
■ Sunglasses or a brimmed hat should be worn to cut down glare
■ Explain that falls can be an early sign of illness that may re-
on sunny days.
quire treatment and the importance of reporting all falling
■ If the older adult feels unsteady, use a cane or walker to
episodes.
help maintain balance. The assisted devices need to be fitted
■ Explain that fear of falling is both a realistic and common fear.
properly and the older adult needs to be trained to use them
■ Discuss fear of falling and its impact on the quality of life.
correctly.
■ Explain the consequences of restricting mobility as a response
■ Older adults should avoid taking chances and putting himself
to fear of falling.
or herself in high-risk situations (e.g., climbing ladders).
■ Explain the need to stay as active as possible, before and
■ Sudden movements, rushing, or quickly changing positions
after a fall.
should be avoided (e.g., from lying to sitting or sitting to
■ Discuss the role of exercises aimed at improving neuromuscu-
standing, particularly when ill, tired, or emotionally upset).
lar performance (activities that improve strength, balance, and
■ Older adults should watch where they walk, looking for uneven
coordination can increase confidence and reduce the risk for
ground, rocks, or other obstructions that could cause tripping.
fall-related injuries).
■ Older adults should exercise extra caution on wet and icy
■ Discuss the use of hip protectors to reduce fear of injury
surfaces.
(and risk of hip fracture).
■ Older adults may want to avoid carrying heavy loads.
■ Discuss the use of assistive ambulation devices and durable
■ Sturdy walking shoes, with low heels and rubber soles should
medical equipment to support safe balance and mobility.
be worn, avoiding backless shoes and strapless sandals.
■ Discuss the need to wear sensible footwear.
■ The home should be made safe. For example, eliminate
■ Discuss possible response to a fall emergency, including how
potential tripping hazards such as clutter and throw rugs,
to get up from a fall and acquiring a personal emergency
improve lighting, add nonslip floor surfaces, and install grab
response system (device designed to reduce the risk of down
bars in bathrooms.
time on the floor following a fall; device also helps to reduce
■ Older adults should exercise regularly to keep muscles toned,
fear of downtime).
joints flexible, and bones strong. Sample statements include:
Behavioral Strategies “Try to include such activities as dancing, gardening, and
stretching exercises to improve flexibility and balance. Weight-
■ Encourage the older adult to ask his or her primary care
bearing activities, such as walking and going up steps, help to
provider about fall risk. Encourage the older adult to get regular
strengthen muscles and bones.” “It’s important to talk to your
physical examinations even if feeling fine.
doctor before starting any exercise program so you don’t hurt
■ Encourage the older adult to ask about the side effects of all
yourself.”
medications. “Do they affect balance and coordination?” The

Vaughan, et al., 2010). About 8% of older adult falls with no
injury and 17.3% of falls with injury occurred in the bathroom
(Stevens, Mahoney, & Ehrenreich, 2014). However, few
studies have been conducted to address interventions for
these fall risks. Incontinence issues can be improved with
scheduled nocturnal prompted voiding or medical (pharma-
ceutical) interventions for urge incontinence, for example.
Shaw and Claydon (2014) recommended a medication review
to reduce the possibility of orthostatic hypotension as an
important component of fall risk reduction. Zermansky
and colleagues (2006) recommend the following “Geriatric
Rules”: lowest effective dose, a regular review of the medica-
tion(s), and reducing or stopping medication whenever pos-
sible. Additional interventions that may be beneficial for
older adults with postural hypotension who spend time in
bed include: keeping the head of bed elevated to 45°, using
pressure stockings, ensuring adequate hydration, encouraging
ankle dorsiflexion/plantar flexion and finger flexion/extension
prior to rising, and encouraging slow rising.
For older adults with health and medical conditions, it is
important that the management of these conditions be opti-
mized. For example, older adults with Parkinson’s disease can
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CHAPTER 16 ■ Neuromuscular and Movement Function: Falls 259

such as delirium and agitation, when restraints are used. The

TABLE 163 ■ Environmental Modifications to Reduce Risk evidence related to the provision of hip protectors to older
of Falls adults who are residents of LTC facilities is equivocal. Current
Floors 1. Avoid polish or wet floors
evidence recommends vitamin D in sufficient dose (1000 IU)
2. Use slip-resistant surfaces for LTC residents (Cameron et al., 2012). Vitamin D seems
3. Add nonslip adhesive strips to be effective in reducing falls and increasing muscle strength
4. Use indoor–outdoor carpet in those with severe vitamin D deficits. Last, there is conflict-
5. Use slip-resistant floor wax ing evidence regarding the influence of bisphosphonates and
6. Avoid thick or patterned carpet
7. Use double-faced tape at carpet edges
strontium ranelate supplementation on fall reduction. The role
of these medications is still under discussion (McClung et al.,
Walls Add grab bars, especially in bath, hall, stairs (round,
2013; Parikh, Avorn, & Solomon, 2009).
16–26 inches high, color contrasted to wall,
2–3 inches from wall)
Lighting 1. Increase intensity by two to three times, especially in
baths and stairways SUMMARY
2. Use three-way bulbs and rheostats Falls are one of the most serious health problems faced
3. Use full-spectrum, fluorescent light
4. Add night lights and bedside lamps with secure bases
by older adults and are the subject of researchers and policy
5. Add easy-to-find switches (accessible, contrasting makers worldwide. Older adult falls contribute to in-
color, pressure sensitive) creased health-care costs, increased hospitalizations, prema-
6. Use tinted windows, Mylar shades to reduce glare ture death, long-term care placement, physical injuries,
7. Add automatic turn-on timers immobility, psychosocial issues, and caregiver burden. It is
Tables 1. Avoid unsteady tables essential for all health-care professionals who work with older
2. Avoid drop-leaf or pedestal styles adults to understand why and under what conditions older
3. Use nonslip tops
people fall and fall risk factors. Of equal importance is an or-
4. Avoid low-lying, glass- and mirror-top tables
ganized “best practice” approach to the assessment of falls
Shelves 1. Move frequently used items to middle shelves and fall risk in older adults, as well as evidence-based multi-
2. Use reachers
disciplinary interventions aimed at preventing falls and the
Bath 1. Use grab bars, securely fastened associated negative consequences and sequelae.
2. Use adjustable toilet seat, securely fastened, with vinyl
with color contrast
3. Use nonslip strips in tub or shower
4. Install soap dispenser CASE STUDY
5. Add hand-held shower hose
6. Use a shower chair Glenda Landing is an 83-year-old woman who has expe-
Bed 1. Place at easiest transfer height
rienced several noninjurious falls at home over the past
2. If on wheels, lock and put on nonslip strips or 3 months. Her falls have taken place while walking to the
immobilize legs bathroom, reaching up into her kitchen cabinets, getting
Stairs 1. Add rails, extended 12 inches beyond stairs and in and out of her bathtub, and getting up from her toilet.
curved in at end After two of Ms. Landing’s falls, she was unable to get up
2. Add nonslip adhesive after falling and had to crawl on all fours to her living
3. Replace worn runners room, where she used the support of a chair to get up from
4. Mark edges
the floor.
Chairs 1. Tailor height to person
2. Feet should be firmly on floor; feet at 90 degrees; seat Medical History
depth 15 to 18 inches
3. Armrests should be 7 inches above seat Ms. Landing has a diagnosis of diabetes mellitus (treated
4. Use sturdy chairs with oral hypoglycemic medications), arthritis treated with
high doses of nonsteroidal anti-inflammatory medica-
tions), frequent nighttime urination (approximately four
be prescribed medications to decrease bradykinesia, those to five trips every night), glaucoma and cataracts, and im-
with osteoarthritis can engage in exercise and self-management paired hearing. Ms. Landing complains of a recent wors-
to control pain; conditions with treatable causes (peripheral ening of her hearing and occasional dizzy spells made
neuropathy due to vitamin B12 deficiency), vision or hearing worse with movement.
problems, and problematic foot problems (bunions, calluses)
can and should be addressed. Psychological History
Protective effects of restraints for fall prevention have never Ms. Landing is fearful about falling. In particular, she is
been demonstrated in controlled trials. In fact, it has been re- fearful of going outdoors by herself and fearful of environ-
ported that fall-related injuries and other effects are increased, ments and situations that may cause her to lose her balance
4605_Ch16_249-262 31/10/17 12:20 PM Page 260
260 PART II ■ Aging: Body Structures and Body Functions
and fall (e.g., walking at night, getting in and out of the
bathtub, and moving to and from the toilet). She also ex-
presses a fear that she will fall and be unable to get up, es-
pecially in her bathtub. As a result, she has restricted her
activities. She does not leave her apartment by herself and
no longer bathes in her tub. Ms. Landing complains
of feeling depressed about her situation and not being
able to go to church or visit with friends. Previously,
Ms. Landing had been independent in her activities of
daily living, but now her falls have dramatically affected
her feeling of safety.
Functional History
Ms. Landing exhibits both gait and balance impairments.
She complains that her walking and balance are worse at
night when she is going to the bathroom. Ms. Landing
has a cane and two-wheeled walker, but she doesn’t use
either device. The cane does not help her balance, and the
walker is difficult to use, particularly when she is walking
outdoors because its rear legs drag on the pavement, caus-
ing her to lose balance. Additionally, Ms. Landing has dif-
ficulty moving to and from her toilet and bathtub. She has
no bathroom grab rails or other equipment to support her
safe mobility.
Social History
Ms. Landing lives alone in a small, cluttered one-bedroom
apartment. Before her falls, Ms. Landing enjoyed going
to church on Sundays and visiting with friends who live
in her apartment building. Ms. Landing has a 54-year-old
married son who lives 10 miles away. Because of his busy
job and family obligations, he is only able to visit with his
mother once a week. During this time, he does his
mother’s grocery shopping and cleans her apartment. He
is very worried about his mother’s safety and is considering
placing her in a nursing home.
Questions
1. What are Ms. Landing’s risk factors for falling?
2. Given her risk factors, what should Ms. Landing’s
plan of care include?
Critical Thinking Questions
1. For what reasons might an older adult underreport
falls? Why might falls be overreported?
2. What are common risk factors for falls, and why do
they predispose an older adult to falls?
3. Compare and contrast the frameworks for fall risk
factors.
4. An older adult you are working with reports having
fallen 2 weeks ago. How will you determine
whether this individual is at risk of falling again?
For example, what assessments would be important
to conduct?
5. Assuming that you determine the older adult’s
(in Question 4) risk of falling is substantial, what
intervention strategies will you use to help reduce
the risk?
6. What are the potential negative outcomes if the
older adult falls again?
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Considerations for Medical Care
LEARNING OUTCOMES
By the end of this chapter, readers will be able to:
1. Describe the health conditions that are most common
among older adults.
2. Discuss the implications of those health conditions for
function and quality of life.
3. Describe the ways in which health conditions present
differently than they do in younger adults.
4. Discuss specific common health conditions affecting older
adults, including cancer, diabetes and other metabolic
conditions, endocrine disorders, urinary tract infections
(UTIs), pneumonia, and other infectious diseases.
5. Discuss the ways in which multiple diseases may overlap,
and the consequences of these interactions for function.
6. Describe relevant issues in use of over-the-counter and
prescription medications in later life.
7. Discuss the ways in which occupational and physical
therapy may contribute to treatment of individuals with
these conditions.
Clinical Vignette
Mary Ramos is a 78-year-old widow who has macular de-
generation, high blood pressure, and arthritis. Until last week,
she was active in many community organizations, socialized
with friends, and helped with child care for her four grand-
children. She described herself as being in good health and
as enjoying her life.
Over the past week, Mrs. Ramos became quite lethargic
and then developed a high fever. When her daughter came to
her home to pick up the two grandchildren, Mrs. Ramos had
been watching, she found her mother lying listlessly on the
couch. The daughter was sufficiently concerned to call emer-
gency medical services, and her mother was taken to the hos-
pital. In the emergency department, she was found to be
seriously dehydrated and delirious; she was diagnosed with a
UTI and put on antibiotics. Since then, her cognitive status
CHAPTER 17
of Older Adults
Patrick Bray ■ Bette Bonder
“I’m not young enough to know—J. everything.
M. Barrie
”
has deteriorated: she does not recognize her children and is not
oriented to place or time although she is oriented to person.
1. What are some characteristics of this situation that
might be found in an adult of any age?
2. What are some characteristics of this situation that
seem unique to an older adult?
3. What role do you see for occupational therapist or
physical therapist in evaluating Mrs. Ramos’s status
and development of an intervention plan?
A t some point during the aging process, illness or disabil-
ity will affect most older adults’ ability to undertake the
activities that give life meaning and sustain well-being. As dis-
cussed, some of those conditions are associated with specific
systemic changes that occur in later life as well as the many
medical conditions that can be seen at any age. “Aging itself is
associated with deterioration in health status, and acute hospi-
talization of the elderly even more so” (Zafrir, Laor, & Bitterman,
2010, p. 10). In the United States, older adults, particularly
those older than 85 years, accounted for a disproportionate
number of hospitalizations, even though these rates de-
clined somewhat between 2000 and 2010 (Levant, Chari, &
DeFrances, 2015). The most common reasons for hospitaliza-
tion, according to Levant and colleagues, were congestive heart
failure, pneumonia, and urinary tract infections (UTIs). These
conditions (among others) may present with “silent” symptoms
that make it difficult for the elderly person to perceive illness;
that is, symptoms may be vague, nonspecific, or hard to distin-
guish from declining function associated with aging.
AROUND THE GLOBE: Acute Care Needs of Older Adults
A study of nonagenarians in Israel found that atrial fibrillation,
infectious disease, and acute coronary syndrome were the main
causes of hospital admission, with mortality of approximately
22 percent (Zafir et al., 2010).
263
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264 PART II ■ Aging: Body Structures and Body Functions
A study of syndromes predicting hospitalization among
older adults in Australia found that those hospitalized were
more likely to have premorbid bladder incontinence and
activities of daily living limitations and to have experienced
at least one fall in the period before admission (Lakhan
et al., 2011).
Differential Impact of Disease
and Disorder in Later Life
Older adults are subject to the same ailments that affect
younger individuals, from colds to cancer, but many of these
conditions have differential presentation in later life (Besdine,
2013). In particular, compared with younger age-groups:
■ Normal age-related changes in physiology and psychoso-
cial factors can affect the development and outcomes of
diseases.
■ The severity of specific conditions can differ for older
adults.
■ Presenting symptoms may differ in later life, including
differences in level of fever and experience of pain.
■ The probability that there are multiple preexisting con-
ditions can complicate intervention.
■ Acute conditions can have significant implications for
morbidity or for postcare function.
■ The impact of hospitalization can be more significant in
later life.
It is worthwhile to examine each of these factors in some
detail.
Physiological and Psychosocial Factors
and Disease
Gradual loss of physical capacity can contribute to develop-
ment and course of disease in later life. For example,
decreases in strength and endurance can lead to less physical
activity, which may further erode cardiovascular capacity. As
a result, a simple cold can have much worse consequences
because the older individual has less extra capacity to cope
with the pulmonary symptoms (National Institute on Aging,
2011).
Another issue that may be overlooked is the impact of
social support, or loss thereof. A recent widow may find that
meals seem less important in the absence of someone with
whom to share them. Malnutrition may result, increasing
health risks. Poor diet can have particularly grave conse-
quences for older adults managing diabetes or other meta-
bolic issues.
Severity of Specific Conditions
As noted subsequently, cancer is common among older
adults. However, some cancers are less virulent in this popu-
lation. Prostate cancer, for example, can be less lethal and
more chronic when diagnosed late in life (Basu & Gore,
2015). Overtreatment can be a greater problem than the
cancer itself. “Aggressive treatment of men with limited life
expectancy for low- and intermediate-grade prostate cancer
is, at best, a poor gamble and, at worst, harmful” (Daskivich,
cited in Castellino, 2014, para. 4). On the other hand, in-
fluenza, which has significant but usually temporary symp-
toms in younger individuals, is much more frequently severe
or even lethal in older adults (Garnacho-Montero et al.,
2013). This may be due to the gradual decline in immune
system function that characterizes later life.
Presenting Symptoms
Pain and fever are two symptoms for which most people seek
medical attention. However, for older adults, these warning
symptoms may be absent or subtle in many illnesses.
For example, older patients may experience little if any
pain in acute bowel infarctions, gall bladder disease, myocar-
dial infarction, and peptic ulcer disease. Pain may also present
in an atypical pattern. For example, appendicitis may begin
in the right lower quadrant rather than periumbically as it
usually does in younger patients.
Likewise, fever may be absent or minimal for elders with
bacteremia, pneumonia, and UTIs. Common presenting
symptoms in later life are nonspecific: delirium, vertigo, light-
headedness, falling, weight loss, or incontinence.
If the individual doesn’t notice symptoms, care can be
delayed, and if the presentation is atypical, diagnosis and ap-
propriate treatment may also be delayed. Given the reduction
in physical capacity that occurs even in active older adults,
such delays can lead to serious, long-term dysfunction or even
to premature death.
Preexisting Conditions
Musculoskeletal, cardiovascular, cognitive, and sensory condi-
tions that are common in later life are not mutually exclusive.
An individual may have diabetic retinopathy, arthritis, chronic
obstructive pulmonary disease (COPD), and cardiovascular
disease, each of which not only has its own consequences but
also affects the impact of the others.
For example, degenerative arthritis (most likely os-
teoarthritis) is quite common in later life, as is osteoporosis
(see Chapter 15). An effective intervention for arthritis is
gentle, non–weight-bearing exercise. An important interven-
tion for osteoporosis is weight-bearing exercise that helps
maintain bone density. When providing services for an indi-
vidual who has both conditions, therapists must ascertain the
right type and intensity of exercise to avoid further damage
to joints and bone while maximizing function (de Rooij
et al., 2013). Comorbid conditions might mediate weight used
in exercise or the number and speed of repetitions. Using the
International Classification of Functioning (ICF; World
Health Organization [WHO], 2001) as a guide, a physical
therapist (PT) can explore comprehensive interventions that
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CHAPTER 17
may include a focus on such body functions and body struc-
tures as range of motion, postural stability and avoidance of
potentially damaging postures, and cardiovascular capacity
(Lorbergs & MacIntyre, 2013).
On occasion, medication to treat one condition can lead
to difficulties in other areas of function. For example, statins
are commonly prescribed to reduce heart disease risk. How-
ever, statins carry a risk of side effects that include severe
muscle cramping that can affect the ability to exercise.
Tamoxifen and aromatase inhibitors, prescribed to reduce the
risk of breast cancer recurrence in some women, contribute
to a kind of mental fogginess that can exacerbate cognitive
symptoms. Considerations about medication use in later life
are discussed in greater detail later in the chapter.
Acute Conditions
Not only do older adults have higher rates of hospitalization
for acute conditions, they also experience greater functional
loss and more frequent readmissions (Courtney et al., 2011).
Some elders recover well from the functional loss, particularly
if they were more functional before the onset of acute illness
(Palleschi et al., 2011). However, without active intervention,
a cascade effect can lead to long-term dysfunction and even
death. Occupational therapists (OTs) can intervene to min-
imize functional loss during hospitalization by providing
sensory input; activities focused on maintaining orientation
to person, place, and time; and practice with self-care, such
as feeding and independent toileting (Canon & do Couto,
2014). Early ambulation and gentle exercise, assisted by a PT,
is important to recovery as well (Skinner et al., 2015).
Think back to the clinical vignette at the beginning of this
chapter, Mrs. Ramos’s confusion and dysfunction may well
be a consequence of the UTI that led to fever and dehydra-
tion. It is entirely possible that adequate rehydration and
treatment with antibiotics may return her to full function.
However, clear evidence also shows that simply being bedrid-
den leads to deconditioning (Wick, 2011). In addition, if
hospitalization is required, this can lead to cognitive decline
with accompanying increased disability and decrements in
function (Wilson et al., 2012).
The Impact of Hospitalization
Older adults can experience much greater deconditioning and
functional deterioration during the course of a hospital stay
than is typically true for younger individuals (Wick, 2011).
This effect is particularly pronounced during a stay in an in-
tensive care unit (ICU) (Brummel et al., 2017). Older adults
may have difficulty remaining oriented to place and time in
a setting where one day is much like the next and sensory
input is both diminished and atypical. Hospitalization is as-
sociated with subsequent significant cognitive deterioration
(Wilson et al., 2011). It is not surprising that Mrs. Ramos
might be disoriented; the key issue is whether this can be
reversed or is the start of a longer-term decline.
■ Considerations for Medical Care of Older Adults 265
✺ PROMOTING BEST PRACTICE
Supporting Autonomy and Function in the ICU
Somme and colleagues (2003) undertook a randomized
controlled trial to determine whether specific interventions
modeled on those provided on geriatric care units would
reduce loss of autonomy among patients in intensive care.
The intervention included provision of enhanced sensory
input, particularly focused on orientation to time and place,
and on attention by an interdisciplinary team to ensure
that psychosocial needs were met. Although the study
did not enroll the number of participants that had been
anticipated, findings strongly suggested that this specialized
intervention reduced loss of autonomy and improved
outcomes.
It is important to note that in addition to increased mor-
bidity and mortality, the factors we have described that differ-
entially affect older adults contribute to greater functional
decline and diminished quality of life. As described later in
this chapter, occupational and physical therapy interventions
can be tailored to ameliorate some of these concerns, reducing
excess disability and contributing to improved quality of life
for older clients.
Common Medical Conditions
in Later Life
The following section discusses some of the most common
medical conditions affecting older adults.
Cancer
Cancer is common in later life. It is not a single disease but
rather a cluster of diseases characterized by abnormal cells
growing out of control. The impact of cancer depends on site,
type, and, to some extent, age.
For all cancers, the 5-year survival rate—the typical sta-
tistic used to assess cancer survival—is lower for older adults
(Centers for Disease Control and Prevention, 2011), although
for some cancers, notably breast cancer, the difference in
survival is very small. It is a bit difficult to interpret the dif-
ferential survival rates because for an older adult, many other
causes of mortality might intervene. Overall, the 5-year
survival rate among individuals older than 75 years is roughly
50 percent for whites and 40 percent for blacks. This com-
pares with roughly 80 percent for individuals younger than
45 years. There is quite a distribution, however, from about
14 percent for lung cancer to about 86 percent for breast can-
cer. For men, the most common cancers are prostate, lung,
and colon. For women, cancer mortality is greatest for breast,
colon, and lung cancer.
Cancer among older adults presents some unique chal-
lenges, but also some of the same issues and considerations
as are seen in treatment of younger individuals. Perhaps the
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266 PART II ■ Aging: Body Structures and Body Functions
greatest challenge at any age is to select the right form and
level of treatment. Cancer treatments, typically surgery, ra-
diation, chemotherapy, or some combination of the three,
have improved greatly for some cancers but remain invasive
and/or often accompanied by severe side effects. It is possible
to overtreat, resulting in poor quality of life and excess dis-
ability, or to undertreat, resulting in early mortality or excess
disability.
Older adults who have survived cancer may have long-
term consequences of their illness (van de Poll-Franse
et al., 2011). Psychosocial, cognitive, and physical changes
resulting from the disease and its treatment can persist
throughout life. Among these changes are the potential for
depression and anxiety, slowed cognition or poor memory
resulting from chemotherapy, or functional deficits result-
ing from loss of range of motion. Pearson and Twigg
(2013) recommend long-term rehabilitation to address
individual needs on an ongoing basis as individuals come
to terms with their experience, reestablish life goals and
routines, and find strategies to cope with the potential for
recurrence (see Figure 17-1).
Decisions about treatment must be based not only on
whatever evidence of efficacy is available but also on personal
preference. Evaluating personal preference can be an impor-
tant area for occupational and physical therapy. It is well es-
tablished that “severe illness, such as cancer, may block the
achievement of personally important goals and result in a loss
of important sources of purpose in life” (Pinquart, Silbereisen,
& Frölich, 2009, p. 253). For older adults, decisions about
treatment may rest on evaluation of life goals, and these con-
siderations may (or may not) differ from those of younger
individuals.
FIGURE 171 Thoughtful communication can help patients cope with
a cancer diagnosis. PHOTOS.com/Thinkstock
AROUND THE GLOBE: Cancer and Comprehensive Geriatric
Assessment in China
As is true in the United States, rates of cancer are high and
increasing among elders in China. A large-scale study focused on
comprehensive assessment of clients to ascertain their goals and
treatment preferences (Kanesvaran et al., 2014). Forty-five percent
of the participants were using traditional Chinese medicine while
also receiving other medical care; these participants were less likely
to choose typical chemotherapy. Two-thirds of the participants
were able to manage their daily activities, whereas the other third
needed support and assistance, particularly with instrumental
activities of daily living (IADL). Compared with a similar study in the
United States, a larger proportion of the Chinese participants were
living with a spouse. Although a large number smoked, many also
participated in tai chi, which showed numerous health benefits.
Occupational and physical therapy interventions respond
to the issues raised by the specific type of cancer and treat-
ment. For example, breast cancer requiring mastectomy can
result in limited range of motion in the associated upper
extremity, edema resulting from removal of lymph nodes,
fatigue associated with chemotherapy or radiation, impaired
cognition associated with medications, and damage to body
image. Physical therapy interventions are instrumental in
minimizing edema and restoring strength/endurance and
range of motion. Occupational therapy can provide energy
conservation strategies and address issues of body image and
loss of roles, routines, and meaningful occupations. Addi-
tionally, OTs can conduct home assessments with recom-
mendations for adaptive equipment. Energy level is often a
concern and can be addressed through instruction on strate-
gies for simplifying activities. Another example for OTs to
consider is when a colostomy—an opening in the abdominal
wall with a bag to allow for collection of body waste—is
necessary, instructions about managing the colostomy may
be needed, coupled again with a focus on body image and
perhaps suggestions about resuming sexual activity.
Regardless of the kind of cancer, therapeutic interventions
that help older adults regain physical capacity so they can
resume needed or desired activities and identify strategies
to manage the emotional consequences of the disease can
significantly improve quality of life.
Diabetes and Obesity
The rate of diabetes is rising rapidly around the world (Bajwa,
Sehgal, Kalra, & Baruah, 2014). This is a disease that presents
both immediate and long-term medical management chal-
lenges. Those long-term difficulties often emerge in later life,
with significant implications for health, function, and quality
of life (Rauseo, Pacilli, Palena, & De Cosmo, 2010). Diabetes
reduces both disability-free life expectancy and overall life
expectancy (Andrade, 2010).
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CHAPTER 17
Day-to-day management of diabetes requires careful atten-
tion to blood sugar levels and is usually based on dietary control
and medication, either oral or injectable (Rauseo et al., 2010).
Although many older adults with diabetes have had the disease
for years, it can also be diagnosed in later life; in either case,
dietary intervention is the fundamental strategy for reducing
long-term complications and avoiding hypoglycemic episodes.
Even for those elders who have been successfully controlling
the condition for long periods of time, later life requires ad-
justments (Bajwa et al., 2014). Among the issues they face are
changes in appetite, the potential for difficulty accessing ap-
propriate foods and/or preparing them, and changes in metab-
olism both of food and of medication. Likewise, reduced renal
function, even in the absence of renal failure secondary to di-
abetes, can alter body chemistry and lead to hypoglycemic
episodes. Monitoring blood sugar (Figure 17-2) is vital to ef-
fective management, but may be more difficult in those with
visual deficits or reduced fine motor coordination.
The long-term complications of diabetes are numerous,
can be serious, and can occur even in individuals who have
controlled the condition well. Complications include renal
dysfunction, including end-stage renal disease; diabetic
retinopathy, sometimes leading to blindness; cardiovascular
disease; and peripheral neuropathy, a condition that reduces
neuronal response to sensation. Individuals with diabetes
tend to have poor wound healing. In combination with the
peripheral neuropathy that reduces sensation of pain, gan-
grene is a not-uncommon consequence of diabetes. In fact,
FIGURE 172 Monitoring blood sugar is an important element of
diabetes management. monkeybusinessimages/iStock/Thinkstock
■ Considerations for Medical Care of Older Adults 267
diabetes is the most significant cause of lower extremity
amputation (Huang et al., 2014).
OTs and PTs must recognize the extent to which diabetes
is associated with disability and with poor quality of life. OTs
can focus on improving management by finding ways to help
elders follow dietary, monitoring, and medication recommen-
dations. An emphasis on functional deficits that interfere
with accomplishing valued goals is also important. PTs can
encourage physical activity that increases effective metabolism
of medications. Skin care is an important issue to minimize
pressure sores and the potential of gangrene. See Chapter 12
for more information on this topic.
Among the specific programmatic factors that have been
found to assist elders to manage their diabetes effectively are
social support (Nicklett, Heisler, Spencer, & Rosland, 2013)
and structured self-management (Brewer-Lowry, Acury,
Bell, & Quandt, 2010).
✺ PROMOTING BEST PRACTICE
Diabetes Management
A culturally tailored, peer-led support group program had
positive impact on diabetes management for a group of
older Mexican Americans (Haltiwanger, 2012). The intervention
involved training peer mentors to run weekly sessions focused
on providing information and management strategies for
participants. Over the course of the 8-week intervention period,
there was improvement in self-efficacy and attitude.
Rehabilitation efforts may also be needed. When diabetic
retinopathy is severe enough to cause significant visual im-
pairment, rehabilitation to manage mobility and self-care,
along with provision of assistive devices to minimize disabil-
ity can be essential. When limb amputation is required, care
for the wound, adjustment to a prosthesis or to wheelchair
mobility, and training on activities of daily living (ADL),
IADL, and other activities can enable the individual to re-
sume independent and meaningful daily life. Chapter 32
provides additional information about working with indi-
viduals who have had an amputation.
A condition closely associated with development of
diabetes is obesity. As is true for younger populations, the
proportion of older adults who are obese is increasing dra-
matically, both in the United States and in many other
developed countries (Tucsek et al., 2014). Obesity greatly
increases the risk of developing diabetes, but it is also associ-
ated with increased cardiovascular disease, musculoskeletal
problems, and Alzheimer’s disease. Although the relationship
between obesity and mortality appears to be somewhat
weaker in older adults than younger individuals (Canning,
Brown, Jamnik, & Kuk, 2014), this relationship still exists
and, further, there is significant evidence of increased mor-
bidity (Tucsek et al., 2014).
Interventions to reduce obesity emphasize physical activity
and diet. However, because many weight-loss strategies fail,
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268 PART II ■ Aging: Body Structures and Body Functions
interventions must be tailored for gender and ethnicity
(Malhotra, Malhotra, Chan, & Østbye, 2012) as well as for
psychosocial factors such as self-efficacy (Rejeski, Mihalko,
Ambrosius, Bearon, & McClelland, 2011) to foster the like-
lihood of success.
Urinary Tract Infection
UTIs are extremely common, particularly in women (Arinzon,
Shabat, Peisakh, & Berner, 2012). Menopausal women
who are sexually active are particularly at risk. In pre-
menopausal women, the symptoms are mostly local: blad-
der pain, burning on urination, frequency, and urgency.
In menopausal women, the symptoms are often more
systemic, including back pain and general body discomfort.
In addition, older women may experience difficulty void-
ing. Evidence shows that the disorder is not harmless, par-
ticularly in older women; in fact, it has been associated with
vertebral fractures, incontinence, rheumatic diseases, and
multi-infarct dementia (Eriksson, Gustafson, Fagerström,
& Olofsson, 2010b). It has also been associated with
lowered morale and quality of life (Eriksson, Gustafson,
Fagerström, & Olofsson, 2010a).
Assessing UTI can be difficult both because of its different
presentation in later life and because it can be challenging to
get accurate reports from the individual. In particular, UTI
is common in women with dementia, who may have difficulty
with toileting and who may also have difficulty communicat-
ing (D’Agata, Loeb, & Mitchell, 2013). It is important to
keep in mind that while less common, UTI can occur in men
as well, so care providers must remember to check for the
possibility of infection.
Individual episodes of UTI can be effectively treated with
antibiotics (Eriksson et al., 2010b). Estrogen treatment,
either oral or topical, can prevent recurrence, although estro-
gen has side effects, such as high blood pressure and the
potential for blood clots, that must be considered.
Treating incontinence can also reduce UTIs. Occupa-
tional therapists can help individuals establish regular toilet-
ing habits and schedules; schedule fluid intake; manage
clothing; transfer safely to and from the toilet, with the help
of mobility devices as needed (Mathur, Browning, & Mistri,
2010). Physical therapists are often involved in incontinence
management, with a focus on strengthening pelvic floor
musculature (Ghaderi & Oskouei, 2014). They may also provide
biofeedback and urgency control techniques (Mathur et al.,
2010).
Infectious Diseases
Susceptibility to infection increases in later life (Cagatay
et al., 2010) due to existing chronic conditions, decline in im-
mune function, immunosuppression related to medication,
or any number of other possible causes. At the same time,
symptoms of the infection are often atypical compared with
those seen in younger individuals. In particular, fever may or
may not be present, and when it is present, it may be due to
a noninfectious cause such as malignancy.
Influenza is the most frequent cause of death from infec-
tious disease in later life (Pop-Vicas & Gravenstein, 2011).
Most years, older adults account for 90 percent of the annual
death rate from flu. Typically, symptoms include fever, chills,
aches, headache, cough, and respiratory symptoms. In older
adults, however, the flu may present with cough, fatigue, and
confusion. This atypical presentation can delay diagnosis, re-
ducing the potential for antiviral treatment, which should be
given ideally within 48 hours of the first symptoms. Another
challenge for care of older adults is the increased risk of
secondary pulmonary complications.
In fact, pneumonia is another common infectious dis-
ease in older adults, sometimes occurring because of an-
other illness like flu or cold. Pneumonia can be classified
as community acquired (the most common), hospital ac-
quired, or health-care associated (occurring in residents of
nursing homes and other group living situations) (National
Heart, Lung, and Blood Institute, 2011). Older adults’ re-
duced cough and swallowing reflexes can contribute as this
may lead to aspiration of food and liquids. Pneumonia also
occurs independent of other infections, as in the case of as-
piration pneumonia (Juthani-Mehta et al., 2011). Modifi-
able causes of pneumonia include poor dental hygiene and
mobility limitations that reduce pulmonary capacity. OTs
can play an important role in improving dental hygiene by
providing positioning, and, as needed, assistive devices.
OTs are also licensed in some states to provide dysphagia
treatment; this treatment may also be provided by a speech-
language pathologist. PTs can assist in prevention by ad-
dressing pulmonary capacity and can enhance recovery
through graded physical activity to regain strength and
endurance.
Another infectious disease that should not be overlooked
in older adults is human immunodeficiency virus (HIV;
O’Brien et al., 2014). The rate of HIV infection is increasing
in this age-group in part because of the potential for initial
infection during unprotected sex. As treatment for HIV has
improved, making it a more chronic condition, individuals
who contracted the virus earlier in life are now living into old
age. This means that therapists must consider both those in-
dividuals dealing with recently acquired HIV and those who
have had the condition over a sustained period. According to
O’Brien and colleagues, HIV is experienced as a chronic
illness that can cause numerous disabilities resulting from
fatigue and pain. ADL, IADL, work, and social activities can
all be affected. There is now evidence of increased risk of car-
diovascular disease, diabetes, musculoskeletal and cognitive
disorders, and cancer. These issues tend to be episodic in
nature, requiring interventions that assist the individual in
developing coping strategies to address unpredictable periods
of illness and dysfunction (Solomon, O’Brien, Wilkins, &
Gervais, 2014). Interventions are focused on supporting func-
tion and minimizing the negative consequences of these as-
sociated disorders. Evidence shows that a focus on coping
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CHAPTER 17
skills and resilience can improve quality of life (Emler, Tozay,
& Raveis, 2011).
Nutritional Deficiency and Oral Health
For some older adults, nutritional deficiencies are a great
problem (Kaiser, Bandinelli, & Lunenfeld, 2010). Chapter 9
described changes in olfaction and gustatory sensation that
can make food less appealing in later life. Older adults who
live alone may fail to remember meals, or find eating alone
depressing. Inadequate nutrition can increase frailty, con-
tributing to osteoporosis, anemia, cognitive decline, lowered
physical capacity, and other conditions that reduce ability to
function in day-to-day life (Ford et al., 2014).
One cause of nutritional deficiencies in later life is poor
oral health (Wu, Plassman, Liang, Remie, Bai, & Crout,
2011). Older adults as a population have a higher rate of oral
disease (Yellowitz & Schneiderman, 2014), a situation which
is worse among the economically disadvantaged (Wu et al.,
2011). There are many reasons for the higher rate of poor oral
health, including lack of access to care and lack of informa-
tion about its importance. However, poor oral health has sub-
stantial consequences for overall health and well-being,
resulting from difficulty getting adequate nutrition due to
tooth loss or difficulty chewing. Therapists should attend to
their older clients’ oral health status, and encourage regular
visits to the dentist. They may need to involve social workers
who can assist in locating services that the individual can get
to and can afford.
Swallowing
One reason for poor nutrition is increased difficulty swallow-
ing. Swallowing is a complex process that is involved with
the movement of food and water from the oral cavity,
through the pharyngeal system, and into the esophagus to be
transported to the gut. Presbyglutition, normal age-related
changes associated with swallowing, is a normal part of bio-
logical aging whereas dysphagia, impairment in swallowing,
is considered abnormal. As individuals age, they experience
changes in the swallowing system across both sensory and
motor functioning. Because sensory functions have been pre-
viously discussed, this section largely focuses on changes in
motor functions.
Motor functioning of the swallowing system experiences
changes across three main continua including decreased
strength, slower movements, and less efficient closures.
Decreased strength is marked by changes in lip tensions,
tongue thrust, and pharyngeal propulsion that manifest in
poorer oral manipulation and packaging of a bolus, and
reduced ability to propel the bolus to the base of tongue
for the pharyngeal phase of swallow. Without sufficient
strength in the pharyngeal stage, food cannot be properly
propelled downward, leading to delayed transit times, mis-
aligned protective timings, and residual food along the pha-
ryngeal tract. Slower movements across the swallowing
■ Considerations for Medical Care of Older Adults 269
system can leave individuals at higher risk of aspiration.
Less efficient relaxation of the upper esophageal sphincter
(UES) can also put older individuals at risk for aspiration
(Logemann et al., 2009; Besanko et al., 2011). Some addi-
tional factors that can have a negative impact on an older
adult’s swallowing are the presence of dry mouth, impaired
dentition, altered taste perception, poor oral hygiene, and
cognitive factors.
Older individuals often naturally compensate for the
changes in swallowing. They may take smaller bites, chew
more thoroughly, and swallow multiple times per bite. In-
dividuals may also avoid certain textures or foods that pose
particular difficulty for them. However, when the individ-
ual can no longer effectively compensate for changes, social
consequences may occur with significant impact on the
quality of life as related to the social aspects of eating. Em-
barrassment caused by prolonged eating times, compensa-
tory strategies, or frequent choking and coughing can lead
individuals to withdraw from social eating situations. In
addition, when an individual withdraws from social eating
situations, as in a residential or retirement community, the
quantity and quality of their nutrition can become limited.
Asking an older adult questions such as “Do you cough or
choke when you eat or drink?” may elicit a very different
and likely more accurate response than “Are you having
problems swallowing?” Developing a shared knowledge and
semantic vocabulary around normal and impaired swallow-
ing habits is essential because eating is critical in maintain-
ing health and well-being. When in doubt, a referral to
speech-language pathologist for a formal evaluation is
warranted.
Frailty Syndrome and Posthospital Syndrome
Clinicians have long observed that even in the absence of a
diagnosable illness, some older adults become quite frail
toward the end of life. Frailty syndrome “1) is a clinical
syndrome, 2) indicates increased vulnerability to stressors,
leading to functional impairment and adverse health out-
comes, 3) might be reversible or attenuated by interventions”
(Chen, Mao, & Leng, 2014, p. 434). The syndrome includes
weakness, slowness, low level of physical activity, low level of
energy, and unintentional weight loss. Frailty is associated
with poor health outcomes regardless of any coexisting med-
ical condition and, in combination with other disability or
illness, predicts particularly poor outcomes. Frailty appears
to be caused by dysregulation of various systems such as mus-
culoskeletal and endocrine systems. In particular, chronic in-
flammation has been implicated. Frailty syndrome is quite
common in later life, leading to disability, poor quality of life,
and early mortality (Ruiz, Cefalu, & Reske, 2012).
Frailty syndrome is particularly responsive to exercise
(Chen et al., 2014). Medications (e.g., testosterone) have
been tried, but the evidence is not as compelling with regard
to their benefit. Interventions to address social stressors can
be beneficial.
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270 PART II ■ Aging: Body Structures and Body Functions
INTERPROFESSIONAL PRACTICE
Interdisciplinary Teams in Treatment
of Frailty Syndrome
Interprofessional teams appear to be the most successful in
addressing frailty syndrome (Chen et al., 2014). Teams should
include a geriatrician, nurse, social worker, pharmacist, and
occupational and physical therapist. Goals are to improve
function, reduce hospitalization and adverse events, address
disability, improve quality of life, and decrease early mortality.
Posthospital syndrome has some features in common with
frailty syndrome. However, unlike frailty syndrome, which can
occur in any older adult, posthospital syndrome is always as-
sociated with a hospital stay. It has been observed that “patients
who were recently hospitalized are not only recovering from
their acute illness; they also experience a period of generalized
risk for a range of adverse health events” (Krumholz, 2013,
p. 100). Approximately 20 percent of older adults discharged
from a hospital stay are readmitted within 30 days for heart
failure, pneumonia, infection, COPD, and other disorders, re-
gardless of the cause of the initial hospital stay (Krumholz,
2013). It appears that the combination of stress related to hos-
pitalization, sleep deprivation, pain, and sensory deprivation
put hospitalized older adults at risk of adverse outcomes.
Posthospital syndrome is closely associated with functional
deficits (Hoyer et al., 2014). This association suggests that
interventions to support function during the course of hos-
pital stays might prevent or minimize negative health out-
comes posthospitalization. Clearly occupational and physical
therapy are important to ensure that older adults receive
interventions to promote function.
Medication
Older adults are subject to a significant number of health
conditions, including those described in this chapter and in
Chapters 10 through 13. One consequence of the increased
number of health conditions is a potential for increased num-
bers of medications to control various aspects of health. Some
medications, like statins, which reduce low-density lipopro-
tein (LDL), and bisphosphonates, which may be prescribed
to minimize osteoporosis, have preventive functions. Others,
like antidepressants and insulin, are prescribed to address
existing medical conditions such as depression and diabetes.
In addition, as is true for younger populations, older adults
may choose to use any number of over-the-counter medica-
tions such as nonsteroidal anti-inflammatory drugs (NSAIDS,
e.g., ibuprofen or naproxen), cold medications, and vitamins.
General Principles for Effective Medication
Use in Later Life
Effective medication management for older adults requires
special consideration (Hubbard, O’Mahony, & Woodhouse,
2013).
The first consideration is the changes in pharmacokinetics
that accompany aging. Pharmacokinetics refers to the impact
of body function on the drug. As the body ages, many
biological functions slow. In the case of drugs, the impor-
tant factors include reduced metabolism and elimination
(Hubbard et al., 2013). The delay in metabolism and elimi-
nation can lead to increased drug levels in the bloodstream
or body, with associated toxicity. There is evidence that war-
farin, a blood thinner, is particularly difficult to regulate in
older adults (Perrero, Willoughby, Eggert, & Counts, 2004).
Pharmacodynamics refers to what the drug does to the
body. Ideally, a drug’s effects are therapeutic. In later life,
slowed absorption and distribution can reduce these positive
effects (Hubbard et al., 2013). Every drug also has adverse
effects. In the case of statins, for example, some individuals
experience severe muscle cramping and/or cognitive fuzzi-
ness (Reiner, 2014). Benzodiazepines, used for sleep or to
reduce anxiety—and also found in over-the-counter cold
medications—have particularly negative impact on older
adults (Hubbard et al., 2013). For example, dextromethor-
phan (used as a cough suppressant) can cause confusion and
dizziness. Pseudoephedrine, used to reduce nasal secretions,
can cause shakiness and nausea. Both these drugs cause
increase fall risk.
Because older adults often have multiple conditions that
require medications, polypharmacy becomes another critical
concern. More than 76 percent of older adults in the U.S. use
at least two prescription drugs, and 37 percent use five or
more (Gu, Dillon, & Burt, 2010). Drugs not only have indi-
vidual adverse effects, they can also interact with each other
(Hubbard et al., 2013). Drug interactions can result in
diminished therapeutic effectiveness if one drug blocks the
action of another, for example, or they can cause excessive
adverse effects if one drug potentiates another.
An added concern is that some of these issues may not be
readily obvious to the physician or pharmacist. For instance,
the individual may have one prescription from a cardiologist
for statins, another prescription from a psychiatrist for an
antidepressant, and be taking an over-the-counter sleep aid
(Chui, Stone, Martin, Croes, & Thorpe, 2014). Particularly
if these drugs are obtained from different sources, neither the
physicians nor the pharmacists filling the prescriptions may
have the full list. Electronic medical records that include lists
of a patient’s medications and that are available to care
providers in a given health-care system may improve com-
munication among providers, but it remains to be seen
whether they will reduce inappropriate drug interactions.
How do these factors appear in specific clients? It is not
unusual for an individual to be prescribed a dose of one or
more medications that is too high and to have several med-
ications with interacting adverse effects. The individual may
appear to be developing dementia, may be lethargic and un-
motivated, or may complain of vague pain or sensory prob-
lems. Prescribing physicians and the pharmacists who fill
those prescriptions need to be vigilant to avoid poor patient
outcomes such as dysfunction, poor quality of life, and, in
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CHAPTER 17
some instances, even institutional placement. The entire
health care team, including the PT and OT, must be vigilant
in identifying possible consequences of medications.
As an example, one 94-year-old woman was found by her
relatively inexperienced physician to have blood pressure
somewhat above the recommended level. Anxious to make
sure he adequately addressed her high blood pressure, he pre-
scribed a medication at a dosage suitable for her body weight,
but not her age. Two days later, she fainted during a family
event; the family took her to the emergency department,
where she was found to have very low blood pressure. She
had no further episodes of loss of consciousness once she
stopped the medication. Her physician had not noted that
(a) for older adults, somewhat higher blood pressure is ex-
pected and acceptable and (b) older adults require much
lower dosage of the medication in question.
Older adults may struggle to manage and maintain
the complex patterns of medication that may be prescribed
for them (Schlenk, Bernardo, Organist, Klem, & Engberg,
2008). Medications sometimes need to be taken more than
once a day, with or without food, early in the morning, late
at night. Such schedules can be a challenging memory task
for the older adult. In some instances, the individual may be
considered “nonadherent” when the problem is actually an
overly complicated schedule. In addition, patient package
inserts may contain information that is excessively detailed
and confusing.
Therapists have several important functions relative to
older adults’ medication routines. First, the therapist may no-
tice adverse effects that have not been reported. Unexpected
sleepiness, pain, or bruising with sudden onset may reflect
the introduction of a new medication that the patient does
not tolerate well. The therapist may also note the failure of a
medication to have the desired therapeutic effect. If depres-
sion does not lift within a few weeks of introduction of an
antidepressant, or if pain is not diminished despite the addi-
tion of a pain medication, the physician needs to be informed
so that alternatives can be tried. The therapist may also dis-
cern the individual’s difficulties managing the medication
schedule. Assistance structuring the schedule, such as practice
maintaining a daily pill dispenser, may help. Or the therapist
may need to inform the primary care physician that the
patient’s medication schedule or number of drugs may need
alteration. Pharmacists can be helpful and may be more read-
ily available than physicians.
Pain Management
Pain management in health care has received a great deal of
attention in recent years. Now referred to as the “fifth vital
sign,” pain is assessed frequently in health-care encounters,
typically by asking the individual to rate his or her pain on a
1-to-10 scale. Pain can result from acute or chronic illness,
disability, or can be idiopathic—of uncertain origin. Pain
has both physiological and emotional/perceptual components
(Kumar, 2011); understanding the individual’s experience
■ Considerations for Medical Care of Older Adults 271
of pain is essential to effective treatment regardless of the
person’s age.
For older adults, pain can be exacerbated by the interac-
tion of multiple factors. As an example, one 90-year-old man
reported increasing back pain. He had long-standing spinal
stenosis and arthritis, which he had experienced for many
years as moderately painful. He then developed the flu and
was in bed for 10 days during which time he experienced
much more intense pain. Although he recovered from the flu,
he remained fatigued and spent a good bit of time sitting in
his favorite recliner. The lack of physical activity made his
back pain even worse because it compressed the spine and re-
duced muscle strength and tone. He began to have difficulty
getting up from the chair, dressing himself, and bathing.
Addressing pain may involve pharmacological or non-
pharmacological approaches (Hadjistavropoulos, 2012). Ef-
fective use of medication can be challenging with older adults
for the many reasons described above. Opioids can cause
sleepiness, cognitive problems, and are not well tolerated by
some individuals (Boockvar, 2013). They are not always effec-
tive in relieving pain, and often cause constipation and other
gastrointestinal problems. NSAIDs often cause stomach
upset, particularly with prolonged use.
Self-management techniques (shifting attention, gentle
exercise) and other physical modalities such as heat can be
effective for some individuals (Hadjistavropoulos, 2012). The
most effective pain management is multidisciplinary.
INTERPROFESSIONAL PRACTICE
Multidisciplinary Approach to Pain Management
“Single modality treatment approaches are inadequate in
addressing the multidimensional impact of chronic pain”
(Corran, Helme, & Gibson, 2001, pp. 7–8). Pain management
is most helpful when it includes medication, physical and
occupational therapy, and psychological interventions. Among
potential interventions are breathing and relaxation exercises,
analysis and modification of pain-causing body mechanics,
and environmental modifications to improve ergonomics.
One intervention that is decidedly not helpful and must
be avoided is to simply indicate that pain is a normal part of
aging (Schofield, 2010). Effective pain management is pos-
sible at any age, and as is true for other concerns, the experi-
ences and needs of older adults should not be dismissed
lightly.
Substance Abuse
All too often, the issue of substance abuse in later life
is overlooked (Duncan, Nicholson, White, Bradley, &
Bonaguro, 2010). Some attention has focused on alcohol
abuse among older adults, but there is not an extensive lit-
erature on the subject. Much of the information on drug
abuse has focused on misuse of prescription medications.
Duncan and colleagues (2010) note that there is now a
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272 PART II ■ Aging: Body Structures and Body Functions
clear trend toward increased abuse of illicit substances
among elders, perhaps because of the experiences of the
current cohort of aging adults who represent the baby
boom generation. Over-the-counter medications, espe-
cially those used to treat colds or sleep problems, can also
be abused. As discussed in Chapter 1, cohort effects influ-
ence many aspects of the aging experience, and the Baby
Boomers were the first generation in which widespread use
of illicit substances such as marijuana was typical.
Older adults who have abused substances over long peri-
ods of time often experience excess illness and disability as a
result. They are underrepresented in older age-groups because
of the potential for early death (Duncan et al., 2010). The
proportion of elders with substance abuse disorders is smaller
than in other age-groups, but therapists must be alert to the
potential. Screening and brief intervention, with referral for
more intensive treatment as needed, can be effective in re-
ducing the health impact of substance abuse in later life
(Schonfeld et al., 2015).
Implications for Occupational Therapy
and Physical Therapy
As seen throughout this text, PTs and OTs have unique per-
spectives on evaluation and intervention to address client
well-being. Frameworks like the ICF (WHO, 2001) and the
Occupational Therapy Practice Framework: Domain and
Process, Third Edition (American Occupational Therapy
Association, 2014) guide therapists to organize their approach,
while incorporating the special considerations that apply in
working with older adults. These documents highlight the
role of OTs and PTs in supporting function, regardless of
medical diagnosis.
During acute hospitalization, regardless of the reason for
the inpatient stay, intervention to maintain body systems and
body function are highly significant. Deconditioning is a
problem for all hospitalized patients (Wick, 2011), particu-
larly those whose stays are extended or who are in the ICU,
and especially those who are older. Deconditioning cannot
be avoided entirely, but gentle range of motion—active if
possible, or passive—along with at least some movement
either in bed or walking to the bathroom or in the halls
are strategies that can reduce the negative impact of bedrest
(Figure 17-3).
An added concern for older adults who are hospitalized is
the lack of sensory input that helps to maintain cognition
(Crippen, 1999). During the typical hospital experience, one’s
clothing is taken away, along with jewelry and other valu-
ables. Hospital rooms tend to be plain, with unfamiliar
equipment as the major decoration. Auditory input includes
beeping from sensors and noise in the halls, and food tends
to be bland and mushy. Unpleasant for younger people, this
odd environment can lead to devastating consequences for
elders. Sensory input through music, reading articles from
the news, and reminding the patient of the date, time, and
FIGURE 173 Hospital rooms and routines are unfamiliar and
disorienting. Artush/iStock/Thinkstock
current events can all help to support cognition. Many hos-
pitals now have information boards in patient rooms; keeping
them current is important and sometimes overlooked.
Both PTs and OTs have a role in reducing readmission.
Intervention in the hospital focused on avoiding additional
injury due to falls, pressure ulcers, or deep vein thromboses
all can minimize length of stay, posthospital complications,
and the need for readmission (Roberts & Robinson, 2014).
Mobility and self-management programs can ease the adjust-
ment to the home environment, maximize adherence to med-
ical regimens, and encourage occupational engagement to
enhance quality of life.
Many of the conditions described in this chapter are
chronic and often lifelong. The Institute of Medicine
(2012) notes that diseases such as diabetes, cancer, and HIV
result in significant mortality and also in a wide range of
physical, mental, and social difficulties that affect the indi-
vidual and the family. Such diseases require long-term in-
tervention and support while individuals are living in the
community and, ideally, maintaining important activities.
For these individuals, occupational and physical therapy
intervention may be episodic as the conditions evolve, but
they are always focused on helping individuals accomplish
the goals that matter to them.
Consider some specific examples. As described earlier,
cancer survivors often experience deficits in function and
quality of life, especially in the first year after treatment
(Hwang, Lokietz, Lozano, & Parke, 2015). Body system dif-
ficulties such as lymphedema often respond well to physical
therapy that provides appropriate exercise, compression gar-
ments, and instruction about skin care (Leard & Barrett,
2015). Cognitive deficits associated with “chemobrain” may
require occupational therapy focused on adaptive intervention
(notes and reminders, development of specific routines) to
manage forgetfulness and difficulty concentrating (Player,
Mackenzie, Willis, & Loh, 2014).
4605_Ch17_263-276 31/10/17 12:20 PM Page 273
CHAPTER 17
Examining pain associated with cancer and cancer treat-
ment illustrates the ways in which physical therapy and oc-
cupational therapy intervention addresses the functional
consequences of a symptom that may cut across diagnoses.
Recommendations for physical therapy to address cancer pain
encourage a biopsychosocial model that deals with the various
physical mechanisms causing pain as well as the patient’s
emotional response (Kumar, 2011). That same model is rec-
ommended as an organizing framework for occupational and
physical therapy intervention for chronic pain, regardless of
its source (Lotze & Moseley, 2015; Robinson, Kennedy, &
Harmon, 2011). Gentle exercise, positioning, and instruction
in breathing techniques may be the focus of the PT, whereas
the OT emphasizes relaxation techniques, modification of
activities to reduce demand on painful body parts, and ex-
pressive occupations such as journaling or painting that redi-
rect attention and allow for expression of emotions.
Previous sections of this chapter have addressed various
chronic diseases. Here, too, physical therapy and occupational
therapy interventions focus on the impact of those diseases
on body function and body systems, activities, and participa-
tion (Hand, Law, & McColl, 2011). Interventions that fa-
cilitate function in these domains improve performance and
self-efficacy for clients of any age.
This does not mean that therapists should ignore the
unique characteristics of various disorders. For example, in-
dividuals with diabetes need to carefully monitor diet, exer-
cise, and medications. OT interventions to help them develop
daily routines improve self-management (Fritz, 2014). Oc-
cupational therapy also has a role in the management of obe-
sity, including educational interventions and environmental
modifications to encourage physical activity (Haracz, Ryan,
Hazelton, & James, 2013). Physical therapy to address the
need for exercise for patients with diabetes and to manage
obesity can also improve outcomes (Ries, 2015). Exercise in-
terventions reduce obesity and associated conditions like
asthma, and improve quality of life (Freitas et al., 2015).
✺ PROMOTING BEST PRACTICE
Productive Activities and Inflammation
Multiple chronic diseases, including arthritis, hypertension,
and heart disease are associated with inflammation. Kim and
Ferraro (2012) investigated whether productive activities would
reduce C-reactive protein, which is a marker of inflammation.
They found that multiple roles, and volunteering in particular,
may protect individuals from inflammation associated with
heart disease.
SUMMARY
Older adults experience many of the same illnesses, acute
and chronic, that affect younger individuals, but age-related
changes mean they may experience different symptoms and
■ Considerations for Medical Care of Older Adults 273
that their illnesses may have different courses than younger
individuals. Some conditions may be more severe in older
adults, others less severe. For chronic conditions, long-term
consequences emerge in later life, with potentially debili-
tating impact. Age-related changes in physiology, body sys-
tems, and body function must be understood to ensure that
effective interventions are identified, and potential for harm
avoided.
Physical and occupational therapy focus on function.
Their interventions can maximize positive impact of med-
ical treatments by assisting patients to understand and fol-
low recommendations. They can also maximize activities
and participation by emphasizing maintenance or enhance-
ment of physical capacity, by identifying and supporting the
occupations most valued by clients, and by modifying envi-
ronments to support performance.
Subsequent chapters in this book focus on providing care
to support specific occupations and tailoring that care for
the system in which it is provided. For PTs and OTs, med-
ical diagnosis is one of many factors that affect the collab-
oration between client and care providers to maximize
function and quality of life. Understanding the ways in
which these conditions unfold is important information in
anticipating the kinds of functional deficits that the indi-
vidual may experience, the needs she or he may have for
support or intervention.
CASE STUDY
Mr. Bingham is an 80-year-old African American man
who lives in a second-floor walk-up apartment with his
wife of 60 years. He has two adult daughters, one son, and
eight young adult grandchildren. One of his daughters
lives in a downstairs apartment, and his son lives a mile
away. Most of the grandchildren have moved away, although
two still live in the area.
Mr. Bingham worked for many years as an account-
ant. He retired at 65 and since then has been involved
with his church choir, reading to elementary school chil-
dren at the local school, and helping his neighbors in
the apartment building with small chores and repairs.
He and his wife enjoy going to church events and to
dinner with friends. His wife takes care of laundry,
cooking, and cleaning in the apartment. Mr. Bingham
manages the finances, handles household repairs, and
maintains the car.
Mr. Bingham was diagnosed with type 2 diabetes
30 years ago. He had good care at that time, attended a
diabetes education class, and has managed his diabetes
well with diet and oral medication. He was encouraged
to exercise, but “doesn’t like to.” So other than his house-
hold activities, he is relatively sedentary.
Recently, Mr. Bingham developed a bad cold that lin-
gered for several weeks. He had a severe cough, fatigue,
and a mild fever. His wife and daughter were so worried
4605_Ch17_263-276 31/10/17 12:20 PM Page 274
274 PART II ■ Aging: Body Structures and Body Functions
they took him to the local emergency department. An
x-ray revealed that he had pneumonia, and he was hospi-
talized and prescribed antibiotics.
Questions
1. What are some potential consequences of the
hospitalization for Mr. Bingham’s overall health
and function?
2. What occupational therapy and/or physical therapy
interventions might be helpful while Mr. Bingham is
in the hospital?
3. Describe some considerations about strategies that
might be helpful for Mr. Bingham once he returns
home to ensure that he regains his premorbid level
of function?
Critical Thinking Questions
1. What are some ways in which older adults have
better outcomes of medical conditions than younger
adults?
2. In the context of what you read in Chapters 6
through 13, discuss how systemic changes affect
the consequences and outcomes of care for acute
medical conditions.
3. What are potential emotional consequences of a cancer
diagnosis for older adults? How, if at all, might these
differ than those experienced by younger individuals?
4. Discuss reasons that older adults might have diffi-
culty managing their diabetes. What are some
strategies that therapists might use to help them
improve their ability?
5. What are some reasons that issues relevant to
HIV might be overlooked in an older population?
6. Why are occupational therapy and physical therapy
perspectives important in addressing substance abuse
in older adults?
7. Why might a team approach be most effective in
addressing medical issues for an older population?
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PA RT III
Active Aging: Supporting Client
Activities and Participation
B y now it should be clear that different professions
conceptualize elements of later life through different
lenses. In particular, the meaning of function differs, with
implications for evaluation and intervention to support
well-being. Biologists emphasize the function of anatomical
structures and physiological processes. Sociologists focus on
function in social, cultural, and environmental contexts.
Occupational therapists and physical therapists define func-
tion as ability to accomplish those activities that individuals,
families, and communities need and want to do.
Having examined the many factors that contribute to
function as understood by occupational therapy and physical
therapy, it is time to focus on the activities themselves. Just
as biological and social factors change throughout the life
course, so do occupational profiles. Self-care requirements
and wishes change, the balance of work and leisure shifts, and
many other elements of occupational constellations alter.
And, as is true of biological and social factors, there are both
general, common age-related changes and highly individual
needs and preferences.
This section of the text explores important categories of
occupation in detail. By now it will come as no surprise that
while these chapters describe general characteristics of
occupational categories, the way they are enacted and interact
for specific individuals is unique. Some individuals may well
prefer to receive help with self-care or instrumental activities
of daily living so that they have more energy for meaningful
leisure occupations. Other elders may retain a fierce sense of
independence with regard to taking care of their basic needs.
Of course, in addressing these preferences, consideration of
context is vital. An older adult might prefer to be assisted with
self-care, but if his or her social support network does not offer
such help, either resources must be identified or strategies for
simplifying the activities must be considered.
Such consideration may extend to thinking about strate-
gies for using technology (both high and low tech) to support
function, thus maximizing independence and minimizing the
need for human assistance. In addition, careful consideration
must be given to driving and other community mobility, both
as occupations in their own right and as a means to access
occupations.
Ensuring that older adults have the greatest possible
opportunity to enact meaningful occupations is a complex
undertaking that requires careful evaluation. The final chapter
in this section explores strategies for accomplishing that
evaluation.
277
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“involves
The capacity to do something useful for yourself or others is key to personhood, whether it
the ability to earn a living, cook a meal, put on shoes in the morning, or whatever
other skill needs to be mastered at the moment.
LEARNING OUTCOMES
By the end of this chapter, readers will be able to:
1. Define self-care activities within the domains of everyday
occupations.
2. Distinguish between activities of daily living (ADL) and
instrumental ADL (IADL) activities and describe their
relevance in health, wellness, and quality of life.
3. Identify the symbolic and practical meanings of self-care
activities.
4. Understand the performance of self-care activities as a
function of the individual and the environment.
5. Understand the relationship between self-care performance
and perceptions of competence and control.
6. Summarize research findings on limitations in self-care.
7. Identify common assessments of ADL and IADL used for
older adults.
8. Identify intervention strategies for enabling self-care
performance.
Clinical Vignette
Robert Macarthur is a 75-year-old man recently diagnosed
with Parkinson’s disease and mild dementia. He lives alone in
his three-story home and until recently was able to manage
with occasional help from friends. Over the past few months,
Robert has developed tremors and difficulty with gross and fine
motor movement. He is able to walk but is slow and unsteady.
Stairs have been difficult as have showering and dressing.
Mr. Macarthur is a retired high school French teacher
with a moderate pension, but recently his funds have
diminished due to various medical costs and need for home
adaptation. Historically he was very active, loved to play
tournament tennis, and traveled the world with his ex-wife
and various friends. He has expressed frustration at his
decreased motor abilities and increased forgetfulness.
He has one son who lives in the same city but no other
CHAPTER 18
Self-Care
Kristine Haertl
—M. C. Bateson (1996, p. 11)
”
family nearby for support. Mr. Macarthur’s physician has
recommended he consider moving, but he fears leaving his
community and friends he values.
1. What are some of the psychological implications of
Robert’s situation, and how might an occupational
therapist (OT) address them?
2. What might a physical therapist (PT) focus on in
concert with the OT?
3. What are the current and potential effects of Robert’s
diagnoses on self-care?
A complete understanding of the functional performance
of older adults includes recognizing the importance of
daily activities and how they contribute to overall health and
well-being. Self-care skills are affected by declining function,
including sensory limitations, cognitive declines, reduced
strength and agility, and restricted mobility. These often ac-
company chronic disease and expected physiological changes
that occur through the aging process. Emphasis is placed on
preserving function and developing strategies to maximize
quality of life throughout the performance of activities of
daily living. This chapter considers self-care, a special category
of the domain of everyday human activity that has important
implications for the health and well-being of elderly persons.
The chapter begins with a definition of self-care and
describes a framework for understanding how daily living
tasks often present challenges to older adults as they attempt
to fully engage in life and participate in society in order to
achieve a sense of well-being. Within this framework, self-
care may be viewed as a foundation to social participation.
This discussion is followed by a brief review of common
limitations to functional performance and how they can be
assessed. The chapter concludes with a description of the
possibilities for intervention, including requirements for
assistance in performing self-care tasks.
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280 PART III ■ Active Aging: Supporting Client Activities and Participation
Defining Self-Care
Self-care is daily activity composed of duties and chores rang-
ing from personal care (e.g., bathing, dressing, grooming)
to personal business (e.g., using the telephone, managing
medications, banking, or shopping for food). These tasks are
fundamental to living in a social world; they enable basic
survival and sustained health and create a sense of self-efficacy
and greater life satisfaction. Following a comprehensive
analysis of 139 definitions of self-care, Godfrey et al. (2011)
proposed the following definition: “Self-care involves a range
of activities deliberately engaged throughout life to promote
physical, mental, and emotional health, maintain life, and
prevent disease. Self-care is performed by the individual on
their own behalf, for their families and communities, and
includes care by others” (p. 11). For the purposes of this chap-
ter, emphasis is placed on individual self-care activities that
are sometimes referred to as activities of daily living (ADL)
or independent activities of daily living (IADL; American
Occupational Therapy Association [AOTA], 2014).
The Practice Framework (AOTA, 2014) classifies ADL as
including bathing/showering, toileting and toileting hygiene,
dressing, eating and feeding, functional mobility, personal
device care, hygiene and grooming, and sexual activity. The
Framework indicates that IADL are more complex and support
life within the home and community including care of others,
care of pets, child rearing, communication management, driv-
ing and community mobility, financial management, health
management and maintenance, home management, meal
preparation and clean up, and spiritual activities. Together
basic or personal self-care activities (ADL) and IADL may be
viewed as forming a foundation for survival and participation
in the community.
Positive aging emphasizes the importance of personal
choice, and the capacity to participate in multiple domains
including that of personal care (Brownie & Horstmanshof,
2012). Not only is independence in performing self-care
ADL a significant aspect of life satisfaction in older persons
(Sato, Demura, Kobayashi, & Nagasawa, 2002), but contin-
ued participation in one’s personal care routine is viewed as
essential to avoiding disability, maintaining independence,
and promoting health (Hoy, Wagner, & Hall, 2007). These
elements—the person, his or her transactions within the
physical and social environment, and the successful perform-
ance of the specific tasks necessary to those interactions—are
referred to repeatedly in the description of a general concep-
tual framework for self-care.
Models to Explain Everyday Functional
Abilities
Many models in the social and behavioral sciences explain
the factors that influence everyday actions. Most usually
consider the individual person as well as the environments
in which a person transacts the business of living. Such
“contextual or ecological” models are often described in terms
of “person–environment fit.” The implication is that people
best meet the demands of living when their capabilities fit
well with those demands (Deci & Ryan, 1991, 2011). Deci
and Ryan’s Self Determination Theory of Motivation (SDT)
proposes that individuals have innate tendencies to act in
effective ways within everyday activity and that social context
and psychological experience affects behavior (Deci & Ryan,
1991; 2011). This theory emphasizes the innate properties
of an activity or occupation that have intrinsic value and
motivation.
Competence is defined as the ability to do something
successfully or efficiently (Oxford University Press, 2014).
Ecological or person–environment-fit models view compe-
tence as dependent both on the individual’s capabilities and
skills and on the nature of the task and the environment in
which it is performed. The term environment here includes
not only physical aspects, such as natural terrain or the man-
made, “built” environment (such as buildings, tools, and other
objects), but also the less apparent sociocultural environment
that influences the attitudes and expectations of performance,
through policies, customs, or societal prejudices. In rehabil-
itation, emphasis is placed on considering person factors
along with contextual aspects of the activity. Both physical
context and social contextual factors (e.g., cultural, social,
temporal) influence an individual’s self-care performance. For
instance, an aging client with increased weakness and spasticity
poststroke will have varying ability to perform independent
dressing skills based on person factors (e.g., motivation, area
of stroke) along with contextual factors such as the setup of
the room, the type of clothing, and the adaptive equipment
available.
Competence, Value, and Meaning in Self-Care
Before 1990, the term everyday competence appeared in
the gerontological literature to refer to a person’s ability to
perform activities considered essential for independent living,
even though an individual may not perform these tasks on a
regular basis or may do so only infrequently (e.g., White,
1959). Modern understanding of competence involves
physical, psychological, and social functioning, which are
dependent on a host of underlying factors.
Personal value and meaning affect occupational perform-
ance. In the context of self-care, someone who values per-
sonal appearance may take extra time and care dressing and
grooming. The nature, type of dress, and context in which
the grooming takes place is further affected by cultural norms
and social expectations. The successful completion of the
dressing and grooming would therefore contribute to an
individual’s self-perception and personal satisfaction.
An individual’s ability to carry out daily activities com-
petently is also affected by client factors, context, and task
requirements. Personal competence is unique for each
individual and is constantly changing. Although everyday
competence may involve instrumental tasks that are viewed
4605_Ch18_277-294 31/10/17 12:17 PM Page 281
as mundane or as less meaningful than discretionary activ-
ities, these tasks are nonetheless foundations for participa-
tion in a social world and are important symbols of personal
competence and efficacy.
Significance of Self-Care
Self-care is integral to human function (Orem, 1995).
Research has identified self-care activities as a contributing
factor to healthy aging and longevity (Gilbert, Haggerty, &
Taggert, 2012) and quality of life (Landa-Gonzalez, &
Molnar, 2012). Decline in the ability to perform ADL and
IADL may lead to increased dependence on the health-care
system and increased need for in-home supports. Self-care
factors including personal mobility, fall risk, malnutrition,
and cognitive impairment have been shown to predict pro-
longed hospital stays in the older population (Lang et al.,
2006). In addition, decreased ability in ADL upon discharge
from the hospital negatively affects the recovery prognosis
(Boyd et al., 2008), thus rehabilitation intervention involves
special attention to ADL.
The extent of an individual’s ability to perform self-care
tasks independently affects decisions about the need for
personal care assistance or special environments, including
the need for home health services, assistance from caregivers,
or placement in long-term-care facilities. In Western coun-
tries, especially in the United States, approaches to caregiving
often stress independence, whereas in other parts of the
world, interdependence is more common, as cultures with
kinship networks often have multigenerations living together
and caring for one another.
For example, in the United States, a chronically ill indi-
vidual is defined by the Health Insurance Portability and
Accountability Act as any individual who has been certified
by a licensed health-care practitioner as being unable to per-
form (without substantial assistance from another individual)
at least two ADL for a period of at least 90 days due to loss
of functional capacity (U.S. Department of Health and
Human Services Centers for Medicare and Medicaid Services,
2005). As older adults experience a decline in function,
increased assistance or a change in residence may be required
to provide supports needed to manage daily self-care require-
ments. Yet in other countries and with other cultures, efforts
may be made to maximize time spent at home and caring for
kin. For instance, Asian cultures often emphasize caregiving
and respect of elders (Lai, 2007), which may result in multiple
generations living together; thus, consideration of caregiving
in the context of self-care must take on a cultural lens.
AROUND THE GLOBE: ADL and IADL Difficulties
and Long-Term Care
About 20 percent of European residents older than 65 years who
have functional limitations receive institutional long-term care
(Onder et al., 2012), and an additional 30 percent receive care at
home (Giannakouris, 2008). By comparison, in the United States,
CHAPTER 18 ■ Self-Care 281
roughly 4 percent of those older than 65 years were in an assisted
living facility because of functional limitations as of 2009 (Federal
Interagency Forum on Aging Related Statistics [FIFARA], 2012),
About 41 percent of Medicare enrollees reported a functional
limitation and 12 percent had difficulties with one or more IADL
(FIFARA).
Practical Importance of Self-Care: Nutrition, Safety,
and General Health
Self-care activities are important because they are necessary
for survival, safety, and general health. One of the primary
health and survival requirements is adequate nutrition. With-
out nourishment, health declines rapidly. Good nutrition
requires the ability to plan menus and prepare food, as well
as the ability to eat independently, or “self-feed.” In addition
to motor, sensory, and cognitive disabilities that limit meal
preparation, some elderly people have dental problems or
lack the teeth to eat regular meals. Lack of appetite and
willingness to eat may also affect nutritional intake. Level of
education, socioeconomic status, and degree of urbanization
have also been shown to affect nutrition (Weimer, 1998),
and physical inactivity and poor diet have been linked to
decreased quality of life (McNaughton, Crawford, & Salmon,
2012).
Because of these factors, older adults may be at risk for
poor nutrition. A study of homebound older adults found
poor dietary quality was universal; half or more consumed diets
that deviated from recommended standards for at least 13 of
the 24 nutritional guidelines studied (Millen et al., 2001).
Challenges also exist to maintain adequate nutrition in sup-
ported living environments given the limitations on choice
and dietary restrictions placed on an individual receiving care;
quality nutrition within health-care institutions is integral to
the well-being and health of aging populations (Saeidlou,
Merdol, Mikaili, & Bektas, 2011). Clearly, nutrition is an
important public health issue among seniors, which relates
directly to self-care activities in both meal preparation and
meal consumption.
Safety is another concern for older adults. The inability
to maintain a safe living environment may lead to injury.
For instance, to maintain adequate nutrition, one must have
the ability to prepare and cook healthy meals. Research has
demonstrated that lack of mobility in seniors and poor envi-
ronmental setup often leads to safety hazards in the kitchen
(Ibrahim & Davies, 2012). Additional physiological and
cognitive effects of aging often result in diminished sensory
function such as poor visual acuity due to macular degenera-
tion. Care should be taken to minimize environmental hazards
and teach compensatory and adaptation skills necessary for
safe performance of ADL and IADL.
According to the Centers for Disease Control and Pre-
vention (2014), falls are the leading cause of fatal and non-
fatal injuries in seniors. Care must be taken not only to
maintain physical health and mobility but also to minimize
environmental barriers that could contribute to falls or to
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282 PART III ■ Active Aging: Supporting Client Activities and Participation
functional mobility deficits. For example, steps and passage-
ways within living environments for community-dwelling
elders must be well lit, glare free, and without unnecessary
obstacles or hazardous surface conditions. See Chapter 16
for additional discussion on falls and falls prevention.
Finally, the ability to perform self-care activities promotes
better general health. Adequate personal hygiene and sani-
tation protect the individual from germs that spread disease.
Laws protecting public health are based on awareness that
neglect of hygiene can contribute to poor health.
Self-care performance has practical importance because
it enables people to maintain their personal health and the
environments in which they live. It also has symbolic impor-
tance because it enables social relationships, fosters and reflects
self-identity, and promotes psychological well-being.
Importance of Self-Care for Self-Identity
and Socialization
Western cultural norms place value in meeting self-care
needs and fitting in with society. Meeting social expectations
requires role performance that extends to dress, appearance,
speech, mannerisms, and other elements of symbolic com-
munication in the culture. Functional capacity and personal
self-care have been shown to relate to healthy self-esteem,
life satisfaction (Backman & Hentinen, 2001), and healthy
aging (Gilbert et al., 2012). Self-care has also been shown to
influence personal identity and perception of life situation
(Sundsli, Espnes, & Soderhamn, 2013). Maintaining func-
tion is necessary not only for performing daily living tasks but
also for promoting an individual’s self-esteem, social accept-
ance, and, ultimately, social well-being.
Importance of Self-Care for Psychological Well-Being
Studies have shown that the inability to perform everyday
tasks, such as self-care and IADL, has a negative impact on
psychological well-being (Badke, 2000). Drageset (2004)
found that as competence in ADL declined among seniors
in nursing homes, their loneliness and social isolation tended
to increase. A randomized controlled study in postoperative
hip surgery patients compared those patients who had
occupational therapy versus those who had no therapy; at
2 months postsurgery, the therapy group had statistically
significantly higher levels of mobility-related IADL and
higher levels of health-related quality of life and well-being
(Hagsten, Svensson, & Gardulf, 2006). Ability to perform
self-care and ADL also facilitates leisure and social activi-
ties, as well as a greater sense of psychological well-being
(Lawton, 1990).
Part of this psychological effect of self-care and well-being
is related to perceptions of competence and agency, or the
ability to act on the environment. In earlier decades, remaining
at home gave elders a sense of control over their environment
and promoted a sense of well-being (Zingmark, Norberg, &
Sandman, 1995). More recently, additional emphasis has been
placed on providing a variety of housing options including
retirement communities and other alternatives (Blanchard,
2013; Guo & Castillo, 2012). As individuals age, decline in
function may lead to the need for in-home supports or other
housing alternatives. Physiological changes associated with
the aging process often create conditions that decrease per-
formance or enjoyment of daily activities. The following
section addresses the impact of various impairments on daily
function.
Prevalence and Type of Limitations of
Activities of Daily Living Among Older Adults
Data from the National Health Interview Survey in 2011
showed that among elders older than age 75, 12 percent
needed help from another individual to complete ADLs, and
20 percent needed help to complete IADLs (U.S. Depart-
ment of Health and Human Services, 2012). Those of low
socioeconomic status were nearly three times as likely to need
ADL/IADL assistance, yet the report did not explore reasons
for the difference. In addition, those between ages 45 and 69
were three times more likely to be unable to work due to
health reasons as those aged 18 to 44. There is a trend toward
decreasing disability, perhaps due to improvements in general
health and in technology (Spillman, 2003).
In the United States and elsewhere, socioeconomic status
is associated with IADL function (d’Orsi et al., 2014; U.S.
Department of Human Services, 2012).
Effects of Medical Conditions
on Self-Care
Rates of disability and associated functional limitations have
been shown to increase with age (Thompson, Zack, Krahn,
Andresen, & Barile, 2012). Additional factors contributing
to functional limitations in aging populations include pain
secondary to chronic conditions (Covinsky, Lindquist,
Dunlop, & Yelin, 2009) and diseases, such as heart failure,
stroke, cognitive impairment, and diabetes mellitus (Miller
et al., 2004). The following section covers specific conditions
common in older adult populations and the impaired function
that may result. An awareness of potential impact on self-
care due to aging and disability is critical to the development
of strategies for evaluation and intervention. For additional
detail on these conditions, see Chapters 7 through 17.
Stroke
Cerebrovascular disease can result in weakness or paralysis of
extremities on one side of the body, visual limitations,
vestibular and sensory problems, and loss of the ability to
communicate, all of which may have a devastating impact
on the ability of an individual to perform self-care tasks.
Kwakkel, Wagenaar, Kollen, and Lankhorst (1996) reviewed
the literature to determine variables capable of predicting
functional ADL outcomes after stroke. Their analysis suggested
4605_Ch18_277-294 31/10/17 12:17 PM Page 283
that paralysis, sitting balance, level of social support, urinary
continence, and cognitive factors that influence orientation
to time and place are the factors most predictive of ADL
function after stroke. Kristensen, Post, Poulsen, Jones, and
Minet (2014) found that many individuals with mild stroke
were able to regain independence in ADL and IADL;
however, some required additional adaptations and special
equipment, which suggests the importance of rehabilitation
in providing resources and strategies in functional recovery.
Cardiovascular Disease
Persons with cardiovascular disease report significant func-
tional limitations as compared to the general population
(Scott & Collings, 2012). Lack of energy, decreased fitness,
lower limb swelling, and angina may all impair an individ-
ual’s ability to perform daily self-care, especially in activities
that require a significant amount of mobility or energy
expenditure. Rehabilitative efforts in cardiac recovery often
include progressive exercise, psychosocial and spiritual
counseling, and home programs designed to follow medical
limitations yet maximize self-care functions (Huntley,
2008).
Dementia and Cognitive Decline
Studies have verified that cognition and memory play a crit-
ical role in the performance of everyday tasks. A decline in
cognitive functioning is inherent in the aging process and
lessens the rate at which older adults process information,
thereby reducing their ability to perform ADL in a timely
manner and diminishing the time available for other perhaps
more meaningful activities (Lawton, 1994; Owsley, Sloane,
McGwin, & Ball, 2002). Functional limitations occur due to
difficulties with planning, preparing, and following through
the task requirements of ADL and IADL. The ability of
individuals with dementia to complete ADL and IADL affects
levels of care needs and institutionalization (Luttenberger,
Schmiedeberg, & Grabel, 2012). Evaluation and intervention
in dementia care often includes an assessment of current
functional level, living environment, and ability to follow
through daily tasks with good safety and judgment.
Joint Inflammation and Disease
In a 10-year follow-up within a National Retirement Study,
persons with arthritis were significantly more likely to have
difficulties with functional mobility and ADL than those
without the condition (Covinsky, Lindquist, Dunlop, Gill,
& Yelin, 2008). Research also demonstrates that those with
rheumatoid arthritis (RA) with higher levels of pain and
disability have lower levels of agency (personal competency
and follow through) with self-care (Ovayolu, Ovayolu, &
Karadag, 2012). Persons with RA who attend and follow
through with a joint protection program may increase their
long-term functional ability (Hammond & Freeman, 2004),
CHAPTER 18 ■ Self-Care 283
thus demonstrating the effectiveness of rehabilitation inter-
vention for persons with joint disease.
Sensory Problems
Sensory problems impact the daily functioning of older
adults. These problems are covered in detail in Chapters 9
and 14 but are briefly described here in relation to their
impact on self-care performance.
Vision Problems
Vision impairment causes limitations in dressing, eating,
writing, reading of medications, and other important items
(Markowitz, Kent, Schuchard, & Fletcher, 2008), and func-
tional mobility (Cobb, 2013). Studies of community-
dwelling elders indicate that visual impairment is correlated
with the need for assistance in ADL and IADL, resulting
in higher levels of loneliness and poorer self-rated health
(Jacobs, Hammerman-Rozenberg, Maaravi, Cohen, &
Stessman, 2005; R. Williams, Brody, Thomas, Kaplan, &
Brown, 1998). Intervention and use of assistive devices can
increase daily function (Dahlin-Ivanoff & Sonn, 2004).
Hearing
The impact of hearing deficits on the quality of life is well un-
derstood, but some evidence shows that hearing impairments
can also influence performance of ADL. Diehl (1998) found
significant relationships among general health, cardiovascular
health, and hearing impairment when measuring an older
adult’s performance on a set of observed tasks of daily living.
In addition to the value of assistive listening devices, the
acoustic treatment of surfaces to reduce extraneous sounds
and rearrangement of furniture can be useful in reducing the
consequences of hearing loss (McNair, Brown, Stone, &
Sims, 2001). Therefore, these characteristics should be given
careful attention and consideration by those who have the
ability to modify living environments.
Touch
Diminished sense of touch may cause safety issues such as
lack of sensitivity to temperatures (e.g., in adjusting water
temperature for the shower) and in fine motor tasks such as
threading a needle. Sensory loss associated with conditions
such as stroke requires strategies to facilitate coping and
occupational adaptation (S. Williams & Murray, 2013).
Techniques such as sensory stimulation have been shown to
facilitate tactile responsivity in older adults (Voelcker-Rehage
& Godde, 2010). A thorough sensory evaluation with aging
populations should include not only hearing and vision but
touch sensation as well.
Taste and Smell
The impact of declines in taste and smell on nutrition is readily
apparent. If food is enjoyed less, appropriate intake may
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284 PART III ■ Active Aging: Supporting Client Activities and Participation
become problematic. Because of these sensory deficits, elder
persons may not take in adequate nutrition or may choose to
put too many spices (e.g., salt) on their food (Saxon, Etten,
& Perkins, 2010). Additionally, olfactory deficits can increase
the risk of ingesting spoiled food by older adults living in the
community (Ripich, 1995). Continued monitoring of nutri-
tion intake is a critical part of the rehabilitation team’s roles
and responsibilities.
Measuring Self-Care Performance
Self-care and IADL evaluations for the elderly population
are performed for several reasons. Evaluation of self-care
gives a better understanding of geriatric medical problems as
a decline in function is an early indicator of disease or illness.
Self-care assessments also identify the level of impairment or
disability. A brief discussion is provided here, with greater
detail included in Chapter 27.
The results of self-care assessment as part of a comprehen-
sive evaluation helps professionals identify the individual’s
potential level of functioning and develop effective interven-
tions. Determining an elderly person’s ability to live inde-
pendently and the supports (internal and external) needed to
do so can be ascertained, in part, through an assessment of
self-care and IADL skills. Gerontology literature has focused
on prediction of ADL function to assist in determining
the need for residential placement (Albert, Bear-Lehman, &
Anderson, 2014). There is somewhat less emphasis on mea-
sures that guide possible remediation or compensatory strate-
gies, although remediation or compensation can help older
adults avoid institutionalization.
Because self-care and IADL are multifaceted, it is neces-
sary to use assessment measures that are multidimensional.
Often, therapists use more than one type of method to gain
a greater understanding of an individual’s capabilities. A
review of a person’s history, interviews with the individual
and the caregivers, and direct observation of task performance
supply objective and subjective data. This adds detail about
the individual’s performance, and when used with a variety
of evaluation techniques, the sum of these methods leads to
the clearest determination of where and why limitations in
function occur.
In the event of functional difficulties in a particular ADL/
IADL, the complexity of everyday tasks demands that the
evaluator pay careful attention to the factors underlying
the individual’s inability to perform. For example, a person
involved in a cooking task may have difficulty following writ-
ten directions because of visual impairment or problems with
verbal directions because of hearing impairment. The person
may also have memory deficits that make it difficult to recall
the correct sequence of steps to execute a task successfully.
Persons with aphasia may have difficulty with reception or
expression of language, causing poor comprehension or
communication resulting in impaired daily function. For
example, someone with receptive aphasia might be able
follow written, but not verbal, directions to fry an egg or vice
versa. Determining the underlying cause of the functional
deficit is necessary for successful intervention planning.
✺ ■
PROMOTING BEST PRACTICE
Evaluation of Self-Care
Use validated, standardized scales when possible.
■ Choose measures that are sensitive to change in client
status.
■ Remember that performance-based measures are best.
■ Measure performance in the actual living setting.
■ Include IADL in any comprehensive assessment.
■ Incorporate living area assessments into overall evaluation.
■ Consider the client’s needs, lifestyle, and living setting before
setting intervention goals based on assessment.
Assessing Factors Contributing to Self-Care
Deficits
Sensory and Sensorimotor Deficits
The majority of self-care and IADL assessments require
adequate vision. The Rivermead Perceptual Assessment
Battery was initially designed to assess visual perceptual
skills after head injury or stroke and later to assess older
adults as well (Whiting, Lincoln, Bhavani, & Cockburn,
1985). A newer test of ADL for persons with visual impair-
ment, the Melbourne Low Vision ADL Index, has been
developed and demonstrates satisfactory reliability and
validity (Haymes, Johnston, & Heyes, 2001a, 2001b, 2001c).
The test is not only a measure of ADL but is also useful for
measuring the impact of disability on ADL function
(Haymes et al., 2001a). Tests of visual field or neglect may
be paper-and-pencil tasks or computerized virtual analysis
(Ulm et al., 2013).
Hearing loss distorts any assessment process because of
potential difficulty hearing the instructions and misinterpre-
tation of the information. Various self-care instruments may
be used to assess individuals with hearing impairment. In
addition to tools designed by occupational therapy, research
has demonstrated the validity of the WHO DASII (World
Health Organization, 1999) as an effective tool for assessing
activity limitations for persons with adult acquired hearing
loss (Chisolm, Abrams, McArdle, Wilson, & Doyle, 2005).
AROUND THE GLOBE: Hearing Interventions in Developing
Countries
Although persons in many nations have ready access to
rehabilitation services, those in developing countries may not
have the same opportunities for evaluation and intervention.
For persons in developing countries with little access to hearing
specialists, recent trends have included the use of self-fitting
hearing aids, which may enhance hearing capabilities (Convery,
Keidser, Dillon, & Hartley, 2011; Dillon & Keidser, 2011) and thus
functional performance.
4605_Ch18_277-294 31/10/17 12:17 PM Page 285
Many assessments for self-care and IADL skills include
tasks with motor components. These tasks frequently require
the manipulation of objects or the use of pen and paper that
may be difficult for elders because of decreased flexibility,
coordination, and other declines. The Assessment of Motor
and Process Skills can be used to assess observable motor
skills required to carry out IADL (Fisher, 2006). However,
the training and costs of administering this assessment limit
its practicality in many settings. It does provide a standard-
ized means of assessing motor and processing skills during
ADL performance. Another test, the A-One (Arnadottir,
1990) assesses neurobehavioral dysfunction within an ADL
context, and may be used to determine the extent a sensory
motor dysfunction impacts occupational performance.
Cognitive Impairment
Measures such as the Cognitive Performance Test (Burns,
2011) may facilitate an understanding of the potential impact
of cognitive decline and functional performance, yet therapists
must be aware that mild cognitive impairment may be less
likely to be detected in ADL measures (Jefferson et al., 2008).
Another evaluation, the Bristol Activities of Daily Living Scale
(Bucks, Ashworth, Wilcock & Siegfried, 1996) is designed
especially for persons with dementia. The instrument consists
of caregiver ratings for 20 daily living activities. The scale’s
psychometric properties indicate satisfactory reliability, and it
correlates well with the Mini Mental Status Examination.
Assessing Instrumental Activities of Daily Living
Several assessments have been designed specifically to
measure IADL functioning in older adults. Examples in-
clude Tappen’s (1994) Refined ADL Assessment Scale and
the Older Americans Resource and Services (Pattie, 1988).
The Assessment of Living Skills and Resources combines
11 IADL tasks with varying available resources to determine
the level of risk when comparing current resources available
to resource needs for the individual (Baer & Smith, 2001).
Another evaluation, the Independent Living Scales (Loeb,
1996), provides a comprehensive assessment of IADL along
five scales including (a) memory/orientation, (b) managing
money, (c) managing home and transportation, (d) health
and safety, and (e) social adjustment. Results are placed on
a normative scale and provide insights for intervention and
discharge planning.
Interestingly, of the various tools available, the Lawton
Instrumental Activity of Daily Living Scale (Lawton &
Brody, 1969) has stood the test of time and is one of the most
widely used IADL instruments in older adults (Graf, 2008;
Vergara et al., 2012). This test has established psychometric
data supporting the original English version, and in recent
years, the Spanish version has been shown to have robust
reliability and validity (Vergara et al., 2012). This test is
more abbreviated than many other IADL measurements
because it measures eight domains and can be done within
about 15 to 20 minutes.
CHAPTER 18 ■ Self-Care 285
With many of the assessment tools described in this
section, observation of performance is necessary to validly
assess everyday competence because client self-reports often
overestimate ability (Hilton, Fricke, & Unsworth, 2001).
Burton and colleagues (2009) found that sensitive IADL
questionnaire measures can be comparable to performance-
based assessments in predicting function. For example, the
inability to manage finances may be one of the earliest detec-
tors to mild cognitive impairment and future conversion to
dementia (Gold, 2012). Thus, rehabilitation practitioners
should familiarize themselves with reliable and valid perform-
ance and questionnaire-based IADL assessment tools.
Home-Based Assessments
For a comprehensive IADL evaluation, home-based assess-
ments may be advantageous because they allow the individ-
uals evaluated to perform tasks in their natural environments
and the contexts in which they typically occur. They have
been shown to yield more accurate results (Bottari, Dutil,
Dassa, & Rainville, 2006). These assessments take the envi-
ronment into account when assessing the client’s ability to
carry out day-to-day activities safely and provide a firsthand
account of actual performance. In addition, they allow recom-
mendations for equipment, modifications, and adaptations
specific to each individual’s home.
Several assessments that evaluate self-care (ADL) and
IADL performance in older adults may be used in the home
or clinic. The Performance Assessment of Self-Care Skills
(PASS) is a criterion-referenced, performance-based obser-
vational tool that helps therapists determine safety aspects,
independence, and outcomes of functional mobility; basic
ADL; and IADL performance tasks (Holm & Rogers,
1999). The Functional Independence Measure (FIM) has
been shown to be a valid measure of basic ADL (e.g., bathing,
dressing, toileting) in older adults (Claesson & Svensson,
2001). The Arnadottir (1990) OT-ADL Neurobehavioral
Evaluation (A-One) is another carefully defined scale to
measure performance and underlying cognitive processes.
In this assessment, client neurobehavior is assessed through
observation of dressing, grooming, hygiene, transfer, mobil-
ity, feeding, and communication. Selection of IADL assess-
ment tools should consider the reason for referral, ability of
the client to engage in the evaluation process, the reliability
and validity of the tool, and the ability of the assessment to
provide the desired information in the therapy process.
Assessing Environmental Factors
When assessing function in the older adult population, eval-
uators often overlook environmental factors—the physical
environment (e.g., living space and the objects therein) and
the social and cultural environment (e.g., group memberships
and interactions) in which the individual performs life tasks.
The level of assistance, support, and adaptations individuals
require to carry out self-care and IADL is also a component
of the environment. The availability of such support may
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286 PART III ■ Active Aging: Supporting Client Activities and Participation
enhance function, just as lack of support can hinder the
individual’s level of functioning. Assessing the environments
in which specific tasks take place can be difficult because
the environment is often a home, a workplace, or another
location in the community.
Assessment of the social environment concerns the care
receiver and the caregiver, which in this context can be defined
as a knowledgeable person who is able to provide assistance
to older adults and receive training in their care. It is impor-
tant that the caregiver is able to manage caregiving needs
and has a healthy attitude regarding functional independence.
Strategies for working effectively with informal caregivers
are discussed in Chapter 24. Involvement of older adults in
social activities may be compromised by a decline of inde-
pendence, the inability to perform self-maintenance tasks,
or poor mobility. Cultural factors, such as the individual’s
health, beliefs, values, roles, education, experiences, and
family makeup, need to be taken into account to ensure that
the assessment is relevant to the individual being assessed.
Several assessments are available to evaluate the impact
of older adults’ environments on their level of functioning
and ability to maintain self-care. Because the environment
is not an isolated component of everyday functioning, many
assessments also address cognitive, self-care, and IADL
function. The Home and Community Environment Instru-
ment (Keysor, Jette, & Haley, 2005) is an example of a help-
ful instrument. It assesses the following domains: (a) home
mobility, (b) community mobility, (c) mobility devices,
(d) communication devices, and (e) attitudes. This assess-
ment has shown promising psychometric properties for
home evaluation.
Safety
Ensuring safety in the physical environment is crucial to
maintaining the older adult’s current level of functioning
and to preventing further disability. In addition to the tools
discussed in the previous section, two useful assessments that
address safety include Darzins’s (1994) Functional Assess-
ment and Safety Tool (FAST) and the Safety Assessment of
Function and the Environment for Rehabilitation (SAFER)
(Oliver, Blathwayt, Brackley, & Tamaki, 1993). Both the
FAST and the SAFER were designed to evaluate older
adults’ ability to perform functional activities safely within
their home environments; the FAST also addresses available
support systems. A summary of some of the more common
self-care assessments can be found in the online ancillary
materials.
Activities of Daily Living Intervention
As previously described, progression of normal aging, patho-
logical conditions, and trauma can create impairments and
limitations in function that interfere with the performance of
ADL and IADL. In many cases, intervention techniques can
address these difficulties (see Box 18-1).
BOX 181 Important Questions for Setting Self-Care
Intervention Goals
■ How important is the activity to the client and his or her
well-being? Is it client-directed?
■ Does the client feel the time and effort required for self-
performance is worth the benefit?
■ What assistive technologies are available to facilitate
the task?
■ Does the living environment support safe performance and
quality of life?
■ To what extent will the activity contribute to the individual’s
sense of identity and social participation?
■ Have the perspectives of family members or caregivers been
considered?
■ What is the client–environment–task fit in developing
the ADL and IADL goals?
For older adults, the limitations of function often are due
to chronic and progressive disorders or injuries due to falls
and accidents. Compensatory strategies may helpfully focus
on adaptation of the environment, task, or the use of residual
function. In changing the context of performance, the indi-
vidual may be provided with assistive devices, or modifica-
tions may be made in the physical environment. If the current
living situation does not promote optimal occupational per-
formance, the individual may choose to move to a congregate
home or an apartment complex designed for older adults or,
in cases of significant functional deficits, in an assisted living
or skilled nursing facility.
Remediation strategies are directed at correcting the un-
derlying pathology or physiological change. If this is accom-
plished successfully, performance of ADL requirements
usually improves. This is an area in which involvement of the
whole treatment team can help ascertain potential prognosis
and the most helpful course of action. For instance, if an
individual has a cognitive impairment due to a stroke or head
trauma resulting from a fall, the timing of the incident, the
amount and type of damage, and physician prognosis for
improvement have a bearing on intervention planning.
Physical therapy may be central to efforts to remediate
underlying body function deficits.
The following sections provide brief summaries of skill
training, environmental changes, assistive technologies, and
task modification approaches useful for enabling people to
perform self-care tasks. The section is not meant to be ex-
haustive, but rather to summarize approaches that may be
used in ADL and IADL intervention.
Skill Training
The use of skill training in elder rehabilitation requires clinical
discernment as to the client’s goals, desired skills, prognosis,
and projected living environment. For instance, an individual
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CHAPTER 18 ■ Self-Care 287

with a left cerebrovascular accident (CVA) who has good

prognosis for recovery may go through fairly intensive phys-
ical and cognitive rehabilitation in hopes of returning to
independent living in his or her home. However, skill training
in high-level IADL such as financial management would not
likely be undertaken for someone with moderate to advanced
stages of progressive dementia. Thus, establish/restore
approaches as outlined in the Practice Framework (AOTA,
2014) are usually used when prognosis for significant recovery
is positive. Such approaches are generally used when it is
expected skills can transfer to the client’s living environment
(Latham, 2008). Conversely, if the client’s current and
projected future skill level does not match the demands of the
context (environment), modifications to the task or environ-
ment are often used to enhance functional performance. FIGURE 181 Rhoda Erhardt, MS, OTR/L, FAOTA, designed her home
based on principles of universal design. The home features open
spaces, wide hallways, natural light, and adapted living areas (see
INTERPROFESSIONAL PRACTICE additional photos of bath areas). Photo courtesy of Kristine Haertl.
Roles in ADL and IADL
Although occupational therapy practice heavily focuses on
ADL and IADL, several professions are concerned with an
motor and sensory deficits. Store- and street-located automated
individual’s ability to carry out daily self-care. Nurses may
teller machines (ATMs) must be available at an accessible
initially work with the client, especially in acute care, to ensure
height, but drive-through ATMs can often be a problem
safe practices in transfer and daily care. Referrals will likely
because they are exempted from the legislation. Chapter 23
be made to occupational and physical therapy for additional
addresses community mobility in greater detail.
rehabilitation. OTs generally conduct formal assessment in
Within the home, individuals with deficits affecting
ADL and IADL and develop intervention plans guided toward
mobility often require ramps, widened doorways, or other
successful rehabilitation and discharge (e.g., to the client’s
accommodations for facilitating wheelchair access. In multi-
home). PTs will often address strengthening and functional
story homes, the conversion of downstairs rooms to bedrooms
mobility required for self-care activities. For instance, following
or bathrooms may be necessary. In general, safety can be
a hip fracture, the OT may address hip precautions and return
enhanced by replacing rugs and carpets with tile, wood, or
to dressing, bathing, and other self-cares, a PT may emphasize
linoleum. Leg extenders can be added to low chairs or beds
strengthening and return to safe walking, and both may
to improve the ease with which people can transfer to or from
work on safe transfers and recommendations for the home
them. High legs on beds or chairs can be cut to lower the
environment. There is some disagreement about which
height, and in recent years motorized furniture is available to
disciplines should provide self-care intervention; understanding
lift a person to a stand if weak leg muscles make sit-to-stand
the complex nature of this functional area can help clarify the
movement difficult. For those in wheelchairs, simply remov-
roles of various professionals who may contribute to client
ing interior doors may provide sufficient access. If privacy is
improvement.
not an issue, this approach avoids costlier modifications.

Environmental Modifications Bathroom and Dressing Areas

Environmental modifications range from curb cuts to major
alterations in the design of rooms or dwellings. Environmen-
tal modifications for self-care activities related to mobility,
food preparation and eating, toileting, and dressing can
enhance ADL abilities. Environmental modifications may
be particularly problematic in low-income areas or in devel-
oping nations where other health-care concerns take priority.
Figure 18-1 shows what is possible when adequate resources
are available and structures carefully considered.
Mobility
Community mobility and the performance of some IADL
tasks, such as shopping, often depend on the presence of curb
cuts, ramps, and signage that permit travel by persons with
Bathroom modifications for safety and access include higher
toilet seats and shallow sinks positioned in lowered counters
(Figure 18-2). Grab bars should be installed for showers
and tubs, and insecure towel racks removed or replaced
(Figure 18-3). Glass shower doors should be replaced with
shower curtains. A tub chair (Figure 18-4) and removable
showerhead is often helpful for those with coordination and
balance issues. All areas need adequate lighting and nonskid
surfaces (Christensen, 2004). Cabinets may be lowered and
cabinet doors removed to make them accessible for persons
with physical limitations. Adequate room must be ensured
for transfers from wheelchair to bed. Electric beds that can
be purchased or rented can improve accessibility to persons
with physical limitations. Closets should have adequate
reachable storage and access to clothing and other needed
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288 PART III ■ Active Aging: Supporting Client Activities and Participation
FIGURE 182 A raised toilet seat is often helpful for elders with
mobility difficulties. Photo courtesy of Kristine Haertl.
FIGURE 183 Grab bars and shower curtains enhance safety and ease
of mobility in and out of the shower. Photo courtesy of Kristi Haertl.
items. Control systems to operate lights, drapes, fans, televi-
sions, stereos, and heat are available and can greatly reduce
the physical demands of adjusting the environment.
Kitchen Modifications
Common kitchen modifications include lowered counters
and sinks, and the installation of microwave ovens as adap-
tations for persons with mobility restrictions. The choice of
appliances (side-by-side refrigerators, bottom or top freezers)
depends on the individual’s limitations. In the kitchen and
FIGURE 184 This reclining tub chair adds safety and mobility options
for those who prefer taking baths over showers. Photo courtesy of
Kristine Haertl.
all rooms, lighting and color contrast should be planned to
improve visibility without glare.
Although modifications may be made to create better,
safer, and easier home environments for self-care and every-
day living, only a small percentage of older adults who need
such modifications have had them installed. This may be
due to financial restrictions, lack of awareness, or inadequate
intervention strategies. Yet research shows that home modi-
fications facilitate the ability for individuals to age in place
(Hwang, Cummings, Sixsmith & Sixsmith, 2011). Modifi-
cations should consider the aesthetic preferences and needs
of all the home’s inhabitants.
✺ PROMOTING BEST PRACTICE
Self-Care
Research demonstrates that community-based exercise
promotes health and wellness, function, and decreased health-
care costs in stroke survivors (Stuart, Chard, & Roettger, 2008).
A partnership between the Veterans Administration and the
Administration on Aging has worked to conduct a translational
research initiative implementing an exercise program that has
been shown to be effective for stroke survivors in Italy. A key
factor identified in the program’s success is access to quality
exercise and gym facilities. Rehabilitation professionals are
key in developing quality programs to facilitate stroke
rehabilitation to maximize self-care, health, and wellness.
Figure 18-5 depicts a well elder without any chronic illness
and his dedication to exercise.
Assistive Devices for Self-Care
The use of assistive devices can help older adults overcome
impairment, promote safety through the prevention of acci-
dents, and enhance independence and quality of life. Timers
on stove burners, electronic sensors for turning on lights,
4605_Ch18_277-294 31/10/17 12:18 PM Page 289
and monitoring water temperature can support ADL and
IADL and minimize accidents. Research has demonstrated
that while assistive technology can increase functional
performance, older adults need support in learning how
to work with assistive devices and in getting used to them
(Skymne, Dahlin-Ivanoff, Claesson, & Eklund, 2012).
Current advances have significantly broadened the scope,
sophistication, and availability of assistive devices as described
in Chapter 21.
Task Modifications
Task modification—also known as compensation—strategies,
a final category of intervention, may successfully address some
self-care limitations in older adults with intact cognition and
endurance who have caregiver support and the motivation to
practice. Modification means substituting one act for another
or using a device to replace lost ability. For example, adults
who cannot reach or bend because of balance deficits or
restricted range of motion may use a reacher to pick up objects
on the floor. Use of the reacher, however, requires upper
extremity coordination, wrist and grip strength, and adequate
cognitive skills.
Compensation or task modification strategies are often
coupled with remediation strategies. Teaching task modifi-
cation requires adequate practice to facilitate automatic per-
formance of ADLs (Flinn & Radomski, 2008). Simple task
alteration may include use of built-up utensils or the an
FIGURE 185 Wayne, age 82, routinely bikes more than 75 miles a week.
He attributes his positive health behaviors and exercise in maintaining
independence in ADL and IADL. Photo courtesy of Kristine Haertl.
CHAPTER 18 ■ Self-Care 289
extended handle, whereas significant alterations may include
learning to dress with one limb or perform a task with the
nondominant hand. Significant alterations take more time
and energy to master.
Task modifications are appropriate if the older adult
desires or needs immediate success, if the therapist expects
little or no improvement in the older adult’s sensory or motor
deficits, if the person prefers this method, or if the therapist
identifies problems with safety. A simple example of self-task
modification might be recommending that the older adult
with limited standing tolerance sit down to perform activities
typically performed while standing, such as washing dishes.
Older adults with fatigue or limited endurance can perform
more difficult IADL earlier in the day, thus avoiding the
exertion, stress, or cognitive errors when they have the least
energy. Regardless of the intervention used, a client-centered
focus is integral to the development of intervention goals and
strategies for treatment.
SUMMARY
The self-care activities of older adults discussed in this chapter
are of vital importance to meaningful participation in the
home environment and in the larger social world. The nor-
mal aging processes as well as various health conditions can
cause sensory, motor, and cognitive losses that limit self-care
performance, yet maintaining positive health and exercise
can help delay the onset of ADL and IADL difficulties (see
Figure 15-5)
Assessment of an individual’s performance in his or her
environment can identify potential interventions to help older
adults manage needed ADL and IADL performance. In
addition to skill training, environmental modifications, assis-
tive technologies, and modifications in task performance may
reduce the need for institutionalization (and loss of control
and self-identity) by preserving self-care functions. If, with
this help, elders can successfully remain at home, or if they
can live productively in a community, this may foster the self-
esteem and sense of well-being that we all cherish as adults.
CASE STUDY
Occupational Profile
George Arkmadian is a 74-year-old man who was admit-
ted to the acute care unit of the local hospital after he was
found by his wife with slurred speech and significant
weakness on the left side of his body. He stayed in the
acute care unit for 9 days before being transferred to the
inpatient rehabilitation unit for more intensive therapy to
address his decreased ADL functioning. His past medical
history includes a right CVA 7 years before this admis-
sion, hypertension, coronary artery disease, and mild
dementia. Mr. Arkmadian presented to the inpatient
rehabilitation unit with residual left limb weakness, left-
sided paresis, incoordination, and slight left neglect. He
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290 PART III ■ Active Aging: Supporting Client Activities and Participation
stated that he was independent in ADL before hospital-
ization. Mr. Arkmadian lives with his wife and son in a
one-story home with a ramped entry. He already had a
raised toilet with arms, a handheld shower, and a wheel-
chair, as well as a tub bench and rolling walker that he
does not use. Given his cognitive changes in recent years,
his wife has slowly taken on the household IADL such as
financial management and driving.
Identified Problem Areas Related to Self-Care
■ Requires supervision with ADL (needs help with
lower extremity dressing) and transfers
■ Has decreased strength, balance, and endurance to
perform basic ADL
■ Has decreased coordination (difficulty with snaps on a
shirt)
■ Needs verbal cues to use affected side and to modify
actions when problems arise in task performance
■ Some lack of awareness of safety, especially with
relation to visual neglect
Goals for OT and PT
Mr. Arkmadian will:
■ Demonstrate safe stand pivot transfers for toilet, tub,
wheelchair, and bed with supervision (OT and PT)
■ Perform feeding, grooming, dressing, and bathing
with supervision and minimal cuing (OT)
■ Demonstrate proper positioning of trunk and affected
limb while seated in the wheelchair, during transfers,
and when repositioning in bed (PT)
■ Demonstrate safe use of recommended assistive
devices (OT)
■ Perform left upper extremity home exercise program
for coordination with supervision (PT)
Mr. Arkmadian’s family will demonstrate the following:
■ Assist with self-care activities
■ Verbally communicate understanding of home exercise
program
■ Provide encouragement to attend to the affected side
■ Encourage return to leisure interests and daily activity
as able to do so safely
Intervention Plan and Discharge Status
The intervention plan for Mr. Arkmadian’s week and a half
stay in the inpatient rehabilitation unit included an activity
program implemented collaboratively by occupational and
physical therapy. Occupational therapy focused on ADL
training to address bilateral coordination and scanning of
the left visual field. In addition, client and family education
that emphasized safety awareness, guided supervision to
Mr. Arkmadian during his daily activities, and recom-
mended compensatory strategies and modifications that
support Mr. Arkmadian’s functional independence were
provided. Physical therapy emphasized proper management
of the left upper extremity for positioning, instruction and
practice of safe transfers, and instruction and practice using
mobility aids for ambulation.
Mr. Arkmadian was discharged to his home with his
wife and son. Both his wife and son attended family
education sessions before discharge to familiarize them
with the home exercise program, provide information on
the use of the recommended assistive devices, and make
suggestions to assist with the supervision of self-care activ-
ities as well as modifications that may promote participa-
tion and independence in his desired leisure activities.
Written and printed handouts that covered the material
addressed in the family education sessions were provided.
Questions
1. What frame(s) of reference might the OT and
PT use to frame assessment and intervention for
Mr. Arkmadian?
2. How does the family’s understanding of the situation
and the recovery process influence Mr. Arkmadian’s
potential for functional improvement?
3. What assessment tools could be used to assess this
client’s skills in self-care?
4. If Mr. Arkmadian indicated that he would not use
the assistive devices that were recommended for him,
what other strategies might assist him in his self-care?
Critical Thinking Questions
1. How would you prioritize your approach to evalua-
tion and intervention of ADL and IADL?
2. Describe factors that interact to influence the ability
of seniors to perform ADL and IADL.
3. Discuss the importance of functional performance
in ADL and IADL as related to self-identity,
psychological well-being, health, and wellness.
4. In what ways might environmental circumstances
affect client performance, and how might this be
relevant in framing intervention?
5. Why might environmental modifications increase or
support performance of basic self-care and IADL?
6. List significant predictors of limitations in ADL and
IADL function.
7. Differentiate between remediation and compensation
in planning interventions for self-care limitations and
indicate when you would use each.
8. Describe how occupational and physical therapy
domains of practice complement each other in
addressing self-care issues.
4605_Ch18_277-294 31/10/17 12:18 PM Page 291
Acknowledgment
Special thanks to my friend and esteemed colleague, Charles
Christiansen, EdD, OTR/L, FAOTA, who contributed to
significant portions of this chapter in previous editions.
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Anita C. Bundy
“You matter because you are you. You matterdo alluntilwe canthe last… tomoment of your life and we will
LEARNING OUTCOMES
By the end of this chapter, readers will be able to:
1. Define leisure from an occupational therapy perspective.
2. Discuss occupational engagement issues related to
longevity and age-related disability.
3. Consider leisure as a statement of identity.
4. Define three important elements that, when considered
collectively, promote total engagement in leisure: control,
motivation, and disengagement from unnecessary
constraints of reality.
5. Understand the potential for focusing on leisure, rather than
occupational performance components, in occupational
therapy intervention.
6. Identify the role of physical therapy and other disciplines in
addressing leisure performance.
Clinical Vignette
Elaine Powers is a 73-year-old “semiretired” geologist. About
4 years ago, Elaine began running as support for her partner,
who was training for a marathon. When her partner was
injured, Elaine continued running, entering and finishing her
first marathon. She has been running ever since and now is
ranked as one of the best in her age-group.
1. What is your reaction to a 73-year-old who takes up
running for the first time?
2. What roles might OT and PT have in supporting
her ability to maintain her ability to participate in this
activity?
3. What needs do you think Elaine might be satisfying
in participating in this activity?
L ongevity and an increase in life expectancy afford
humans as occupational beings various opportunities and
challenges. With an estimated 30 years added to life, pop-
ulation aging creates a powerful new demographic and social
dynamic in 21st-century societies (Kalache, 2013). Alexander
Kalache, international ambassador and activist for the
CHAPTER 19
Leisure
■ Sanetta H. J. Du Toit ■ Lindy M. Clemson
help you LIVE until you die.
—Dame Cicely Saunders
”
rights of older people, explained the practical impact of
longevity:
I am now 67 years old. In Australia, I could apply for the
age pension. When my grandfather was my age, he carried
a walking stick and was shuffling towards his grave. I live
a vibrant, active life—I have friends, family and work
commitments in different continents and as a result I fre-
quently dash around the planet. My life, like that of so
many of the 760 million people in the world over the age
of 60, is totally different from that lived by my grandpar-
ents. Simply by virtue of the numbers and diversity of peo-
ple involved, baby boomers are reinventing the experience
of ageing. As the global population continues to age, our
generation is forcing society to rethink what it means to
grow old. (2013, p. 11)
The impact of living longer requires special measures to en-
sure that older adults experience added years as a time of living
well. At a time when active aging is viewed as a right, older peo-
ple should be enabled to engage in leisure activities that pro-
mote health and allow them to remain part of the lives of
significant others and to explore new pursuits (Csikszentmihalyi
& Kleiber, 1991; Iso-Ahola, Jackson, & Dunn, 1994; Mobily,
Lemke, & Gisin, 1991; Wilcock, 2007; Zimmer, Hickey, &
Searle, 1997). Occupational therapists, as agents for enhanc-
ing meaningful engagement, should carefully consider the full
role of leisure for their aging clients. Physical therapists,
whose focus is on clients’ physical capacity, must also address
those aspects of physical function that support leisure.
Leisure is described as one of the main occupations within
most theoretical models of occupational therapy practice
(Mackenzie, 2011). Nonetheless, leisure is an obscure con-
cept that is not always easily defined.
AROUND THE GLOBE: Differences in Definitions of Leisure
In some Eastern countries, including Japan and India, there is no
word for leisure (Hammel, 2014).
295
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296 PART III ■ Active Aging: Supporting Client Activities and Participation

■
In Western countries, leisure generally is defined in one
of three ways (Csikszentmihalyi & Kleiber, 1991):
Discretionary time—time not obligated to work, self-care,
or instrumental activity (e.g., shopping, child care)
■ Culturally sanctioned activity—an activity readily recognized
as leisure (e.g., fishing, quilting)
■ A state of being relaxed, contented.
None of these traditional ways of defining leisure is, by
itself, sufficient. Leisure is much more than doing partic-
ular activities during unobligated time (Wilcock, 2007) or
feeling relaxed. In fact, Jonnson (2008) and Hammell
(2009) warned that classification in restrictive domains
(i.e., activities of daily living/self-care, leisure, and work) is
a poor way to describe human occupations. Rather, client-
centered services require that occupations be categorized
by the nature of the experience derived while engaging in
them (Hammell, 2009; Jonnson, 2008). For Hammell
(2009), occupation as experience includes consideration of
meaning, purpose, choice, and control. In this chapter, we
embrace an experience-based conceptualization of leisure.
We concern ourselves with leisure in which participants are
fully engaged and that contribute to self-actualization
through reinvigoration, consolidation, and reinvention
(Csikszentmihalyi & Kleiber, 1991; Hogg, 1993; Kalache,
2013; Mannell, 1993).
Leisure is commonly linked with life satisfaction and
quality of life for men and women of all ages, with and
without disabilities (Beck & Page, 1988; Bevil, 1993;
Fernández-Mayoralas et al., 2015; Gabriel & Bowling,
2004; Griffin & McKenna, 1998; Kinney & Coyle, 1992;
Lau, Chi, & McKenna, 1998; Lindberg, 1995; Pereira
& Stagnitti, 2006; Riddick & Stewart, 1994; Rodriguez,
Látková, & Sun, 2008; Zoerink, 2001). Researchers
(Atchley, 1989, 1993; Kelly, 1993) have suggested that in-
dividuals maintain a core set of leisure activities across the
life span. Some of these activities are learned early in life
and derive their meaning from culture and the influence
of significant others (Csikszentmihalyi & Kleiber, 1991;
Iso-Ahola et al., 1994; McGuire, 2004). Importantly,
leisure may provide a buffer against some forms of age-
related disability (e.g., dementia; Coleman & Iso-Ahola,
1993; Fabrigoule, 1995; Kleiber, Hutshinson, & Williams,
2002; Wang et al. 2013), making it an important concern
of occupational therapists (Bevil, 1993; Freysinger, 1993;
Griffin & McKenna, 1998; Lau et al., 1998; Mishra, 1992;
Pereira & Stagnitti, 2006; Tatham & McCree, 1992; Voelki,
1993; Wilcock, 2007). For physical therapists, whose
scope of practice includes “work with individuals to pre-
vent the loss of mobility before it occurs by developing
fitness- and wellness-oriented programs for healthier and
more active lifestyles” (American Physical Therapy Asso-
ciation, 2015, para. 2), it is important to remember that
fitness and wellness programming both supports physical
function and can be defined by clients as leisure pursuits
in and of themselves.
✺ PROMOTING BEST PRACTICE
Benefits of Leisure
Research has found that leisure
■ promotes life satisfaction, quality of life, and personal
well-being (Fernández-Mayoralas et al., 2015; Pereira &
Stagnitti, 2006; Rodríguez et al., 2008; Zoerink, 2001) and
■ provides a buffer against age-related disability (Kleiber et al.,
2002; Wang et al., 2013).
This chapter comprises five major sections:
1. A review of issues raised by theorists and researchers
related to leisure and aging.
2. A discussion of leisure as a statement of identity.
3. A definition of three important elements of leisure that
is fully engaging: internal control, motivation, and
disengagement from some constraints of “real life.”
4. A model of leisure for use by occupational therapists
who seek to assess and promote meaningful engage-
ment with older clients.
5. A case study employing the model.
Leisure and Aging
There is a plethora of literature on leisure and aging, includ-
ing perspectives on the following:
■ the psychological benefits (e.g., well-being, life satisfac-
tion, happiness, and social participation; Adams, 1993;
Bevil, 1993; Fernández-Mayoralas et al., 2015; Gabriel
& Bowling, 2004; Graney, 1975; Griffin & McKenna,
1998; Lau et al., 1998; Lawton, 1993; Nimrod, 2007;
Pereira & Stagnitti, 2006; Rodríguez, et al., 2008;
Zoerink, 2001);
■ the form and meaning of leisure (Bevil, 1993; Kelly, 1982;
Lawton, 1993);
■ the ways in which leisure is affected by demographic
and cohort characteristics (Chin-Sang & Allen, 1991;
McGuire, 2004; McPherson, 1991; Pereira & Stagnitti,
2008; Riddick, 1993; Riddick & Stewart, 1994; Spiers
& Walker, 2009; Timmer, Bode, & Dittmann-Kohli,
2003);
■ the likelihood that leisure decreases when disability interferes
with participation (Corr & Bayer, 1992; Lindberg, 1995;
Iso-Ahola et al., 1994; Jackson, 1990; Jackson & Dunn,
1988, Mansson, 1995; McGuire, 1989; Zimmer et al.,
1997); and
■ the impact of interventions to promote continued partici-
pation in favorite leisure activities (Ferreira, Owen, Mohan,
Corbett, & Ballard, 2015; Searle, Mahon, Iso-Ahola,
Srolias, & Van Dyck, 1995).
In this section, we focus on some of the literature that
reflects the press for active aging. The World Health Orga-
nization’s (2002) Active Ageing Policy Framework supports
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older adults to experience health, participation, security, and
lifelong learning and ensures they are acknowledged for their
life experience, needs, desires, and capacities (Kalache, 2013).
Focusing on intrinsic human needs (Hammell, 2009) has
yielded new insights about the value of engaging in mean-
ingful activity, including leisure.
Research with older adults (N = 154, average age 80.5 years)
has revealed that well-being and quality of life are associated
with engagement in activities with great personal signifi-
cance, rather than being busy with activities that have less
personal value (Eakman, Carlson, & Clark, 2010). In that
same vein, Gitlin and colleagues (2008) demonstrated the
effectiveness of a tailored activity program (TAP) “tapping
into” the personal interests of people with dementia by training
carers to modify activities, environments, and communication
skills in order to reengage them in enjoyable activity, often
considered leisure.
Jonsson (2008) attributed traits such as highly meaningful,
committed, and regular engagement to (leisure) occupations.
Doing meaningful occupation contributes to a sense of pur-
pose and meaning in everyday life, ultimately promoting
self-worth (Hammell, 2007). Ball, Corr, Knight, and Lowis
(2007) categorized activities that relatively healthy older
adults (N = 70, mean age 72 years) enjoyed doing as fol-
lows: active leisure (e.g., gardening, walking, organized sport),
passive leisure (e.g., reading, television/radio, crosswords,
letters/emails, poetry), social leisure (e.g., socializing with
friends/neighbors, visiting family, church, volunteering), hob-
bies/interests (e.g., eating out, theater, crafts, baking), and
other (e.g. holiday/travel, shopping, education). Given the
range of possibilities and the relatively greater health and
wealth of the current generation of older adults, we can ex-
pect that they will continue their involvement in valued
leisure well into retirement. Some may develop new interests.
Researchers have found that older adults especially value
leisure that supports their cultural identities and sense of be-
longing (Pereira & Stagnitti, 2006). A group of 10 well-
elderly Italians (mean age 71.8 years) living in an Australian
community expressed their enjoyment of participating in
bocce with family and friends (Pereira & Stagnitti, 2006).
Personality traits also contribute to the types of leisure that
are most highly valued.
AROUND THE GLOBE: Leisure in the Netherlands
Oerlemans, Bakker, and Veenhoven (2011) studied 438 retired
older adults (mean age 65 years) living in the Netherlands, finding
that leisure involving social participation was highly valued by
the extroverts. The more time these extroverts spent in social,
physical, and cognitive activities, the happier they were. In
contrast, involvement in household activities related negatively
to happiness.
Although some older adults prefer social or physically
effortful activities, quiet activities, done alone, can be enjoyable
CHAPTER 19 ■ Leisure 297
and restful. They may appeal to individuals with particular
personality types. However, individuals who enjoy quiet, soli-
tary activities may be at risk for being labeled “socially with-
drawn” (Nimrod, 2007). Occupational therapy theorists (e.g.,
Hammell, 2007) have a role to play in promoting the value
of quiet leisure as a restorative occupation.
Sometimes older adults seek to be co-present with others
but not, as such, involved. Consider older adults who enjoy
“hanging out” in malls or shopping centers (White, 2007).
Being beside others, even when not directly involved with
them, can be very important. Thus, public spaces should pro-
vide areas where older adults can feel safe and comfortable.
Physical and sensory demands of the environment also need
to be addressed: adequate lighting, accessibility of toilets and
ramps, and minimizing displays that cause visual illusions or
give off overwhelming auditory stimuli (Kottorp, Tanemura,
Ferreira, Holthe, & Nygard, 2014; White, 2007).
For older adults living in residential care settings, co-
presence is a given and not a choice. Here the need for soli-
tary leisure pursuits that nourish the mind, spirit and being
must be honored (Wilcock, 2007).
Neil Allan, an 84-year-old widower, has been a resident of
Sunshine Manor for the past year. He has no children and
sold his flat when he realized that he was too lonely and frail
to enjoy living alone any more. Because of his economic
situation, Neil has to share a room with a 96-year-old
bed-ridden male resident. His roommate is very ill and
mostly unresponsive. Because of the level of care that his
roommate needs, Neil has virtually no privacy. In the
activity room, Neil has found refuge—a quiet space to read,
listen to his radio, work on one of his craft projects, and enjoy
quiet contemplation.
Participation in leisure that reflects hope for the future al-
lows older adults to become who they want to be, despite
changing circumstances and altered abilities (Hammell, 2007).
The idea that we can develop throughout life is a noteworthy
point for health and social policy makers who are charged with
promoting active ageing (Walker, 2012). García-Martin,
Gómez-Jacinto, and Martimportugues-Goyenechéa (2004)
showed that intrinsically motivated activities carried out in
small groups enhance social support, perceived control, and
self-efficacy. Unfortunately, although centers and adult day
programs may get participants out of the house and occupied,
they rarely create real leisure (Tse & Howie, 2005). This
is particularly true for the “younger old” (Pardasani, 2004)
and minority groups who are perceived as “different” (Bigby
& Balandin, 2005; Pardasani, 2004).
Leisure as a Statement of Identity
Because leisure experiences are freely chosen, they make
important statements about who we are (Kelly, 1982;
Neulinger, 1974; Scraton & Holland, 2006). In fact, Plato
is credited with having said that you could learn more about
a person in an hour of play (read here, active leisure) than in
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298 PART III ■ Active Aging: Supporting Client Activities and Participation
a year of conversation. We commonly decorate our homes
with mementos of leisure experiences and pictures or other
reminders of leisure companions (Csikszentmihayli &
Rochberg-Halton, 1981; Rockwell-Dylla, 1991). Older
adults, in particular, enjoy displaying those objects and
reminiscing. In so doing, they make statements about their
accomplishments and identities. Thus, when at risk of
losing valued leisure pursuits, individuals also risk losing
important parts of themselves.
Leisure identities and activities, perhaps in part because
of their significant relationship with the perceived self, also
seem to be particularly vulnerable to age-related barriers and
disability. “If I can’t do it the way (often translated “as well
as”) I used to, I don’t want to do it at all” is a comment fre-
quently made by older people who no longer engage in par-
ticular leisure pursuits. Rockwell-Dylla (1991) relayed the
story of Stan, a 62-year-old man who had been an avid golfer
before suffering a stroke. Following the stroke, he was un-
willing even to hit whiffle balls in the yard, despite the urg-
ings of his wife. Rockwell-Dylla wrote:
Stan didn’t take [his wife] up on her suggestions
because he knew he wouldn’t be able to hold the golf
club like he used to do with ease. He wasn’t afraid of
having to learn to do something in a new way, but what
did concern him was how he appeared in front of other
people. Stan shared with me how he thought the
neighbors would make comments like “what’s he trying
to do, he’s a disabled person, we don’t want anything
to do with him.” (p. 85)
Golfing once made a statement about Stan’s physical
prowess. However, after his stroke, he perceived that golfing
would make a statement about his physical disability. Stan
seemed to worry about looking foolish. Perhaps he feared
that his neighbors would generalize his physical disability to
a mental impairment. He seemed to fear that his neighbors’
memories of Stan the athlete would be replaced by visions of
Stan the “cripple” or Stan “the fool.” Stan feared he could no
longer make desirable statements about himself through golf,
so he gave it up. Perhaps he would have benefited from
having someone help him “change the frame” around golf.
Rather than a statement of his incapacity, he might have been
helped to transform golf into a “psychological triumph”
(Lawton, 1993, p. 37).
In contrast, engagement in leisure activities that had
previously been an important part of her life was integral
to 74-year-old Sarah Madison’s recovery after a stroke.
Sarah had been depressed not only because of the loss of
physical capability but because her children wanted her to
go into a retirement village to receive “the kind of care they
felt she needed.” Sarah chose instead to attend a day ther-
apy center where she was introduced to Sailability. Becoming
a “sailing grandmother,” winning a championship race, and
being featured in a local newspaper were turning points in
her recovery. She did not have the strength or movement
to handle the sails, but she said, “I’m the captain. I choose
who rolls the sails and tell them how to do it. You have to
think or you might hit another boat.” When Sarah was a
child, her family had sailed, and many years later sailing re-
newed her identity and self-confidence. Sailability kept her
independent and mentally alert. She went every week. Clearly
leisure not only reflects identity; it also contributes to it.
Leisure as a Fully Engaging Experience
We propose that leisure is a fully engaging experience
that contributes to self-actualization. Numerous authors
(Csikszentmihayli, 1975, 1985; Gunter, 1980; Kleiber,
1985; Mannell, 1993; Wilson, 1981) have used various
terms (e.g., flow, involvement, serious leisure, committed
leisure) to describe the total engagement in an activity that
characterizes leisure. Loss of self-consciousness, the open
cognitive set, and the pleasurable sensations associated with
total engagement in a leisure activity are crucial to the ex-
perience of an activity as leisure (Csikszentmihayli, 1975,
1985; Kleiber, 1985). Leisure activity in which one becomes
totally involved leads to self-actualization (Csikszentmihalyi
& Kleiber, 1991).
The concept of total engagement is particularly powerful
in examining and seeking to promote leisure with older in-
dividuals. Asking older adults, “Tell me about the activities
you do (or have done in the past) in which you become totally
engaged (forget about everything else)” has been much more
successful in identifying the experience of leisure for an indi-
vidual than asking people what they do in their leisure.
In response to the latter, people often indicate that they
have no leisure. If they attempt to answer the question, they
seem constrained by listing activities that have been socially
sanctioned as leisure, for example, golf, gardening, games, or
television. In contrast, when people talk about activities in
which they become totally engaged, they often relate thick
narrative accounts (Geertz, 1973; Jonsson, 2008) of their ex-
periences. It is then quite easy to elicit further information
about the benefits that they derive from those pursuits. In the
case of individuals who have lost the ability to engage in those
engaging activities, one also can examine whether or not it is
possible, or desirable, to adapt the previously enjoyed activity
or a suitable substitute.
Desiree Ashkie is a 78-year-old traditional Navajo
woman. In addition to all of the traditional activities in
which she has engaged since a very young age, Desiree
works several hours each week as a volunteer in a day care
center supported by the Navajo tribal government. When
Desiree was asked (through an interpreter) what she did in
her leisure, she laughed aloud. She indicated that even as a
child she had not had time to play. She lived with her dis-
abled grandmother and was responsible for all the home
maintenance tasks that required mobility (including cook-
ing and cleaning) and for tending the sheep. All of her life,
chores took up most of her time; there was always something
that needed to be done. Play and leisure were “a waste of
4605_Ch19_295-312 31/10/17 12:16 PM Page 299
time”; she rarely even sat down to rest. Desiree clearly was
not interested in talking about leisure. Throughout the
dialogue, her tone of voice remained stern, and at one point,
she asked why the interviewer was asking such silly
questions. In contrast, when Desiree was asked what she
did, now or in the past, in which she became totally
engaged, her voice took on warmth, and she became in-
volved and interested in the conversation. Desiree began to
talk about weaving. She indicated that she learned to spin
yarn when she was about 3 years old and to weave as soon
as she was old enough. When she was engaged in spinning
or weaving, she forgot everything else.
Navajo women do not weave their rugs from patterns; rather,
they create the patterns they envision in their heads on the
loom. Desiree recounted that as the pattern of the rug began to
emerge and the rug “took on a life of its own,” she became more
and more involved in its creation. Csikszentmihayli (1985) and
his colleagues (Csikszentmihayli & Graef, 1980; Larson &
Csikszentmihayli, 1983) described similar benefits when they
asked adults about times they experienced total engagement in
an activity.
For professionals seeking to promote leisure with older in-
dividuals, examining leisure as an experience in which one
becomes totally engaged is particularly valuable (Jonnson,
2008; Jonnson & Persson, 2006; Krefting & Krefting, 1991).
Rowles (1991) noted that older people respond particularly
well to interview. Interview for the purposes of planning in-
tervention is most useful when it elicits rich narrative descrip-
tion and the opportunity to seek additional detail as needed.
INTERPROFESSIONAL PRACTICE
Promoting Leisure
Examining leisure as an experience in which one becomes
totally engaged is particularly valuable (Krefting & Krefting,
1991, Jonnson, 2008; Jonnson & Persson, 2006). This kind
of examination can be done in the context of multiple
professions, each considering an aspect of participation.
For example, the physical therapist might focus on physical
capacity needed for particular activities, while the occupational
therapist works with the client to establish a meaningful
and rich complement of activities. A recreation therapist
might develop programs for activities in a community-based
organization, designed to engage groups of individuals
(Wise, 2015).
Total engagement can occur in the context of virtually any
activity, as long as the person engaged in the activity feels a
sense of control and is able to disengage from his or her real-
life concerns (Csikszentmihayli, 1975, 1985; Kleiber, 1985)
and when that activity is sufficiently motivating. We do not
seek to help older individuals conform to socially accepted
classifications of leisure activity. Rather, we seek to enable in-
dividuals to become totally engaged in, and reap the accom-
panying benefits of, self-defined leisure. In so doing, we seek
CHAPTER 19 ■ Leisure 299
to help them make the statements they want to make about
who they are as individuals.
Elements of Leisure
Leisure comprises three elements: internal control, motiva-
tion, and freedom from unnecessary constraints of reality.
Each factor influences the others (Neumann, 1971). For ex-
ample, when individuals feel in control, they can determine
how to act on their motivations (Neumann, 1971). Each of
the proposed elements of leisure requires further discussion.
Control
Control is a complex phenomenon. Being in control means
that an individual can predict and feel power over certain as-
pects of the environment (Purcell & Keller, 1989). Individ-
uals are free to choose what to do and with whom (Neumann,
1971). Being in control also allows individuals to determine
some, but not all, outcomes of an activity. Leisure activities
may be an important way to fulfill individuals’ needs for con-
trol (Purcell & Keller, 1989). In the absence of control, peo-
ple may feel helpless (Purcell & Keller, 1989). Feelings of
helplessness may result in depression and decreased motiva-
tion, reasoning ability, or self-esteem (Abramson, 1978). We
think of leisure as a way to take control of one’s life. Here we
discuss multiple aspects of control as they apply to the deter-
mination of a leisure experience:
■ Freedom of choice
■ Determination of outcomes
■ Matching challenges to skill
■ Psychological comfort
■ Optimal levels of choice
■ Reciprocity
Freedom of Choice
Freedom of choice typically is the most important determi-
nant of whether an activity is experienced as leisure (Gunter,
1980; Iso-Ahola, 1980; Neulinger, 1974). Generally, if in-
dividuals must, or feel they must, perform an activity, it is
not leisure (Lawton, 1993; Neulinger, 1974). By this crite-
rion, all activities can be leisure under certain circumstances
(Hillman & Chapparo, 1995). What may be among the
most mundane of tasks for some people, for example,
bathing, can become leisure for the individual who chooses
to “steal” some time away from the concerns of daily life for
a long, restful bubble bath.
Relocating to a residential care facility is often associated
with a loss of autonomy, control, roles, and privacy (Lee,
Woo, & Mackenzie, 2002). The demands of group living
and the regimentation linked with daily routines lead to pas-
sive acceptance of a perceived loss of control over daily life
(Burack, Reinhardt, & Weiner, 2012; Lee et al., 2002).
Duncan-Meyers and Heubner (2000) urged occupational
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300 PART III ■ Active Aging: Supporting Client Activities and Participation
therapists to enhance personal control by providing choice
in multiple aspects of activities.
Control entails more than making a decision to engage in
an activity. In the course of an activity, one must also feel in
control of all the various aspects. Control is not an all-or-none
phenomenon. Rarely is a person in total control of any activity
or event; in fact, total control may not be desirable. What is
desirable is that individuals feel that their skills and abilities
are matched to the challenges of the activity (Csikszentmihayli,
1975, 1985). Many things contribute to feelings of control
or lack of control including complexity of the activity, number
of other people involved, and duration. Further, there is
much more to life than programmed activities. We all need
spaces for engagement in rich and personally meaningful ac-
tivities (Power, 2010). Otherwise, the only way residents in
residential care can exert control is to decline participation
(Lee et al., 2002).
In general, the more complex the activity, the more other
people are involved, and the longer the duration, the less likely
a person is to feel in control—and hence to experience leisure.
Because control is such a complex issue, a freely chosen activity
often is not determined to be leisure until it has been com-
pleted. Sometimes, on the basis of past experience or anti-
cipation of relative lack of control, an individual may decide
not to engage in a particular activity or to alter it significantly
to increase the chances that leisure will be experienced.
For example, consider Barbara Major, a 65-year-old
woman who lives alone in a high-rise apartment in
Chicago (Figure 19-1). She has three daughters and sev-
eral grandchildren who live locally and visit frequently.
Although she enjoys their company, she often wishes she
could get away from their demands. Recently, Barbara
received two plane tickets as a gift, enabling her to make
two trips anywhere in the country or to take a companion
with her on a single trip. As Barbara made plans to
travel to Houston to visit a cousin for the Christmas hol-
idays, she entertained the notion of taking Cherie, one of
her older grandchildren, with her. In the end, however,
FIGURE 191 Barbara enjoys spending time with her grandchildren.
(Courtesy of Anita Bundy, with permission.)
she decided to take two trips by herself. In her words, “For
a minute, I lost my mind. I thought it would be fun to
take Cherie, but then I started thinking, ‘I’m doing this
for me. How much fun will I have if I take an 8-year-old
along?’ I’ll go by myself to Houston. And I made a reser-
vation to go to Atlanta for Thanksgiving. I have another
cousin in Atlanta. She has a house there. I always have
fun in Atlanta.”
Barbara opted to use her tickets in a way that increased the
chances she would experience leisure. She saw that if she trav-
eled with an 8-year-old, she might have fewer opportunities
to do what she wanted to do. Barbara might have experienced
just as much leisure had she taken Cherie with her, but her
past experiences suggested that having the responsibility for
an 8-year-old significantly reduced her choices; thus, the
chance for a leisure experience was also reduced.
Determination of Outcomes
For some leisure experiences, particularly creative endeavors,
being in control extends to determining aspects of the out-
come (Neumann, 1971). However, some leisure activities are
selected particularly for their lack of predictability. Many
games fall under this rubric (Caillois, 1979). Older adults
often list bingo and card games as favorite leisure activities
(Havighurst, 1979). Yet when players are certain of the out-
come (i.e., the winner), they throw in the chips or the hand
and begin a new game, thereby reintroducing unpredictabil-
ity (Caillois, 1979).
Even within activities in which a lack of predictability is
a part of the appeal, a certain amount of control must be
present if the experience is to be leisure. Individuals must
feel in control of the necessary materials (e.g., cards) and
other aspects of the situation (e.g., able to hear and under-
stand the meaning of a partner’s bid). In creative endeavors
such as knitting, woodworking, and cooking, control in-
cludes the ability to manage materials in such a way as to
construct a pleasing product. Activities vary widely in their
demand for skill. The degree to which activities are experi-
enced as leisure depends, in part, on the individual’s physical
skills and abilities (e.g., dexterity, strength). However, even
the most physically skilled individual may lack the aesthetic
sense to combine colors, shapes, or spices into a pleasing
product; thus, physical skill alone does not ensure that an
individual will have sufficient control in an activity to ex-
perience leisure.
Matching Challenges to Skill
With regard to control, what all the aforementioned activ-
ities have in common is that the challenges presented
match the skills of the individual (Csikszentmihayli, 1975,
1985; Mobily, Lemke, & Gisin, 1991). If that is not the
case, no matter what the activity, the person engaging in it
cannot experience leisure. The grandmother looking for-
ward to a weekend caring for her grandchildren must feel
4605_Ch19_295-312 31/10/17 12:16 PM Page 301
that she can skillfully manage the range of events that she
might encounter while babysitting. The older man who
experiences leisure in woodworking must feel that he can
manage the materials he will need to create a visually pleas-
ing and, perhaps, utilitarian object. This may entail more
than using tools and managing wood; it also may mean
visualizing an object in a block of wood or creating jigs for
completing some aspect of the project. Similarly, the older
woman knitting an afghan or a sweater must be able to
control the needles and the yarn and, perhaps, follow a pat-
tern easily. We need to support older adults experiencing
periods of ill health to focus on their abilities and interests
to maintain their priorities and values (Hammell, 2009)
and continue to engage in activities that provide them
with leisure.
✺
PROMOTING BEST PRACTICE
Older Adults’ Leisure Repertoires
Mobily et al. (1991) suggested that leisure constellations can
be thought of as “libraries” of activities that are characterized
by intrinsic motivation. They note that older adults’ leisure
repertoires are particularly important because they are likely
to have large amounts of free time but also some age-related
limitations on function.
Psychological Comfort
Frequent participation in an activity often leads to psycho-
logical comfort with that activity. This concept is related to
competence (matching skills to challenges); however, psy-
chological comfort reflects internal rather than external
standards for comparison. Mobily and colleagues (1991) of-
fered the example of a competent reader confronted with
very complex reading material. Although the individual
might be competent by external standards (e.g., as good as
others his age), he may well feel psychological discomfort
with the material. Thus, he is not likely to feel he is engag-
ing in leisure.
Beverly O’Mara is 78 years old. She has always had a
wide leisure repertoire encompassing both sedentary
(e.g., reading) and physically active (e.g., cross-country
skiing, hiking) or outdoor (e.g., camping) pursuits. Al-
though reading is her passion, until recently, the number
of strenuous activities in her repertoire far exceeded the
sedentary ones. Within the past 2 years, Beverly has had
several health-related problems, including the develop-
ment of bone spurs on her heels that have precluded her
participation in strenuous activity. These bone spurs
were treated with only partial success, and Beverly con-
tinues to experience pain from prolonged standing and
walking. A friend suggested that Beverly take up cycling
as an alternative to hiking. As much as she misses stren-
uous physical activity, Beverly balked. She did not be-
lieve she would have any more difficulty with cycling
CHAPTER 19 ■ Leisure 301
than any other woman her age; rather, she had not cycled
in many years and her reaction was one of psychological
discomfort.
Optimal Levels of Choice
To be experienced as leisure, any activity must contain an op-
timal level of choice. Raber, Teileman, Watts, and Kielhofner
(2010) reported on a study of leisure for older adults with
dementia in a residential facility:
Staff typically offered activities that didn’t relate to res-
idents’ volition. On one occasion, Felicity repeatedly
asked for “something to do,” and a staff member re-
sponded by offering her a large, twelve-piece puzzle
that Felicity was not interested in. Moreover, the staff
member did not give cues to do the puzzle or allow her
time to respond, creating high task demand in an ac-
tivity with low attraction. Thus, the resident became
disengaged and the staff member became frustrated
and convinced that the resident really didn’t want to
do anything. (p. 502)
✺ PROMOTING BEST PRACTICE
Importance of Choice in Leisure
Raber and colleagues (2010) found that a lack of choice to
engage in something meaningful may be more disabling to
people with moderate dementia than their severe decrease in
abilities. Careful attention to subtle expressions of preferences
is key for preventing people with dementia to withdraw, cease
engagement, or resist interaction.
Optimal choice is determined by the individual and is a
function of that person’s skill and experience in that activ-
ity. For example, an inexperienced painter, or painters
who perceive themselves as lacking certain abilities, may
be more likely to experience leisure with a paint-by-number
picture than with a blank easel. On the other hand, the
established artist probably would be bored with a paint-
by-number picture.
Reciprocity
Reciprocity means a relationship is balanced or symmetrical.
Individuals feel that, overall, what they receive is similar to
what they give. Otherwise, a state of indebtedness develops
(Goodman, 1984). Indebtedness alters the relationship.
Hillman and Chapparo (1995) relayed the story of an
elderly man who had experienced a stroke. When asked to
associate his role as a father with a major occupational
category (e.g., leisure, self-maintenance), this participant
selected “self-maintenance.”
He lived with his daughter, and seemed to be saying
that, although his children cared for him, he did
not reciprocate by doing anything for them. Their
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302 PART III ■ Active Aging: Supporting Client Activities and Participation
relationship with him seemed to focus on checking
on his ability to care for himself successfully.
Participant: I seem to have more of a relationship with
them than I have with them. Do you understand?”
Interviewer: No, say that again.
Participant: Well, they’re always … seeking to see how
I am … and I haven’t bothered about them!
Interviewer: Oh, I see what you mean. So you think the
relationship’s a bit one way?
Participant: Well, it is … Because after all, they’ve got their
own relationships. (p. 94)
Although the relationship between reciprocity and control,
motivation, or leisure is not clear, individuals may need to feel
sufficient control to be able to give to another. Feeling as
though one is giving to another is often believed to be an im-
portant motivator for leisure for older individuals (Allen &
Chin-Sang, 1990; Havighurst, 1979; Jacobson & Samdahl,
1998; Lawton, 1993).
Muriel Goldblum, an 83-year-old woman, living alone
since the death of her husband and then a longtime com-
panion, was asked about her leisure pursuits. She initially
said crosswords and reading and then, for a long time she
really thought about what leisure really meant. Finally,
“her birds and her lizard” came to mind. Her face lit up and
her words conveyed her joy as she described the wild animals
in her yard. She loves the “chatter and squabbling of the
birds as they push each other to get to the food.” When her
beloved butcher birds are gone for the winter, she “misses
the beautiful trill that announces their presence.” “The
brazen black and white magpies seem to stamp their feet”
when she does not come quickly enough. Her blue-tongue
lizard is “such a treasure.” She has to watch he does not come
in the house in his enthusiasm to reach her.
Loneliness, helplessness, and boredom are “three plagues”
that rob residents of the opportunity to exercise choice and
create meaning in their lives (Power, 2010). Caring for
someone or something may be an antidote to those plagues
because reciprocity makes one feel needed. However, in res-
idential care facilities, frail and vulnerable older adults are
often recipients of care but deprived of caring for another.
They may be viewed as incapable, or it may be that their
family or the care staff do not understand the importance
of reciprocity.
Leisure as Means of Taking Control of One’s Life
Older adults are at risk for feeling little control over their
lives (Mobily et al., 1991; Savell, 1991). This is particularly
true for persons living in institutional care, individuals with
disabilities, and members of other marginalized groups
(Duncan-Meyers & Heubner, 2000; Jacobson & Samdahl,
1998; Lee et al., 2002). Leisure is an important context for
the exercise of control (Duncan-Meyers & Heubner, 2000;
Iso-Ahola, 1980; MacNeil & Teague, 1987; Lee et al.,
2002). In classic studies of nursing home residents, numer-
ous authors (Langer & Rodin, 1976; Perlmuter & Langer,
1982; Schulz, 1976) associated control with increased
self-esteem, happiness, activity, and hopefulness for the
future, as well as decreased pain, need for medication, lone-
liness, boredom, and mortality (Rodin & Langer, 1977;
Schulz & Hanusa, 1978).
Jim Hartford is 87 years of age and, because of cardiac and
orthopedic problems, has severely reduced mobility. His new
scooter has given back some of his most important leisure.
Each year Jim and his wife, Jean, take a holiday to the sea-
side. A merchant navy man in his youth, Jim has retained
his love of the sea. He and Jean get an apartment overlook-
ing the sea and, with the scooter, meander along the long
promenade, experiencing the fresh breezes and the smell and
the sounds of the sea. He says, “I’m self-powered again.
Otherwise I would be stuck.” The scooter has allowed Jim to
regain control over where, when, and with whom he goes.
In turn, he has reclaimed a leisure event that maintains his
identity and gives him great pleasure.
Jacobson and Samdahl (1998) described leisure as a con-
text in which their old lesbian participants, who felt ignored,
invisible, or personally at risk in their “public lives,” could cre-
ate “safe spaces” for social interaction and to meet their needs
for leaving the world a better place than they found it.
Clearly, leisure can be a powerful tool for helping older peo-
ple take control of their lives and express their identities.
Motivation
Motivation is the reason one chooses to engage in an activity;
it reflects the meaning that the activity holds. Typically, mo-
tivation is described as a determinant of leisure. According
to some theories, the motivation for leisure is intrinsic; that
is, the activity is done only for its own sake, for the pleasur-
able experience associated with it, and not for any long-term
gains by the individual, payment, or the benefit of someone
else (Csikszentmihayli, 1975, 1985; Mannell, Zuzanek, &
Larson, 1988; Neulinger, 1974). However, Losier, Bourque,
and Vallerand (1993) found that intrinsic motivation and
self-determined extrinsic motivation were equally correlated
with leisure satisfaction.
The lack of clarity about whether the motivation
for leisure activities is always intrinsic can be seen through-
out the leisure-related literature. Many authors (Allen &
Chin-Sang, 1990; Crandall, 1980; Donald & Havighurst,
1959; Havighurst, 1979; Havighurst & Feigenbaum, 1968;
Kleiber, 1985; Mannell et al., 1988; Menec & Chipperfield,
1997) have examined and discussed older individuals’
motivations for leisure in general or for specific leisure
activities. Typically, many motivations or meanings are
listed. Havighurst’s list is representative; he and his col-
leagues included the following as motivations associated with
leisure activities: just for the pleasure of it; welcome change
from work; new experience; contact with friends; chance to
4605_Ch19_295-312 31/10/17 12:16 PM Page 303
achieve something; makes time pass; allows creativity;
benefits society; helps financially; promotes self-respect;
promotes standing with others; promotes popularity.
Further, Havighurst (1979) and his colleagues (Donald &
Havighurst, 1959; Havighurst & Feigenbaum, 1968) indi-
cated, not surprisingly, that certain motives or meanings are
more commonly associated with some leisure activities than
others, and that certain individuals experience different mo-
tivations or meanings for the same activity. Havighurst and
colleagues are among the few researchers and theorists (Allen
& Chin-Sang, 1990; Henderson & Rannells, 1988; Lawton,
1993; McGuire, 2004) who attempted to examine individual
differences in activity-specific motivations. These researchers
provided significant insight to occupational therapists seeking
to promote leisure with elderly clients (Kelly, 1982).
Even if motivations for leisure activities are mostly intrin-
sic, activities that have extrinsic motivations can also be
highly engaging. In fact, Mannell and coworkers (1988)
found that older people experienced the greatest “flow” in ac-
tivities they performed for their own long-term gain or for
another’s benefit. However, it is worth noting that when the
subjects indicated that they perform activities primarily for
extrinsic reasons, they may be responding as much to per-
ceived social acceptability as to their true motivations.
Pierce (2003) explained the subjective experience of en-
gagement in human occupation as a mix of pleasure, produc-
tivity, and restoration. Presumably individuals are most likely
to experience the three simultaneously in the context of ac-
tivities that are meaningful. In a 10-year longitudinal study
focusing on older adults’ transition from worker to retiree,
Jonnson (2008) emphasized the importance of meaning in
activity. His research findings indicate that in the absence of
meaningful and highly engaging social occupations, activities
such as watching television or paging through a magazine
were categorized by participants as merely passing time
(Jonnson, 2008).
Complexity of Motivation
The motivation to engage in, and the meaning associated
with, a particular activity clearly is a complex phenomenon.
As Havighurst (1979) noted, the experience of leisure is
strongly associated with personality. What “drives” one indi-
vidual is very different from what drives another. Some indi-
viduals are clearly more people oriented than others. Thus,
some people perceive service to others as an important moti-
vation for leisure (Donald & Havighurst, 1959; Eakman
et al., 2010; Havighurst, 1979; Havighurst & Feigenbaum,
1968) and derive meaning from it (Allen & Chin-Sang,
1990; Henderson & Rannells, 1988). Some do not (Timmer
et al., 2003).
Activities that stress interaction with the environment and
other people are more readily observable than inwardly fo-
cused activity (e.g., meditation, reminiscing, creative thought,
aesthetic appreciation). They also are more commonly in-
cluded on leisure activity questionnaires. However, Lawton
CHAPTER 19 ■ Leisure 303
(1994) cautioned researchers and practitioners that “there is
a great void in probing what types of affect occur as a person
engages in inner-oriented activities such as daydreaming,
listening to music, or gazing at a loved one” (p. 154). Are
inwardly directed activities not leisure? “New research is
needed to probe further the place of what have been called
‘introverted activities’ and to understand better how person-
ality and mental health outcomes are related to leisure ac-
tivity choice” (p. 155). Furthermore, practitioners must
consider how personality variables affect the leisure choices
of individuals.
Havighurst’s (Donald & Havighurst, 1959; Havighurst,
1979; Havighurst & Feigenbaum, 1968) and Lawton’s
(1994) statements that leisure activities are associated with
different motives or meanings for different people suggest a
certain degree of complexity in the relationship between
leisure and motivation. There may be many more motiva-
tions associated with a particular activity than are immedi-
ately apparent, and many powerful motivations may not
appear on lists such as those developed by Havighurst. Un-
covering an individual’s motivation for a leisure activity is
particularly important when the need arises to substitute one
activity for another.
Ron Shankar is a 75-year-old retired engineer. As long as
anyone can remember, Ron has built things. He spends a
significant amount of time creating small pieces of furniture
and repairing objects in his home. He enjoys these activities
thoroughly; he expressed pleasure both in the completed proj-
ect and with all steps of the process. He particularly enjoys
figuring out how to do a project and creating the necessary
jigs and devices.
Several years ago, Ron experienced an illness that was
exacerbated by the dust and chemical fumes associated with
woodworking. He was urged by his physician to replace
woodworking with another activity. Ron chose painting as
an alternative because it seemed to offer many of the same
benefits (being creative, working with his hands) without
the negative consequences.
For approximately 1 year, Ron painted instead of doing
woodworking; he became a good painter. However, he also
became increasingly disenchanted with his new leisure ac-
tivity. Painting, while capturing some of the same benefits
of woodworking, apparently was not a suitable substitute.
After that year, Ron put away his paints permanently and,
once again, took out his woodworking tools. “If I’m going
to die,” he expressed, “I’m going to die happy.”
Clearly, the motivations for woodworking most salient to
Ron were not captured in painting. Perhaps if Ron had
worked with an occupational therapist trained to help him
examine his motivations and recapture them in a suitable sub-
stitute, he might have been able to adopt a leisure activity
that did not have the negative consequences associated with
woodworking. Unfortunately, that did not happen.
Sometimes it is possible to capture the most salient moti-
vations for one activity in another and thus to help a person
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304 PART III ■ Active Aging: Supporting Client Activities and Participation
substitute a new leisure activity for one in which he or she
can no longer engage. Rockwell-Dylla (1991) related the
story of Les, a 90-year-old man who had survived two strokes
and a bout with cancer. Les was the retired owner of a paint
company. Before his illnesses, he spent much of his leisure
time decorating the interior of his home. As a result of both
age and disability, Les was no longer able to move furniture
and perform other activities required for interior decorating.
Although he might have elected to direct others in the inte-
rior decoration, this apparently did not hold the same moti-
vation for Les (or perhaps for the others in his life). At the
suggestion of an occupational therapist, Les got involved in
decoupage. He created dishes and other decorative objects,
mixing and matching colors and patterns as he desired. This
substitution of decoupage for home decorating was highly
successful. Although many of the most obvious traits of home
decoration were not present, one important motivation for
Les was “playing” with colors; that activity could be recap-
tured in decoupage. Or, perhaps decoupage captured another
motivation or meaning for Les.
Freedom From Unnecessary Constraints
of Reality
Kleiber (1985) defined disengagement as a space/time context
created by removing constraints. Freedom from unnecessary
constraints of real life (disengagement) is a necessary com-
ponent of leisure. Constraints may be real or perceived, and
they take many forms (e.g., family demands, financial con-
straints, pain, poor health, or disability; Burrus-Bamel &
Bammel, 1985; Havighurst, 1979; McAvoy, 1979). If an
individual is to experience leisure, he or she must be able to
disengage temporarily from those constraints.
As Kleiber (1985) noted, disengagement alone may be suf-
ficient to produce leisure. However, many individuals find it
extraordinarily difficult to maintain their disengagement from
real-life concerns unless they engage in activity in which they
become totally absorbed. What’s more, engaging in activity
that allows one to disengage from some of life’s demands does
not necessarily ensure leisure. When individuals find that they
are motivated to engage primarily in activities that depend on
certain abilities or resources that are constrained, they have
extraordinary difficulty experiencing leisure.
Mary Morrison is 79 years old. Her vision has become pro-
gressively more limited over the past 15 years, in part due
to excessive drinking. Throughout her life, reading has been
a primary leisure source for Mary; she often read for several
hours a day. However, Mary’s vision has now worsened to
the point that she can no longer read even large print. Mary
expresses no interest in talking books, tapes, or the radio as
a substitute for reading. In fact, she has been able to find no
activity, except drinking, that enables her to disengage from
the constraints of her life. The only activities in which she
expresses interest are visually dependent. Thus, her “leisure”
pursuits only serve to remind her continually of the
constraints of her life that most concern her. As she attempts
to disengage, she actually becomes more aware of her diffi-
culties. Mary succeeds in disengaging by drinking, but
drinking exacerbates her visual impairments and con-
tributes to her decreased ability to seek alternative and true
leisure experiences. Mary is caught in a vicious cycle. She is
motivated to engage in a leisure pursuit for which she lacks
a critical ability; because she has little “control” of the writ-
ten word, she is unable to disengage from the constraints of
her visual impairment. To succeed in developing alterna-
tive leisure options, Mary will need help to examine the
benefits she once derived from reading and to devise activ-
ities that provide some of the most important benefits with-
out depending heavily on vision. Alternatively, Mary
might be helped to examine other important motivations
that, if satisfied through activity, might enable disengage-
ment and opportunities for leisure.
A Model of Leisure Engagement
We described three contributors to total engagement in
leisure: control; motivation, and disengagement from unnec-
essary constraints of reality. None of these elements can be
described as all-or-none phenomena; each is much better de-
scribed as a continuum. We propose that control, motivation,
and disengagement from unnecessary constraints of reality,
collectively, determine whether or not a person becomes
totally engaged in, and self-actualized from, a leisure activity.
The summative contributions of control, motivation, and dis-
engagement to total engagement in leisure are illustrated
schematically in Figure 19-2.
The elements of leisure are mutually influencing. That is,
an individual engaging in an activity in which he or she feels
little control is unlikely to be able to disengage from the con-
straints of real life. The converse also is likely to be true.
However, this conceptualization is useful when planning
intervention with older people. Three key values must be re-
flected in promoting leisure (Box 19-1).
The desired outcome of intervention is that people develop
a repertoire of activities in which they can become totally en-
gaged and that allow them to attain self-actualization and
make desired statements of self-identity. Consideration of
the elements of leisure as a continuum enables us to reflect
with individuals in the content of particular activities and de-
termine which of the elements will yield most productively
to intervention. In other words, where can or should we begin
to enable this person to experience leisure in everyday life?
Promotion of Leisure: Application
of the Model
Applied models of leisure are useful only to the extent
that they allow therapists to explain relationships among
constructs, make meaningful predictions, and implement
4605_Ch19_295-312 31/10/17 12:16 PM Page 305
External
Perception of control
Low
Degree of motivation
None
Disengagement
FIGURE 192 Summative contribution of the elements of leisure to total engagement in a leisure activity.
BOX 191 Key Values in Promoting Leisure
■ Leisure is an important lifelong occupation, and its promotion
is a worthy goal for intervention.
■ Because leisure is self-determined, intervention to promote
leisure must be tailored to the needs and desires of individual
clients.
■ Leisure may be experienced alone or in groups of any size,
depending on the individual.
successful interventions. Successful intervention depends on
thorough assessment. Assessment of leisure is more likely
to be thorough (i.e., to capture the most salient aspects)
when it reflects the multidimensional experiences that in-
fluences well-being. Box 19-2 comprises elements of the as-
sessment of leisure as a basis for intervention to promote
total engagement in active leisure.
We suggest that leisure that promotes self-actualization
involves total engagement in activity deemed by the indi-
vidual to be leisure. We propose that three elements con-
tribute to total engagement: control, motivation, and the
ability to disengage from unnecessary constraints of real life.
Assessment based on this conceptual model of leisure en-
tails the examination, with the individual, of the degree to
which these elements are present in particular activities.
There are many ways to go about gathering this informa-
tion, including using checklists such as the Leisure Diagnostic
Battery (Witt & Ellis, 1989), the Leisure Satisfaction Scale
(Ragheb & Beard, 1980), Interest Checklist (Kielhofner,
2008), the Older Person’s Pleasant Events Schedule
(Gallagher-Thompson, Thompson, & Rider, 2004), or the
Volitional Questionnaire (de las Heras, Geist, & Kielhofner,
2007). We believe that interview is an essential tool,
CHAPTER 19 ■ Leisure 305
Internal
High
Distracted
Complete
Absorbed
BOX 192 Assessment
■ Assessment of leisure seeks to determine if an individual
experiences leisure
■ Assessment is more likely to lead to intervention that
promotes leisure if it examines for the presence of intrinsic
motivation, internal control, and freedom from unnecessary
constraints of within activities.
■ Interview is essential for examining leisure in older people.
These questions should be included:
■ What activities keep you totally engaged, allowing you to
forget about everything else (now or in the past)?
■ What do you get from this particular activity? Why do it
instead of others?
■ How able do you feel to make these activities come out
the way you want them to?
■ Asking clients to rate themselves along a continuum that
reflects intrinsic motivation, internal control, and freedom
from unnecessary constraints of reality can be helpful for
gaining their perceptions.
particularly given that little is known about the psychome-
tric properties of most checklists with older people (Chang
& Card, 1994).
We recommend that practitioners assess leisure by
■ collaborating with individuals to identify activities that are
highly significant and infused with meaning and in which
they can become totally engaged and
■ examining individuals’ motivations for, degree of control
in, and disengagement opportunities in each activity by
asking each individual to rate himself or herself along the
continua reflecting the leisure elements.
4605_Ch19_295-312 31/10/17 12:16 PM Page 306
306 PART III ■ Active Aging: Supporting Client Activities and Participation
In the assessment, the practitioner seeks to determine
■ whether individuals experience leisure that is totally engag-
ing and leads to self-actualization,
■ the relative presence of the elements contributing to the
leisure experience, and
■ the interrelationships among these elements.
When this information has been gathered, it is possible
to plan and evaluate the effectiveness of intervention. Inter-
vention must be individually tailored and targeted toward
promoting the leisure experience and eliminating barriers as-
sociated with it.
INTERPROFESSIONAL PRACTICE
Assessing Leisure
Because leisure is a multidimensional occupation, the
perspectives of various disciplines can provide helpful context
and understanding. Assessment processes differ among the
disciplines, with differential emphasis on physical, psychosocial,
medical, and environmental factors all of which contribute to
understanding of the individual’s needs and interests.
TABLE 191 ■ Leisure Education Program Units
UNIT TITLE
1 What do you do for leisure?
2 Why you do what you do?
3 How do you do it?
4 Can you do it?
5 Can or will you adapt?
6 What are the barriers?
7 What plans do you have for your future leisure?
8 What else is there?
9 What resources are available to you?
10 What personal resources are available to you?
11 What community resources are available to you?
12 Reconsidering what you would like to achieve
before we conclude our shared experience.
Source: Adapted with permission from M. J. Mahon, S. E. Iso-Ahola, H. Sdrolias, & J. Van Dyck. (1995.) Enhancing A Sense Of Independence And Psychological Well-Being
Among The Elderly: A Field Experiment. Journal Of Leisure Research, 27, 107.
Among the strategies for promoting leisure are leisure
education programs. These are most helpful when they incor-
porate the dimensions discussed in this chapter (Table 19-1).
Comprehensive exploration of personal values and meanings,
as well as resources and strategies, can be helpful in ensuring
that older adults enact valued leisure occupations.
Role of Physical Therapy in Promoting Leisure
Physical therapy has both an indirect and a direct role in
promoting leisure participation. Physical therapy interven-
tions can address various body system/body structure fac-
tors that may limit leisure engagement. For example,
structured exercise can reduce fatigue, allowing individuals
with a variety of disorders greater energy for leisure pursuits
(cf. Cutovic, Konstantinovic, Stankovic, & Vesovic-Poticl,
2012). Exercise is also important to maintain or improve
endurance, again with direct relevance to ability to partic-
ipate in desired leisure activities (cf. Moriello, Denio,
Abraham, DeFrancesco, & Townsley, 2013).
A more direct role is related to the fact that for many peo-
ple, physical activity in itself meets the definition of leisure,
CONTENT
The client explores the potential benefits of leisure on physical and mental well-
being and his or her personal recreation interests.
On the basis of the list of interests identified in Unit 1, the therapist helps the client
decide what motivates him or her to participate in specific leisure activities.
The client learns to conduct an activity analysis of each of his or her leisure interests.
Clients are taught to realistically assess current and potential physical and mental
capabilities and how they may affect future recreation involvement.
The client is exposed to the concepts of activity adaptation and equipment
modification and is taught how to use the procedures to facilitate satisfactory
leisure participation.
The client explores the variety of barriers he or she may face as well as ways and
means of overcoming barriers to enable participation in chosen leisure pursuits.
The client is taught to make realistic short- and long-range leisure plans.
The client explores other potential leisure pursuits, determines what skills he or she
must acquire to participate in those activities and develops plans for participation.
The client is taught to identify who may act as a support for him or her to carry out
leisure goals and how to make clear and assertive requests for assistance.
The client is taught to assess personal resources including such things as finances,
transportation, and equipment as they relate to the leisure plans.
The client is exposed to community resources and is taught how to assess such
resources as a means of facilitating community based participation.
The client reassesses and, if necessary, revises participation goals. (In part, this is to
ensure that the client is able to continue to reassess leisure goals in the future.)
4605_Ch19_295-312 31/10/17 12:16 PM Page 307
so that physical therapy intervention to, for instance, facilitate
participation in yoga, may offer a leisure outlet that is highly
valued by individuals (Moriello et al., 2013). As is true for
many other kinds of activities, participation in exercise and
physical activity is perceived by some clients as work, some-
thing to be done for health but not for pleasure. For many
others, however, exercise and physical activity meet the cri-
teria for leisure and add an important element of identity,
control, and pleasure.
Occupational and physical therapists have an important
role to play in promoting active aging of older adults, as do
various other related disciplines. The vision for occupational
therapists when supporting the doing, being, belonging, and
becoming of older people is echoed in the well-known quote
by Dame Cicely Saunders expressed at the beginning of this
chapter.
Although occupational therapy professional intervention
is mostly on a one-on-one basis, Wilcock (2007) urged us to
address the overall picture at multiple levels. As these apply
to leisure, they are as follows:
■ personal—identifying health-giving leisure activities that
provide purpose and meaning;
■ societal—advancing ideas to ensure that older adults’ needs
for leisure are considered as a matter of health, right, and
justice; and
■ legislative—addressing the restrictive nature of risk
management and other policies that prevent meaningful
engagement in leisure activities because of extreme
safety measures, therefore decreasing well-being in the
long-term.
External
Perception of control
Low
Degree of motivation
None
Disengagement
FIGURE 193 Anna’s profile of the elements of leisure as they relate to cooking complex meals for her family.
CHAPTER 19 ■ Leisure 307
SUMMARY
In this chapter, we consider leisure to be total engagement
with activities in which older people make important state-
ments about their identities. We delineated three elements
that contribute to the leisure experience: control, motivation,
and freedom from unnecessary constraints of real life. We of-
fered a methodology for examining and promoting leisure
with older individuals. It is our hope that professionals who
seek to promote leisure experiences with their clients will find
our model useful for framing their assessments and interven-
tions and that this model will spark research that will lead,
in turn, to its refinement.
CASE STUDY
Anna Harrison is an 83-year-old woman who lives alone.
She suffered a mild cerebrovascular accident (CVA)
6 months before intervention. Anna said that cooking for
her family was the activity in which she became most en-
gaged. When she cooked big meals, she forgot everything
else and became totally “caught up” in timing events and
creating the perfect combination of ingredients. However,
Anna complained that since her stroke, she was no longer
able to “cook like she used to.” Although she still cooked,
she did it only for herself, rather than for her family, and she
was forced to use mixes, rather than begin from “scratch.”
These adaptations made cooking less enjoyable and failed to
provide Anna with the same leisure experience she once en-
joyed. Anna’s profile for cooking is shown in Figure 19-3.
Internal
High
Distracted
Complete
Absorbed
4605_Ch19_295-312 31/10/17 12:16 PM Page 308
308 PART III ■ Active Aging: Supporting Client Activities and Participation
Anna was highly motivated to do a particular kind of
cooking; she enjoyed the experience and saw it as a means
of giving of herself to her family. The problem for Anna
in cooking from scratch was with feeling sufficient control.
Because of mild weakness on her left side and abnormal
movements in her arm, she no longer felt comfortable lift-
ing and carrying pans. Furthermore, her timing seemed
off, and she worried about having one thing burn on the
stove while she was attending to another thing at the sink.
These concerns prevented her from disengaging from real
life because she was continually reminded of the con-
straints imposed on her by her physical limitations. The
combination of lack of control and inability to disengage
prevented Anna from experiencing total engagement and
leisure.
The physical therapist working with Anna intervened
by facilitating more normal patterns of movement in
Anna’s arm and helping her move more quickly. The
occupational therapist intervened in the context of com-
plex cooking activities that Anna selected. The therapist
understood that the purpose of the intervention was to en-
able Anna to experience leisure by gaining greater control
for cooking in a particular way. Thus, when she made de-
cisions regarding intervention, the therapist framed deci-
sions in the context of leisure rather than in the context
of motor control.
Intervention with Anna was highly successful and took
place over a reasonably short period of time (6 weeks).
When the occupational therapist contacted Anna by
phone several weeks after the last intervention session,
Anna was too busy to talk; she was involved in preparing
Thanksgiving dinner for her family.
Anna’s problems with cooking related to physical lim-
itations that reduced her feelings of control and pre-
vented her from disengaging from the constraints of real
life. Individuals like Anna typically receive intervention
from occupational therapists. However, intervention
often centers on gaining control of movement rather
than facilitating leisure experiences. Although interven-
tion centered on motor control might have been effective
with Anna, we believe that her intervention was much
more meaningful (and perhaps of shorter duration) be-
cause it focused on enabling her to experience leisure, as
she defined it.
Questions
1. Why did the occupational therapist start by assessing
what Anna found most engaging?
2. How did the limitations caused by Anna’s CVA
interact with her values around occupational
enactment?
3. Why did the occupational therapist not choose
to focus on remediating Anna’s physical
limitations?
Critical Thinking Questions
1. Why is it challenging to define leisure?
2. What characteristics are most important to identifying
an activity as a leisure activity?
3. In what ways are leisure activities important to older
people?
4. In what ways does leisure represent an expression
of identity?
5. What considerations are important in intervening
to support an older person’s optimal engagement
in leisure?
6. Observe a group leisure activity in a retirement
setting or nursing home. Describe participants’
reactions to the event using the four factors of
control, motivation, disengagement, and environ-
ment. Map these using the model described in
this chapter.
7. What case might you make to a facility manager that
addressing leisure interests is central to providing
effective therapeutic intervention?
Acknowledgments
The authors wish to acknowledge Jean Cannella, MEd, OTR,
for her contributions to an earlier version of this chapter.
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Brent Braveman
“It is a mistake to regard age as a Asdownhill grade toward dissolution. The reverse is true.
one grows older, one climbs with surprising strides.
LEARNING OUTCOMES
By the end of this chapter, readers will be able to:
1. Describe patterns in changing demographics in older adults
and in older adult workers.
2. Identify and describe models of retirement and patterns of
transitioning to full retirement or part-time work in older
adults.
3. Identify and describe the generational and cultural differ-
ences in interpretation of work and retirement.
4. Describe therapy perspectives on work and retirement as
well as the roles of occupational therapy practitioners and
physical therapy practitioners in aiding older adult workers
to continue to work and/or to transition to retirement.
5. Describe the various types of work and volunteer occupa-
tions (i.e., named and familiar activities) typically performed
by older adults.
6. Describe legislative and policy issues around the world as
related to retirement.
Clinical Vignette
Maria Alvarez has reached the age at which she planned
to retire. For the past 30 years, she has been saving for her
retirement. She contributed to her company’s 401K and has
been working with a financial advisor for the past 10 years
of her employment to be sure she will have enough money
to carry her through her entire retirement and allow her to
participate in activities she has planned. Nonetheless, like
many older adults, Maria worries sometimes that she may not
have adequate financial resources to fully retire without some
employment to supplement her retirement funds.
Maria plans to volunteer with a local literacy agency and
the Red Cross. She also wants to continue to be active in her
church and to travel around the United States to areas she
has been unable to visit when she worked. At 72 years old,
Maria is in good health and has not been placed on any
medications or given any restrictions by her physician. Her
husband of 45 years passed away 5 years ago. She receives
CHAPTER 20
Work and Retirement
■ Patricia Bowyer ■ R. Elaine Fogerty
—George Sand
”
benefits from his retirement plan as well. She lives within
1 to 2 hours of her three children and seven grandchildren.
She hopes to be involved in their activities and to host family
holiday events at her home. She has been looking forward
to her retirement, although the loss of her husband 5 years
earlier has affected her greatly. However, she intends to
fully enjoy her transition to retiree and to pursue the many
other activities she has planned for in the years leading up
to this day.
1. How adequate are Maria’s plans for activities in retire-
ment? What has she included that will be helpful?
What might be missing?
2. What potential barriers to successful retirement might
interfere with her quality of life once she retires?
As “Baby Boomers,” or those persons born between 1946
and 1964, move into their 60s and 70s, more and more indi-
viduals will likely work beyond the traditional retirement
target of age 65. The Pew Research Center (2010) noted that
on January 1, 2011, the oldest members of the Baby Boom
generation celebrated their 65th birthday. In fact, on that day,
today, and for every day through 2030, 10,000 Baby Boomers
will reach age 65. In 2010, roughly 38 percent of the U.S.
workforce was from the Baby Boomer generation (Catalyst,
2012.) As this group reaches retirement age, there will be
grave shortages in the number of younger workers available
to fill the void. For this and other reasons, the number of older
workers will likely increase, and these workers will comprise
a larger percentage of the total workforce. M. Wong, Shulkin,
Casey, Pitt-Catspouphes, and Sloan (2006) noted that in
2006, older workers were the fastest growing demographic
in the labor market. In 2014, the American Association of
Retired Persons (AARP) estimated that 7 of 10 aging adults
planned to continue some form of work during “retirement”
and that only 13 percent planned to fully retire. The impact
of these changes on the U.S. economy and the resulting
ramifications for workers and employers may be dramatic.
313
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314 PART III ■ Active Aging: Supporting Client Activities and Participation
The patterns of work for older workers can vary a great
deal and have changed over time. During the 1970s and
1980s, there was an increased trend for early retirement
among men due to employer incentives and access to
employer-sponsored pensions and health care. Participation
of women in the labor force increased during that time.
This downward trend among men began to reverse in 1990s
(Mulvey, 2011). Between 1990 and 1995, choices were trend-
ing toward part-time rather than full-time employment, but
the trend reversed after 1995 (U.S. Bureau of Labor Statis-
tics, 2008). However, according to an AARP survey in 2014,
the shift was back toward part-time employment (AARP,
2014). The specific factors driving these changes are not clear,
but economic conditions, unemployment, and the resulting
level of opportunity to find full-time work may be responsi-
ble. Older workers were negatively affected by the significant
economic recession in 2008 including lost jobs and reduced
value of retirement investments. The effects may linger even
today, although the economic importance of older workers
to the U.S. and world economies should not be minimized.
It is important to employers and society to keep older
workers engaged to maintain their knowledge base, facilitate
transfer of experience, and maintain volume of active workers
to help fund Social Security (Figure 20-1; Topa, Moriano,
Depolo, Alcover, & Morales, 2009). Moreover, it has been
noted internationally and in the United States that large
numbers of older retirees can strain societal resources such as
health care and income support (Pollard, 2006).
As changes in workers and the workforce emerge, thera-
pists must understand the various ways that both work and
retirement can be conceptualized and the shifts that have oc-
curred in both concepts over time. Work as paid employment
can mean very different things to different people and can
range from boring or repetitive part-time work sought only
to bring a wage to support oneself to a career that can span
decades or most of one’s adult life and is approached with
passion and commitment. This is not to suggest that part-
time work cannot be meaningful or also approached with
passion and commitment. Work can bring great meaning
FIGURE 201 Older workers can serve as good mentors for younger
team members. Pixland/Pixland/Thinkstock
and significantly influence a person’s identity, or it can lack
meaning and add little to a person’s identity or even affect it
negatively. As discussed later in this chapter, the meaning
and interpretation of work across one’s youth and middle age
will influence how one experiences a transition to working or
retirement in older age. From an occupational therapy or
physical therapy perspective, work can also include unpaid
volunteer work or unpaid duties that one performs to con-
tribute to raising a family or managing a home or family
business.
Older workers are employed in all industry types, cate-
gories, and occupations, although a slightly higher percentage
are employed in white-collar jobs than in the total population
of workers (Centers for Disease Control and Prevention
[CDC], 2012). Older workers have as much chance or more
to be laid off than younger workers, and they often face more
difficulties regaining employment after losing a job.
The factors identified that may influence older workers
to remain in the workforce are summarized in Box 20-1.
Models of Retirement and Transition
to Retirement
Opportunities for employment, and the forms that employ-
ment may take, will vary for older adults and may include
everything from traditional work schedules to flexible or
incentivized programs. M. Wong et al. (2006) report that
some employers offer mentoring incentives for older adults
and suggest that more innovative government policies could
provide increased opportunities. Professional and service
occupation employers are most likely to provide opportunities
such as flexible schedules.
The path to retirement is varied, and increased flexibility
in options has slowly grown as employers have recognized
the value of older workers. Options include phased retire-
ment in which employees stay with the same employer while
BOX 201 Factors That Influence Older Workers
to Remain in the Workforce
■ Age increases for Social Security eligibility (Purcell, 2009).
■ Increased life expectancy and improved health in older age
(Centers for Disease Control and Prevention [CDC], 2012).
■ Uncertainty in economic climate, continued need for income
and/or health insurance (American Association of Retired
Persons [AARP, 2014; Purcell, 2009; M. Wong et al., 2006).
■ Continued enjoyment and social and psychological fulfill-
ment linked to identity (AARP, 2014).
■ Employer incentives and sponsored benefits are less common,
yet working increases available annuity payouts or influences
social security payments (Mulvey, 2011; AARP, 2014).
■ To stay physically and mentally active and prevent cognitive
decline (CDC, 2012; M. Wong et al., 2006).
4605_Ch20_313-326 31/10/17 12:13 PM Page 315
gradually reducing work hours and effort (Hutchens, 2010).
Phased retirement can provide a more satisfying path to
retirement for older workers and can be beneficial for the
employer by preserving the human capital that enhances
productivity (Hutchens, 2010). Other approaches can include
job sharing, reduced work schedules, rehiring retirees on
a part-time or temporary basis including using them as
contractors or consultants on an ad hoc basis rather than
replacing them with permanent employees (Mulvey, 2011).
In Japan, for example, phased retirement is provided as an
incentive to higher performers. The result is that the process
of retiring often occurs over several years.
Changing jobs and moving to part-time employment
is also common as a transition to retirement and is referred
to as bridge employment. This approach bridges the time
between leaving a career job and full retirement, providing a
gradual transition for some and needed supplemental income
for others (Atchley & Barusch, 2004). Other less common
transitions include starting a private business or a new career
on a part-time or full-time basis (AARP, 2014).
The Retirement Process and Models
As suggested by the examples of transitions from one form
of employment to another, retirement can be conceptualized
as a process as well as a specific life stage. One conceptual-
ization of the transition includes the life course approach,
focusing on the loss of a key life role (the worker role). The
life course approach examines how transitions are contextu-
ally embedded in the normal and anticipated course of life
events and the context in which the transition occurs affects
adjustment and satisfaction (van Solinge & Henkens, 2008).
A similar concept is life span development in which develop-
ment is conceptualized as extending across the entire life
span and we do not necessarily reach a plateau or decline as
we age. According to a life span development approach,
developmental events (e.g., transition to retirement) emerge at
various points in the life span. Development is also multidi-
mensional and multidirectional. Development is multidimen-
sional because it cannot be described by a single criterion such
as increases or decreases in a behavior. Development is also
multidirectional because there is no single, normal path that it
must or should take. In other words, healthy developmental
outcomes are achieved in a wide variety of ways. Healthy
development also involves both gains and losses (Baltes, 1987).
Atchley and Barusch (2004) presented a model of the
retirement process that outlines the common stages experi-
enced. Their model is shown in Box 20-2.
This model highlights variations in the process of adjust-
ment to retirement as a new state and the level of satisfac-
tion achieved by retirees. van Solinge and Henkens (2008)
differentiated between adjustment and satisfaction in the
following way. Adjustment includes the ways of coping
with the transition and the cognitive and behavioral efforts
to manage the process and adjust to a new life stage. Satis-
faction is the level of happiness with the process and new
CHAPTER 20 ■ Work and Retirement 315
BOX 202 Atchley’s Stages of Retirement
1. Preretirement—planning for retirement and for the process
of leaving the workplace.
2. Retirement—approaches to retirement can vary from focusing
on rest and relaxation to focusing on travel, hobbies, or
new adventures.
3. Disenchantment—a period of questioning that may be
marked by a sense of loss.
4. Reorientation—period of readjustment to form a retirement
lifestyle that is more satisfying.
5. Retirement routine—establishing a comfortable and
meaningful routine.
6. Termination of retirement—the end of retirement when an
individual may no longer be able to live independently.
Source: Atchley, R. C., & Barusch, A. S. (2004). Social forces and aging:
An introduction to social gerontology (10th ed.). Belmont, CA:
Wadsworth/Thomson.
life stage and is influenced by live events. van Solinge and
Henkens further noted that often the level of individual
happiness is relatively stable over time and only temporarily
affected by the transition to retirement followed by a return
to the individual’s “normal” level of happiness. Key factors
that influence satisfaction include access to key resources
including financial resources, the individual’s health status,
and their relationship status.
Some persons experience retirement as primarily a loss and
this may be intensified in those who lack other defined roles
such as family member, hobbyist, religious participant, or
volunteer (Donaldson, Earl, & Muratore, 2010; Szinovacz,
2003). Such a perception of loss can also be accompanied by
the loss of valued personal identity and role related activities
such as socialization with coworkers or work related travel
(J. Y. Wong & Earl, 2009).
Successful adaptation to retirement can be facilitated
through the adoption of alternative roles that fill the void and
are extensions of previous worker roles, via volunteer work,
or through maintaining contact with previous work environ-
ment (Price, 2003; Wiseman & Whiteford, 2009). Contin-
uing to practice work-related skills helps to maintain a sense
of self, sustain productivity, and preserve social relationships
(Price, 2003; Wiseman & Whiteford, 2009). Gottlieb and
Gillespie (2008) noted that engagement in leisure and volunteer
work is likely to increase satisfaction in retirement through
maintenance of identity in alternative productive roles. Their
findings were consistent with Continuity Theory as cited in
Wiseman and Whiteford (2009). Continuity theory suggests
that those who link past experience to current identity expe-
rience fewer negative effects of retirement even though they
no longer experience all of the same rewards (e.g., a salary).
Therefore, adaptation is facilitated by maintaining a link
between pre- and postretirement life.
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316 PART III ■ Active Aging: Supporting Client Activities and Participation

✺ PROMOTING BEST PRACTICE

Time and Structure
Reestablishment of time schedules provides positive benefits
for retirees by helping to structure daily life, provides a sense
of purpose to one’s day, and enables participation in multiple
activities (Price, 2003).

Factors thought to influence retirement adjustment and

satisfaction have also been explored by other researchers.
Three recurring factors studied include retirement planning,
context of work exit, and individual resources. A meta-analysis
by Topa et al. (2009) found a positive relationship between
retirement planning and retirement satisfaction. Retirement
planning may improve retirement satisfaction because it
facilitates developing realistic expectations about retirement;
it may also facilitate goal setting, which improves financial
planning (Taylor & Doverspike, 2003).
The context in which one exits the workforce has also been
found to influence retirement adjustment and satisfaction
(Donaldson et al., 2010; Quine, Wells, DeVaus, & Kendig,
2007; J. Y. Wong & Earl, 2009). Specifically, lack of choice
in retirement or forced retirement is associated with poorer
outcomes for adjustment, health, and well-being (Donaldson
et al., 2010). The perception that one is choosing to retire is
more predictive of retirement satisfaction than is a gradual
versus abrupt exit from the workforce or degree of identity
attached to worker role. Possible explanations for this finding
have been offered. One explanation is that involuntary retire-
ment is associated with not being financially or psychologi-
cally prepared (Bender, 2012). Others have investigated
how lack of choice affects feelings of mastery and control
(Donaldson et al., 2010). This finding is supported by earlier
research suggesting that feelings of control over one’s life
are predictive of feelings of satisfaction in successful aging
(Lachman & Weaver, 1998). Explanations aside, clearly the
conditions of transition are important; choice, timing, and
the nature of exit may promote better adjustment and satis-
faction (Figure 20-2; Donaldson et al., 2010). The findings
regarding the conditions of transition are significant, given
that Topa et al. (2009) found in their meta-analysis that most
retirees perceive the decision to retire as forced. Further
researchers have documented that forced retirement is a
model that is still widely used. In Western cultures, for
example, 10 to 50 percent of retirements are involuntary (van
Solinge & Henkens, 2008).
Individual resources also influence retirement adjustment
and satisfaction. Three types of personal resources are associ-
ated with more successful retirement. These resources include
higher income, better health, and being married (Donaldson
et al., 2010). Higher income levels are associated with higher
levels of well-being; however, this is relative to the individual.
Higher levels of well-being are also associated with receiving
retirement funds via a defined benefit, as opposed to having
a contribution-only plan that does not guarantee specific pay-
ments. The higher level of well-being associated with defined
FIGURE 202 Having valued occupations can ease the transition
to retirement. jacoblund/iStock/Thinkstock
benefits is attributed to the lower risk associated with these
plans. Overall physical and psychological health strongly
influences retirement satisfaction. Better health is associated
with greater perceived well-being and satisfaction during
retirement (Bender, 2012). Finally, being married is a pre-
dictor for greater satisfaction during retirement. This may
be due to increased opportunities to take up leisure activities
and improved social networks (van Solinge & Henkens,
2008).
In summary, retirement is viewed as both a process and a
life stage. The path to retirement is varied; for some, retire-
ment is a move toward different types of work, while others
leave the workforce completely. The Stages of Retirement
model, the life-course approach, life span development, and
Continuity Theory provide examples of theoretical models
that describe both the stages of retirement and the adjust-
ment process. Finally, factors such as retirement planning,
context of work exit, and individual resources also influence
satisfaction and feelings of wellbeing during retirement.
Who Are the Older Workers of Today
and Tomorrow?
As noted earlier, the number of Baby Boomers in the United
States who have reached or who are approaching age 65 has
rapidly increased. Moreover, trends in both age and gender
among this group have emerged. According to the Bureau of
Labor Statistics, between 1977 and 2007, the percentage of
men older than 65 years increased by 75 percent, and the
percentage of women over age 65 increased by 147 percent.
These trends have resulted in an overall jump of 175 percent
in persons over age 65 (U.S. Bureau of Labor Statistics, 2008)
and an increase in the number of employed married women
in this age-group.
4605_Ch20_313-326 31/10/17 12:13 PM Page 317
Barriers to Successful Continued Employment
Faced by Older Workers
Although we are living longer and, to a large extent, healthier
lives, persons who work in older age continue to face barriers.
The CDC (2012) noted that fewer job opportunities for older
workers exist, and participation in training for work is also
decreased. Older workers may face discrimination in hiring,
promotion, and work assignment. In a 2013 survey by
AARP, nearly two in three respondents, or 64 percent, said
they had seen or experienced age discrimination and that
discrimination based on age occurred at a higher rate than in
other years (AARP, 2014). These barriers and discrimination
may be driven by common stereotypes about older workers
including that they are less creative, show less initiative, and
may have difficulty learning new tasks (Mulvey, 2011).
Among older workers, physical and cognitive capacities
vary as much as health status. Many older adults experience
health and vitality far into older adulthood. Yet there are also
those who experience significant health issues in late middle
adulthood and may present as “frail elderly” while still in their
60s. Research on physical and cognitive capacities in older
adults shows that these adults are often able to compensate
for slow declines in abilities. Older workers may miss more
time off if they are injured, but they are less likely to have
severe work injuries or injuries leading to fatality and are
more likely to return to work postinjury than younger workers
(Crawford, Graveling, Cowie, & Dixon, 2010). Aerobic
activity with mechanical paced work may be lower, but report
of fatigue during these activities is less common. The slower
ability to learn new material, especially when faced with rapid
presentation of information, is compensated for by stronger
abilities to problem-solve and to supplement learning with
knowledge gained from experience.
Older workers may experience declines in physical
strength, endurance, balance, and thermal tolerance (i.e.,
working in hot or cold environments; Crawford et al., 2010).
Reaction time also may be slowed, but this is offset by the
tendency for more experienced workers to work with caution
and a focus on accuracy. Strong social support may ward
off problems of emotional fatigue, and deficits in vision or
hearing may be compensated for through environmental
adaptations including glasses, lighting, hearing aids, or pro-
tection from noise. Finally, caregiving can be a challenge
for older workers: 58 percent were responsible for caring
for someone, parents, child, spouse, or friend (AARP, 2014).
For workers between age 45 and 56 years, the rate of care-
giving was even higher, at 66 percent.
Generational and Cultural Perspectives
on Work and Retirement
Generational cohort differences in groups such as the Baby
Boomers and generation X (those born between 1965 and
1984) are of great interest and can be a challenge for em-
ployers. Differences in the generations include different
CHAPTER 20 ■ Work and Retirement 317
conceptualizations of work and loyalty to employers as well
as differences in the need and desire for social approval; such
differences are likely to result in different views of retirement
(Erdheim & Lodato, 2013). It has been suggested that
general work ethic and work centrality (degree of impor-
tance that work holds at a given point in time) decreased
from the Baby Boomers to the gen-Xers (Twenge, 2010).
Younger workers from Gen X, born between 1965 and
1984, and from “Generation Y” who were born between the
mid-1980s and the 2000s (Strauss & Howe, 1991) may be
more likely to hold multiple jobs and have an external locus
of control than Baby Boomers. They are also more likely to
take early retirement and to more highly value leisure while
Baby Boomers are less likely to retire early and more likely
to engage in bridge employment before full retirement.
Understanding and appreciating the generational perspec-
tives on work and retirement will aid rehabilitation profes-
sionals to more accurately assess individual clients and to
remain client-centered in intervention.
Another factor that influences retirement is culture.
Within some cultures, individuals’ retirement is an end goal
from a lifetime of work (Lubrorsky & LeBlanc, 2003; Pew
Research Center, 2009; Sakisian et al., 2011; Street &
Parham, 2002). For others, it is not desirable, and for yet oth-
ers, it is not financially feasible (Lubrorsky & LeBlanc, 2003;
Pew Research Center, 2009; Schramm, 2005). Furthermore,
the notion of retirement is influenced by whether a person
lives in an industrialized Western nation or a developing
nation where fewer resources and less social support may be
available.
Because of the decline in younger workers, many com-
panies and governmental agencies are finding it difficult
to fill open positions with qualified personnel. In some
cultures, there is a set retirement age (Scandinavian coun-
tries) and forced retirement that does not allow individuals
to work beyond a certain age. In each case, an individual’s
retirement and work life are affected by the culture of their
context (Luborsky & LeBlanc, 2003; Pew Research Center,
2009).
AROUND THE GLOBE: Work and Retirement
■ In some Westernized countries, retirement is viewed as the
responsibility of the individual, whereas in other countries
(i.e., China, Japan, Mexico), older individuals are held in high
esteem and are highly valued members of a family unit;
and in yet other cultures (European Union [EU] countries)
retirement is funded by state pensions plans (Martinez-Carter,
2013; Pew Research Center, 2009).
■ In EU countries, there are early retirement incentives that allow
individuals to retire in their 50s and 60s to avoid being laid
off. As a result, companies and governmental agencies can
hire younger and less expensive workers to fill vacancies
(Martinez-Carter, 2013).
■ In cultures in which homes settings are multigenerational,
retirement issues are very different than in cultures in which
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318 PART III ■ Active Aging: Supporting Client Activities and Participation
individuals live alone or with a nuclear family member(s)
(Martinez-Carter, 2013).
■ In countries that hold the older generation in high esteem
(e.g., Japan, China, Latin America), the elders frequently retire
to care for the younger family members (grandchildren/
nieces/nephews) while their children assume the worker role
and support all members of the family (Martinez-Carter, 2013).
Roles of older workers (or retirees) from non-Westernized
countries are quite different than those of older workers in
Westernized countries. In some instances, parents move out
of the home and the grandparents assume the child-rearing
duties altogether while their children work to support the
entire family. In Japan, however, there has been a slight shift
in grandparents’ traditional roles because of the decreased
birth rate and the move of employment from rural areas to
the larger cities, requiring parents to live far from the older
members of a family. China addressed the issue of employ-
ment being geographically further from the multigenerational
family members by enacting a law that requires the younger
generation to care for and visit the older members of families
(Martinez-Carter, 2013; Pew Research Center, 2009).
Previously in many Westernized nations, multiple gener-
ations lived in one home. However, as nations became indus-
trialized, there was a shift from this living arrangement. Also,
in many Western countries, the older generation is not held
in high esteem, which is quite different from Eastern and
Latin American cultures. In the latter cultures, the older gen-
eration is viewed as knowledgeable and wise and the collec-
tive (family) is more important than the individual. From its
inception, the United States has valued the individual and
the idea of self-sufficiency. As the nation moved from one
that was agriculturally based to one that is industrialized (and
now knowledge) based, there was a shift from being family
oriented (Street & Parham, 2002) to being oriented toward
the individual. Therefore, each person’s occupational transi-
tion is envisioned and, ultimately, patterned very differently
(Jonsson, 2010).
The person, the context, and the culture all shape how an
individual’s occupational transition is envisioned (Figure 20-3)
and ultimately lived. One aspect of the occupational transi-
tion does not override another; rather, each one interacts to
guide life leading up to the transition, what is experienced
while going through the transition and ultimately the retire-
ment pattern.
Therapy Perspectives on Work
and Retirement
Occupational Therapy and Older Workers
The occupational therapy process as described in the third
edition of the “Occupational Therapy Practice Framework:
Domain and Process” (American Occupational Therapy
Association [AOTA], 2014) includes the steps of (a) evalu-
ation including development of an occupational profile and
Culture
Context
Individual
FIGURE 203 Occupational transition to retirement pattern. Figure
by Patty Bowyer.
the analysis of occupational performance; (b) intervention
including development of the intervention plan, intervention
implementation and intervention review; and (c) targeting of
outcomes including determinants of success (AOTA, 2014).
The occupational therapy process can be applied to adults
who are transitioning to retirement, planning or struggling
with bridge employment, or who have retired and are expe-
riencing occupational dysfunction or dissatisfaction with their
daily routines and daily life. Developing the occupational
profile includes typical assessment and data gathering about
a person’s home and social world as well as administration of
any assessments related to occupational identity or perform-
ance and in particular the person’s identity, interests, and
competence as a worker. For example, assessments of vision,
hearing, memory, and cognitive processing may be indicated
if any potential deficits are noted. Assessments such as the
Worker Role Interview (WRI) will contribute information
to an assessment of the psychosocial factors that affect work
performance (Braveman et al., 2005). The Work Environment
and Impact Scale (WEIS) assesses workplace conditions that
have an impact on the worker (Moore-Corner, Kielhofner,
& Olson, 1998). Both the WRI and the WEIS are assess-
ments based on the Model of Human Occupation and sup-
plement the typical assessment of occupational performance
that would include assessment of activities of daily living,
instrumental activities of daily living, and other areas of
occupation. Other assessments may be used depending on
the setting and parameters such as the amount of time avail-
able with a client and reimbursement. These assessments
include the Occupational Performance History Interview
(Version II) or the OPHI II, the NIH Activity Record, the
Model of Human Occupation Screening Tool (MOHOST),
or functional capacity evaluations (Gerber & Furst, 1992;
Kielhofner et al., 2004; Parkinson, Kielhofner, & Forsyth,
2006). A brief description of each of these assessments, where
4605_Ch20_313-326 31/10/17 12:14 PM Page 319
they may be obtained, the delivery method, time to admin-
ister, and the information yielded by each is included in the
online ancillary materials for this book.
Intervention may occur in a range of settings including
traditional rehabilitation settings as well as the home or
community settings. Payment for work-related services may
be an issue in settings where service provision depends mainly
on third-party payers such as Medicare or Medicaid, which
traditionally do not pay for work or leisure focused interven-
tions. Client-centered intervention planning requires that
the occupational therapy practitioner involve the client in the
process of establishing short- and long-term goals. Although
occupational therapy practitioners are experts in the occupa-
tional therapy process, we must never forget that our clients
are experts in their daily lives. Through assessment of occu-
pational performance in all relevant areas of occupation,
occupational therapists can help identify potential gaps
between the client’s goals (e.g., returning to full-time work)
and the client’s abilities, given functional limitations or deficits.
Occupational therapy practitioners are also experts in assessing
the physical, social, cultural, and legal environments in which
the client will work.
Client outcomes of the occupational therapy process
can be varied and may include (a) successful return to paid
employment or (b) transition from work to other productive
roles including leisure and volunteer.
Physical Therapy and Older Workers
According to the American Physical Therapy Association
(APTA; 2011) older workers are at higher risk for fractures
and hip injuries because of falls. They are also at higher risk
for falls from ladders or stairs. The role of physical therapy
with older workers is to develop effective risk management
strategies for work settings. Once an injury has occurred,
physical therapists use the Guide to Physical Therapist Practice
(APTA, 2014a) to address the recovery of the injured worker.
This guide provides a structured process for approaches to
evaluation and intervention.
Physical therapists are experts in movement and mobility
and in addressing the underlying capacities and challenges to
these capacities that allow persons to manage their health
conditions and participate optimally in day-to-day life. Phys-
ical therapy practitioners help older adults to continue to
function in their worker role by addressing the challenges
older adults may face such as knee, back or joint pain, arthri-
tis, overuse injuries, cardiopulmonary conditions, maintaining
general fitness including strength and endurance, osteoporo-
sis, and the ability to move in their home, the workplace, and
the community (APTA, 2014b). Physical therapy practition-
ers can play a key role in the prevention of these injuries and
conditions in addition to providing restorative intervention
after onset of an injury or condition. Physical therapy practi-
tioners use a wide range of tests and measures that each focus
on understanding the underlying capacities and their impact
on functional performance. These tests and measures range
CHAPTER 20 ■ Work and Retirement 319
from a focus on ability to move from sit to stand, to ambula-
tion, quality of life, functional movement and mobility during
activities of daily living, postural skills and balance, pain and
fatigue scales, and a wide variety of other areas.
Functional capacity evaluation is particularly important
as a strategy for physical therapy intervention, both pre-
employment and during employment (Legge, 2013). In some
instances, such evaluation is implemented through the use of
proprietary equipment such as the Blankenship and the
WorkHab. A number of other physical capacity measures,
including the floor to waist lift (Gross, Batte, & Asante,
2006), have been demonstrated to provide meaningful infor-
mation regarding ability to undertake physically demanding
work. Legge notes that there is considerable variability in the
reliability and validity of such measures and that therapists
must match the capacity measured by the assessment with
the specific requirements of the job.
Physical therapy interventions are often provided in collab-
oration with occupational therapy. They may include (Legge,
2013) manual handling training, conditioning, fitness, health
promotion, and ergonomic redesign.
The Guide to Physical Therapy Practice, available at the
American Physical Therapy Association Website (http://www.
APTA.org), provides added guidance regarding assessment
and intervention in the workplace. A full list of the tests and
measures used by physical therapy practitioners is available
free of charge in the Table of Contents for the guide.
INTERPROFESSIONAL PRACTICE
Occupational Therapy and Physical Therapy
Working Together
Occupational therapy practitioners, physical therapy
practitioners, rehabilitation counselors, social workers, and
case managers all can play a role in assisting the older adult
to continue to work or transition to retirement. These services
may be accessed in traditional health-care settings such as
rehabilitation hospitals but may also be accessed in senior
settings, independent living centers, vocational rehabilitation
systems operated by city or state governments, and
community-based nonprofit organizations. The focus of
intervention in support of the older worker or support of
the older adult to transition to retirement will depend upon
the values, interests, and needs of the individual. Services are
not routinely available or offered to all older adults and the
individual, family members, or members of the care team
may need to be strong advocates to help older adults receive
necessary services.
Ergonomic and Assistive Technologies
Both occupational therapy and physical therapy practitioners
may use ergonomic strategies to assist the older worker.
Ergonomics is the study of humans, objects, or machines and
the interactions among them (Maltchev, 2012). Ergonomic
approaches include examining body mechanics and posture
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320 PART III ■ Active Aging: Supporting Client Activities and Participation
while seated or while performing work related tasks such
as reaching, bending, twisting, or lifting. Both static and
repetitive tasks are examined, as is the fit of the human body
in the environment (e.g., anthropometrics). Environmental
considerations including noise, vibration, lighting, and
contract stress are also part of ergonomic assessment and
interventions.
The impact of the environment has previously been
mentioned but assessment of the physical demands of a job
including the type, frequency, and duration of tasks can be
included in ergonomic approaches to modifying the environ-
ment. Assessment of the impact of the environment may
occur through simple observation or utilization of specific
assessments such as the Rapid Entire Body Assessment, the
Revised NIOSH Lifting Equation, the Rapid Upper Limb
Assessment or the Strain Index (Innes, 2012). The Center
for Universal Design at North Carolina State University cites
Ron Mace and the following definition “universal design is
an approach identified by designing products and space for
all potential users to the greatest extent possible (Center for
Universal Design, 2008). Universal design includes a set of
strategies related to accessibility for all individuals. Such
design can support older workers—and all workers—in the
workplace. Chapter 21 provides additional information on
technology and universal design.
✺ PROMOTING BEST PRACTICE
Technology and Environment
Gupta and Sabata (2010) identify the following aspects of
technology related to the environment to aid with promotion of
performance including the workplace: communication devices,
special tools and furnishings, lighting, contrasts, visual/auditory
cues, alarms and reminders, and presentation of information in
alternative formats.
Despite stereotypical assumptions about older adults and
technology such as the “digital divide” recent research shows
that older adults express more positive attitudes about the use
of technology than negative attitudes (Mitzner, Boron, &
Sharit, 2010). The term gerontechnology refers to “designing
technology and environment for independent living and
social participation of older persons in good health, comfort,
and safety” (International Society for Gerontechnology,
2014). Chapter 21 provides more information about assistive
technologies.
Volunteerism and Leisure
As previously noted, the adoption of significant and mean-
ingful volunteer and leisure occupations can facilitate the
successful transition to retirement as they provide continued
opportunities for socialization, promote cognitive engage-
ment, promote mobility and fitness, and provide meaning
and a source of identity. The Corporation for National and
Community Service (CNCS; 2013) reported that “Altogether,
more than 64.5 million adults volunteered through an organ-
ization in 2012, for a national volunteer rate of 26.5 percent,
essentially unchanged from the prior year. Volunteers gave
nearly 7.9 billion hours of service, worth an estimated $175
billion, based on the Independent Sector’s estimate of the
average value of a volunteer hour.” Furthermore, the CNCS
noted that seniors (e.g., over age 65) contribute a median of
90 hours of volunteer service annually, which is at a level far
above the level of the general population.
Volunteer activities, like employment, can range from
part-time or intermittent involvement to full-time or short-
term but intensive experiences. Braveman (2012) described
that while many volunteers routinely contribute a few hours
a week, others participate in long-distance volunteering in-
cluding volunteer vacations and travel for a week to several
weeks to a distant location. Organizations such as the Sierra
Club (www.sierraclub.org) and others run programs in which
participants may team up with local organizations or persons
such as forest service rangers to restore wilderness areas,
maintain trails, clean up trash and campsites, and remove
nonnative plants (Sierra Club, 2014).
As you saw in Chapter 19, play and leisure activities also
have a critical role in the transition to retirement. Leisure is
defined in the Occupational Therapy Practice Framework
as “nonobligatory activity that is intrinsically motivated and
engaged in during discretionary time, that is, time not com-
mitted to obligatory occupations such as work, self-care or
sleep” (AOTA, 2014). Primeau (1996) further delineated the
types of leisure activities by identifying four categories in-
cluding (a) leisure as discretionary time, (b) leisure as context,
(c) leisure as activity or observable behavior, and (d) leisure
as disposition or experience. The benefits of leisure for the
individual are wide ranging including the development of
skills, personal independence and growth, socialization,
developing a sense of competency, promotion of a sense of
identity, and the potential to clarify personal values and pri-
orities (National Center on Physical Activity and Disability,
2013). Leisure occupations are discussed in greater detail in
Chapter 19; it is important to recognize that leisure activities
can be important in ensuring a satisfying retirement.
Further, Braveman (2012) described how volunteer and
leisure activities can be used with adolescents, adults, and
older adults to promote participation in general but also to
develop general skills such as work habits to promote success
in employment. Volunteer and leisure experiences also provide
a low risk opportunity for individuals to explore their abilities,
capacities, and limitations such as fatigue, their tolerance for
activity, and the application of prior skills. For older adults
who may wish to transition to new areas of employment,
volunteering may provide exposure to work activities to more
accurately gauge interest as well as an opportunity to gain
practical experience. Occupational therapy and physical ther-
apy practitioners can benefit from using volunteer and leisure
occupations to (a) assess capacity and efficacy; (b) explore
values, interests and motivations; (c) develop habits and
4605_Ch20_313-326 31/10/17 12:14 PM Page 321
routines; (d) develop work skills and gain experience; and
(e) reestablish social connections.
Legislative and Policy Issues Around
the World
A wide range of legislative and policy issues can influence the
older adult worker both in the United States and internation-
ally. Policies can vary greatly depending on cultural values
regarding employment and the involvement of older persons
in the workforce and in society. For example, the changing
demographics in Japan and the rapidly increasing number of
Japanese citizens over age 60 have resulted in notable changes
in employment and in governmental policy over the last
few decades. Japan has long operated under a practice called
life-time employment, which can be described as the “practice
of companies to hire their core employees primarily from
among new graduates and other young persons, to plan their
continual training and development, to continue their employ-
ment within the company group over a long period of time
[usually until age 55 or 60], and not to discharge or lay off such
employees except in very unusual circumstances” (Ornatowski,
1998). However, a series of reforms have been enacted to raise
the age of eligibility for pension benefits, making social benefits
less generous, and to promote continued employment after the
mandatory retirement age, even if in a different job at lower
wages (Oshio, Oishi, & Shimizutani, 2011). The average effec-
tive retirement age in Japan is higher than the average of coun-
tries reporting statistics to the Organization for Economic
Co-Operation and Development (OECD; www.oedc.org)
including the United States and about 29 percent of men and
13 percent of women aged 65 and older are still in the labor
force. Only Korea has a higher share of older persons still in
the labor force (Duell, Grubb, Singh, & Tergeist, 2010).
Many other countries are enacting policies and pro-
grams to promote successful employment in older adults
and descriptions of such efforts can be found at the OECD
website. Individual reports are included for 21 countries
with an analysis of the labor participation of older workers,
current policies and recommendations for future changes
for policy is included. For example, the report for the
United States notes that although the rate of aging of
the population is not as high as some countries and that
the trend for earlier retirement has halted, challenges still
lie ahead due to the aging workforce, and the following rec-
ommendations are explored in more depth in the report
(OECD, 2005):
■ Strengthen financial incentives to carry on working.
■ Speed up the transition from age 65 to 67 for full retire-
ment age.
■ Raise the minimum age for social security.
■ Ensure disability benefits do not become an alternative
route to early retirement.
■ Limit tax advantages in private pension plans for taking
early retirement.
CHAPTER 20 ■ Work and Retirement 321
These policies remain under discussion a decade later, but
legislative action has not occurred.
Kaskutas (2013) provided a list of important policies
related to employment of the older worker in the United
States. These policies include, among others, (a) The Ticket to
Work & Work Incentive Improvement Act, (b) The Americans
with Disabilities Act, (c) The Rehabilitation Act, (d) Workers’
Compensation legislation, (e) Social Security Disability
Insurance, (f) The Family and Medical Leave Act, (g) Long
Term Disability Insurance, (h) The Age Discrimination
Employment Act, and (i) Title VII of the Civil Rights Act.
Occupational therapy or physical therapy practitioners work-
ing with older adults must become familiar with laws and
policies that might help keep the worker on the job. Under-
standing and applying these policies can be complex, and
practitioners should not underestimate the effort that is
required to understand and apply the policies effectively.
For example, older adult workers may be covered under the
American’s with Disability Act (ADA) but not simply because
of their age. The Job Accommodation Network (2013) notes
that “aging, by itself, is not an impairment, but a person who
has a medical condition (such as hearing loss, osteoporosis,
or arthritis) often associated with age has an impairment on
the basis of the medical condition. A person does not have an
impairment, however, simply because (s)he is advanced in
years.” Understanding when a reasonable accommodation may
and may not be required under the ADA can be complex and
may require an in-depth understanding of the law. Practition-
ers who wish to provide services to older workers on a routine
basis will benefit from specific training on the ADA and other
legislation and policies. Strategies for advocating for clients
and for policy change are covered in more detail in Chapter 3.
Other Health-Care Providers Involved
in Work and Retirement
In addition to occupational therapy and physical therapy
practitioners, other types of professionals may assist older
adults with issues related to work and retirement. These
include (a) rehabilitation counselors, (b) social workers, and
(c) case managers.
Rehabilitation counselors help people with emotional
and physical disabilities live independently. They work with
clients to overcome or manage the personal, social, and pro-
fessional effects of disabilities on employment or independent
living (U.S. Bureau of Labor Statistics, 2014a). Rehabilitation
counselors typically have a master’s degree and certification, and
licensure is required in some states. Rehabilitation counselors
may have contact with older adults in independent living
centers, rehabilitation agencies, and private practice. Some
of the services provided by rehabilitation counselors include:
■ Helping clients adjust to their disability through individual
and group counseling.
■ Evaluating clients’ abilities, interests, experience, skills,
health, and education.
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322 PART III ■ Active Aging: Supporting Client Activities and Participation
■ Arranging for clients to obtain services, such as medical
care or career training.
■ Helping employers understand the needs and abilities of
people with disabilities, as well as laws and resources that
impact people with disabilities.
■ Locating resources, such as wheelchairs or computer pro-
grams, that help clients live and work more independently.
■ Advocating for the rights of people with disabilities to live
in the community and work in the job of their choice.
Social workers help people solve and cope with prob-
lems in their everyday lives and some also diagnose and
treat mental, behavioral, and emotional issues. Social workers
might come into contact with older adults in hospitals,
independent living centers, community-based agencies,
human service agencies, and rehabilitation centers. Most
social workers have master’s degrees and are licensed in the
state in which they work (U.S. Bureau of Labor Statistics,
2014b). Some of the services provided by social workers
include the following:
■ Assessing clients’ needs, situations, strengths, and support
networks to determine their goals.
■ Helping clients adjust to changes and challenges in their
lives, such as illness, divorce, or unemployment.
■ Researching and referring clients to community resources,
such as food stamps, child care, and health care.
■ Helping clients work with government agencies to apply
for and receive benefits such as Medicare.
■ Advocating for and helping clients get resources that would
improve their well-being.
Case managers work collaboratively with clients to provide
“assessment, planning, facilitation, care coordination, eval-
uation, and advocacy for options and services to meet an
individual’s and family’s comprehensive health needs through
communication and available resources to promote quality,
cost-effective outcomes” (Case Management Society of
America, 2014). Case managers might come into contact
with older adults in hospitals, independent living centers,
community-based agencies, human service agencies, and
rehabilitation centers. Case managers can have a variety of
backgrounds including nursing, gerontology, and allied
health professions and typically are educated at the bache-
lor’s or master’s level. Some of the services provided by case
managers are the following:
■ Assessing clients’ most urgent needs, appraising the situa-
tion, and listening to the clients’ concerns.
■ Performing an in-depth mental or physical health analysis
of the client.
■ Developing a detailed plan of action to meet these needs,
set goals, and find necessary resources to meet the goals.
■ Consulting with other external agencies to provide support
services and resources.
■ Staying in touch with clients to ensure the services were
beneficial and that their needs are still met after pointing
clients in the right direction for services.
SUMMARY
This chapter explored the topics of work and retirement.
Large numbers of Baby Boomers or those persons born be-
tween the end of World War II (1946) and 1964 are moving
into their 60s and 70s. The patterns of work for these aging
workers can vary a great deal and have changed over time.
Full-time retirement at age 65 is no longer an option for
some workers, and others are making different choices about
how to approach work and retirement as older adults. Models
of retirement and transitions to retirement were explored
including a life course approach and Atchley’s Stages of
Retirement. Retirement planning, the context of work, and
individual resources were discussed as they relate to influences
on retirement adjustment and satisfaction. Generational and
cultural perspectives on work and retirement were explored
and different patterns were described. Finally, the perspec-
tives and roles of occupational therapy and physical therapy
on work and retirement were described, and the potential
roles for occupational therapy and physical therapy practi-
tioners were presented.
CASE STUDY
At the beginning of this chapter, you learned about Maria
Alvarez. You saw that she has a good social support net-
work, many interests, and a variety of plans for what she
will do in retirement. However, she also has some con-
cerns about factors that could make her retirement less
satisfactory.
She lives in a two-story home that is not accessible. She
has to climb stairs to enter her home, and all the bedrooms
and bathrooms with showers and bathtubs are on the sec-
ond floor. Also, her washer and dryer are in the basement
of her home. She realizes that to age in place she must
make structural adjustments to the main living level in her
home. She also worries about transportation. Because she
lives in a rural area, she has to be able to drive. She has
noticed over the years that her vision is not as good as it
had been. This is particularly true of her night vision. She
fears that she will be unable to drive at some point and
will essentially become a shut in. Although her family does
live near her, most are 1 to 2 hours away and work, are in
school, or have the responsibility of raising young children.
Therefore, it would not necessarily be easy for them to take
her to places she needs and wants to go, such as the gro-
cery store or to church activities. She worries about main-
taining her independence and not feeling like she is a
burden to others. She recognizes that she will need to
address all of these issues before they require her to
move from her home or to essentially become isolated and
unable to easily move about her community.
Because of her concerns, Maria began to gather infor-
mation about the areas that could affect her ability to age
in place. She mentioned to a friend the structural issues
4605_Ch20_313-326 31/10/17 12:14 PM Page 323
with her home, and her friend had the same concerns
when she retired 5 years earlier. The friend mentioned that
she had been put in contact with an occupational therapist
with skills in home modification. Maria obtained the
occupational therapist’s contact information and arranged
an appointment. After meeting with the occupational
therapist, Maria became less concerned about aging in
place as the occupational therapist provided information
on universal design and environmental modifications. The
occupational therapist was also able to direct Maria to
two other occupational therapists, one who specializes in
low vision and another who was skilled in assessing driving
and community mobility needs. The occupational thera-
pist also consulted with a physical therapist skilled in
working with older adults. The physical therapist deter-
mined that a physical capacity evaluation would be help-
ful to help Maria identify strategies for maintaining or
enhancing her ability to maintain the endurance and
strength needed for her daily activities. With the support
of these therapists to address Maria’s concerns, aging in
place now seems like it is possible.
Questions
1. What role do the environmental features in her home
have to do with Maria’s potential satisfaction with
retirement?
2. How might aging in place relate to ability to partici-
pate in meaningful retirement activities?
3. How might maintenance of Maria’s functional
capacities, including her strength, endurance, and
mobility, affect Maria’s transition to retirement?
4. The case as presented here talks relatively little
about Maria’s interests and planned activities.
Why might a focus on environment and physical
capacity be central to ensuring her satisfaction in
retirement?
Critical Thinking Questions
1. Beyond financial issues, what are some key questions
for older adults considering retirement?
2. What are some important steps to be taken before
retirement occurs?
3. What kinds of activities or occupations do you
think are most important to continue into
retirement?
4. Why might employers want to retain their older
employees? What steps can they take to do this?
5. What are some ways that retirement has changed
over the past two decades? What impact might these
changes have for individuals? For employers?
CHAPTER 20 ■ Work and Retirement 323
6. If an employer is uncertain about an older adult’s
ability to maintain productivity, what contribution
might OT make to help address this concern?
7. How might OT and PT work most effectively
together to support older adults who want to
continue to work? Who want to retire?
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Environment, Products, and Technology
“How old would you be if you didn’t know how—Satchel
LEARNING OUTCOMES
By the end of this chapter, readers will be able to:
1. Describe the three ways the built environment can be
adapted or modified to benefit older individuals.
2. Differentiate among accessible design, adaptable
design, transgenerational design, and universal
design.
3. Define and describe assistive technology.
4. Differentiate between high-tech and low-tech devices.
5. Describe the devices used for individuals with mobility
impairments, including environmental control devices
and mobility aids.
6. Describe the devices that may be helpful to individuals
with visual impairments.
7. Describe devices that may be helpful to individuals with
hearing deficits.
8. Describe the devices that may be helpful to individuals
with cognitive impairments.
9. Describe how the World Health Organization’s Interna-
tional Classification of Functioning (ICF) model and
Occupational Therapy Practice Framework (American
Occupational Therapy Association, 2014) can be used
to determine the types of devices that may be helpful
to a particular individual.
10. Discuss the limitations in the usefulness of technological
devices.
Clinical Vignette
Ralph Smith, a 74-year-old retired teacher from rural South
Georgia, is about to be discharged from his local hospital. A
week ago, while tending his garden, he felt dizzy, had trouble
seeing clearly, and developed an intense headache. His wife
drove him to the hospital where he was diagnosed with a
hemorrhagic stroke. As a result of this stroke, Mr. Smith now
has difficulty walking and has lost most of the function in his
right arm. Before the stroke, Mr. Smith would go for long
walks in the morning with his dogs, and often spent the
afternoons tending to his chickens and taking care of his
garden. Mr. Smith lives with his wife in a small farmhouse
CHAPTER 21
Sergio Romero
old you were?
Paige
”
he built himself with the help of his brother and his next-
door neighbor.
1. Do you think Mr. Smith will be able to continue par-
ticipating in the activities he likes?
2. How would you help Mr. Smith so he can continue
doing the things he likes? How would you change his
environment?
3. What tools can Mr. Smith use to compensate for some
of his limitations?
T
his chapter begins with an overview of how the built
environment can be adapted or modified to increase or
maintain functional performance for older individuals with
disabilities. This is followed by a discussion of how the World
Health Organization (WHO) International Classification
of Functioning Disability and Health (ICF; 2013) model can
be used as a tool to evaluate needs and select appropriate
assistive devices. The chapter then describes some common
assistive technology devices used to compensate for various
age-related problems (i.e., mobility, vision, hearing, and
memory) and concludes with a brief discussion of important
issues related to technology and older adults.
This chapter emphasizes the use of technology to support
function. It is important to understand what constitutes
technology. In its broadest sense, it can be considered mak-
ing, modifying, and using tools, machines, and methods of
organizing to solve a problem or achieve a goal (Schulz et al.,
2015). The particular emphasis of this review is on what
Schulz and colleagues have labeled quality of life technologies.
“These are not only systems that are compensatory or assistive
(e.g. assistive technology) but also technologies that are pre-
ventive and that entertain, and stimulate, elevate mood, or
improve psychological well-being” (p. 724).
Aging and Functional Performance
Recent data suggest that most people over age 64 years are
living longer and healthier lives compared with the same
age-group 10 years ago (Administration on Aging, 2013).
327
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328 PART III ■ Active Aging: Supporting Client Activities and Participation
However, with advancing age come two major challenges that
impact functional performance. The first is a gradual decline
that can result in compromised hearing, vision, mobility, and
cognitive processes. The second is the probability that one or
more chronic diseases, such as arthritis, macular degenera-
tion, heart disease, or Alzheimer’s disease will result in addi-
tional disabilities (WHO, 2001).
Demographic factors, such as age, gender, race, health,
living arrangements, and social support, contribute to both
limitations in functional performance and diversity or het-
erogeneity of the older population in the United States (He
& Baker, 2004). Although disease and age-related frailty
and disability are common in this group, when presented
with alternative living arrangements, older adults overwhelm-
ingly choose living at home. In fact, 90 percent of adults over
age 65 report they would prefer to stay in their current resi-
dence as they age (Keenan, 2010). Because most housing and
communities are not typically designed to meet the needs and
preferences of seniors as they age, various solutions are being
implemented in homes and communities to assist older
persons in “aging in place”—remaining in their homes as
long and as independently as possible (Cameron et al., 2012;
Daniel, Cason, & Ferrell, 2009; Horowitz, Nochajski, &
Schweitzer, 2013).
The Built Environment and Functional
Performance
Almost everything we do in life is affected by what has been
built around us. Our ability to receive an education, find
housing, participate in religious activities, shop, bank, recreate,
travel, and earn a living are all affected by the built environ-
ment. Yet for almost 200 years, our schools, courts, houses,
religious buildings, stores, banks, theaters, restaurants, public
transit systems, and overall workplaces were built with the
able-bodied population in mind. Access to these buildings,
facilities, and services was only a dream shared by millions of
individuals with disabilities (Peterson, 1998).
The concept of designing products and the built environ-
ment for people with disabilities did not appear until the
1960s when the American National Standards Institute
established Standard A117.1, “Making Buildings Accessible
to and Usable by the Physically Handicapped.” The initial
focus of emerging standards was on people with disabilities
of any age. It was not until somewhat later that the unique
needs of older adults were considered. Over the years, additional
legislation (e.g., Americans with Disabilities Act and Fair
Housing Amendment Act) increased the rights of people
with disabilities to access all public buildings and public
and private housing ( Karger & Rose, 2010; Ostroff, 2010).
Although these laws improved the opportunities and inde-
pendence afforded to those with disabilities, they have not
adequately addressed the needs of older adults, which in some
ways are different from the needs of younger people with
disabilities (Putnam, 2011). Older adults often experience
simultaneous decline in several abilities (i.e., vision, mobility,
and hearing), which cannot be addressed solely by removing
certain environmental barriers.
AROUND THE GLOBE: Disability-Specific Laws
Although the United Nations Convention on the rights and
dignity of persons with disabilities called for every country to
adhere to a set of principles to promote participation, many
countries have struggled to enact them (Lang, 2009). Without
such laws, individuals with disabilities have less access to
education and work, their life spans are shorter, and they
experience greater difficulty during later life. These are issues
of concern for therapists whose interventions emphasize
supporting function and wellness.
Vanderheiden (1998) suggested three possible approaches
to ensure effective interaction with the environment:
1. Change the individual
2. Change the environment
3. Provide individuals with tools they can use
Each approach is seen as equally important and necessary
to “function effectively in the various environments and sit-
uations they encounter on a daily basis” (Vanderheiden, 1998,
p. 31). Each area is briefly discussed in the following sections.
Change the Individual
This approach addresses the methods used to enhance the
physical, psychological, and social abilities of the individual
for accessing and using the environment (Vanderheiden,
1998). These methods include the following interventions:
surgery, therapy, training, education, and teaching of com-
pensatory strategies and adaptive techniques. One advantage
of this approach is that it improves the innate abilities, skills,
and strategies that individuals “carry” with them.
Change the Environment
In many cases, the impact of disability on functional perform-
ance can be overcome or reduced through the design of the
places we live, work, play, and worship. This is often referred
to as accessible design, defined as design that “is readily
accessible to and useable by individuals with disabilities”
(U.S. Department of Justice, 2010, p. 1). Accessible design
is often achieved by providing separate design features for
specific disabilities, such as paddle blade faucet handles
on large lowered sinks in public restrooms for those with
mobility impairments. These solutions can be costly because
they are added on to existing designs or new construction
at the end of the design process. They can be stigmatizing
because they draw attention to the individuals who have to
use these features (e.g., ramps next to entrances with stairs).
In addition, this approach, based on bureaucratic standards
4605_Ch21_327-340 31/10/17 12:35 PM Page 329
and codes, often results in design that has an institutional or
medical feel. Three subsets of accessible design are adaptable
design, transgenerational design, and universal design. These
are discussed in detail later in the chapter. Accessible designs
may incorporate features from one, two, or all three of these
subsets. A height-adjustable stovetop, for instance, is an
accessible design feature within an environment that incor-
porates features of both adaptable and universal designs, but
not transgenerational design, because the feature was not
specifically made to accommodate all of the changes people
might experience as they age.
✺ PROMOTING BEST PRACTICE
Home Modification and Function
A review by Chase, Mann, Wasek, and Arbesman (2012)
demonstrated that multifactorial programs that included
home evaluations and home modifications, physical activity,
education, vision and medication checks, and assistive
technology resulted in a decreased rate of functional decline,
decreased fear of falling, and increased physical factors such
as balance and strength.
Adaptable Design
Adaptable design involves making modifications to a stan-
dard design for use by a particular individual with a disability,
such as adding large grips to kitchen utensils to help someone
with rheumatoid arthritis (Deardorff, 2003). These features
sometimes appear added on to a product or environmental
space, which may result in the design being stigmatizing and
expensive.
Transgenerational (Life-Span) Design
Transgenerational, or life-span, design considers the changes
individuals experience as they age (Deardorff, 2003). This
type of design does not address the full range of possibilities
that can affect individuals throughout their lifetimes, such as
congenital conditions, injury, illness, gender, cultural back-
ground, and literacy level. Grab bars in a bathroom might
help both young children and elders but are not specific to
particular kinds of conditions.
Universal Design
Universal design is defined as “the design of products and
environments that can be used and experienced by people
of all ages and abilities, to the greatest extent possible, with-
out adaptation” (Deardorff, 2003, p. 120). This is the most
inclusive and least stigmatizing of the three types of designs
because it benefits everyone—young and old, men and
women, children and older adults, small people and large
people. Furthermore, universal design solutions are fully
integrated into the environmental design before the process
begins to accommodate a wide range of the populations.
The goal of universal design is to minimize the amount
of adaptation needed by the individual and maximize the
CHAPTER 21 ■ Environment, Products, and Technology 329
individual’s natural inclusion into all daily activities (Carr,
Weir, Azar, & Azar, 2013).
Smart homes are a specific application of some elements
of universal design. “A smart house is a house that has highly
advanced automatic systems for lighting, temperature control,
multi-media, security, window and door operations and many
other functions” (Craven, 2012, para. 1). Functions might
include the ability to monitor contents of a refrigerator or an
individual’s location in the home and options for summon-
ing help. Such monitoring and control features can improve
an older adult’s safety and function. These homes are increas-
ingly popular for everyone, as are other elements of universal
design that might also include structural elements such as wide
doors, adjustable counter height, and one-floor living.
Another way to conceptualize application of technology
is in terms of the purpose and life domain (Schulz et al.,
2015). Purposes include monitoring, diagnosis, and treatment
(including prevention). Domains include physical and mental
health, mobility, social connectedness, safety (including man-
agement of emergencies), and everyday activities and leisure.
This organizing framework is helpful in identifying both the
ways in which occupational and physical therapists can think
about assessing the value of specific technologies to address
patient needs and also in terms of how they might identify
situations for which new technologies might be helpful.
The Center for Universal Design (1997) in Raleigh, North
Carolina, established seven principles to guide the design
process, evaluate existing and new designs, and teach what
universal design encompasses. These principles are as follows:
1. Principle 1: Equitable use—The design is useful and
marketable to people with diverse abilities.
2. Principle 2: Flexibility in use—The design accom-
modates a wide range of individual preferences and
abilities.
3. Principle 3: Simple and intuitive use—Use of the
design is easy to understand, regardless of the user’s
experience, knowledge, language skills, or current
concentration level.
4. Principle 4: Perceptible information—The design com-
municates necessary information effectively to the user,
regardless of ambient conditions or the user’s sensory
abilities.
5. Principle 5: Tolerance for error—The design minimizes
hazards and the adverse consequences of accidental or
unintended actions.
6. Principle 6: Low physical effort—The design can be
used efficiently and comfortably and with a minimum
amount of fatigue.
7. Principle 7: Size and space for approach and use—
Appropriate size and space is provided for approach,
reach, manipulation, and use regardless of the user’s
body size, posture, or mobility. (n.p.)
Advantages of universal design include reduced need for
assistive technology, decreased cost of a device, increased avail-
ability of usable designs, increased longevity and reliability and
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330 PART III ■ Active Aging: Supporting Client Activities and Participation
ease of repair, increased inclusion of people with disabilities
into society, reduced social stigmatism, and decreased
amount of personal assistance needed by people with disabil-
ities (Story, 1998). Universal design offers older adults and
those of any age who have disabilities many advantages, but
it will not fully replace the need for interventions to enhance
the individual’s abilities, or the need to provide individuals
with tools, or assistive technology. Thus, for some individuals
and for some activities, there will always be a need for specific
devices and personal assistance.
Provide Individuals With Tools
Humans are “tool users,” and with the exception of a few
animal species such as chimpanzees that use sticks to dig up
insects, and sea otters that use rocks to break clam shells, no
other species use objects, or tools, to enhance task perform-
ance. Our tools range in complexity from spoons to space
shuttles and from can openers to computers. Tools that are
used to strengthen, compensate, or provide a better match
between a person’s abilities and the demands of the environ-
ment are called assistive technologies, adaptive devices, or
assistive devices. Specifically, assistive technology device is
defined by the Technology Related Assistance for Individuals
with Disabilities Act of 1988 (1994) as “any item, piece of
equipment, or product system, whether acquired commer-
cially off the shelf, modified or customized, that is used to
increase, maintain, or improve functional capabilities of
individuals with disabilities” (n.p.). This broad definition
includes low-tech devices (e.g., those traditionally used by
therapists, such as button hooks and reachers; Figure 21-1)
and high-tech devices (e.g., computer hardware and software,
such as voice recognition and screen magnification software
for persons with low vision, electronic monitors, and sensors).
FIGURE 211 Not all assistive devices are high tech. A thermostat
with large numbers can help someone with a visual impairment
better control the environment.
There is a strong belief that technology can be an impor-
tant contributing factor in improving quality of life (Schulz
et al., 2015). Applications go far beyond health, safety, and
monitoring functions to include entertainment, social con-
nectedness, and access to resources for pleasure. For example,
27 percent of individuals older than 65 years use social
networking sites to maintain important ties (Duggan, Ellison,
Lampe, Lenhart, & Madden, 2015). Such computer-based
activities have the potential to help elders maintain the greatest
possible level of independence, and to enrich their lives (Boot
et al., 2015).
Assistive technologies have demonstrated utility in many
health related situations, especially in terms of monitoring
and disease management (Schulz et al., 2015). In particular,
Schulz and colleagues reported that telemedicine has been
extensively studied and shows positive impact on management
of a variety of chronic diseases such as diabetes. They also
reported that positive effects have been shown for computer-
assisted interventions such as cognitive behavior therapy to
reduce anxiety. Assistive devices are also demonstrated to
reduce the amount of informal care needed (Anderson &
Wiener, 2015).
However, there are also disadvantages including cost, lack
of consumer awareness of products, social stigma regarding
use of assistive technology, and that assistive technology
advancements cannot keep up with the rate at which main-
stream technology is advancing. Technological advances
such as miniaturization are addressing some of the stigma
associated with the use of assistive devices. For example,
the latest hearing aid devices are practically invisible.
Assistive devices do not always have the straightforward
impact expected. Although Anderson and Wiener (2015)
reported that these devices reduce the need for informal care-
giving, they had no similar impact on formal caregiving. This
may be due to differential levels of care needed by those
who seek formal care. Similarly devices to improve outdoor
mobility for older adults had complex impact (Clarke, 2015).
As an example, ramps were not found to improve outdoor
mobility for those using wheeled mobility devices or walkers.
Clarke’s (2015) conclusion is important to bear in mind: “The
relationship between the environment and mobility disability
is complex, incorporating interactions between individual
capacity and environmental barriers and facilitators. We
currently have very little understanding of the relative (or
joint/interactive) contribution of the environment in creating
difficulty for outdoor mobility” (p. S13).
Aging in Place
A person’s home is a comfortable, familiar location that may
promote independence, identity, and life satisfaction and
gives older adults a sense of connectedness and safety
(Stevens-Ratchford & Diaz, 2003). The Centers for Disease
Control and Prevention (2013) defined aging in place as “the
ability to live in one’s own home and community safely,
independently, and comfortably, regardless of age, income,
4605_Ch21_327-340 31/10/17 12:35 PM Page 331
or ability level” (para. 5). Three areas that should be addressed
when helping older adults “age in place” include interventions
at the person level, changes to the environment, and provision
of assistive devices. All areas should be considered when
working with a client. Mann, Ottenbacher, Fraas, Tomita,
and Granger (1999) demonstrated this point by investigating
the effectiveness of assistive technology and home modifica-
tions in reducing the rate of declined functional status for
physically frail older persons living at home. Furthermore,
this study documented the cost-effectiveness of an intensive
approach to the provision of assistive technology and home
modifications. Individuals who receive all the assistive devices
and home modifications they need spend less time in hospi-
tals and nursing homes, and average costs associated with
institutional care are significantly less. These findings provide
strong support for a thorough approach to functional and
home evaluation, followed by procurement of needed devices
and home modifications, with appropriate training and
follow-up. The remainder of this chapter focuses on assistive
technology.
Assessing the Need for Assistive
Technology
The WHO’s (2013) ICF model offers practitioners a system-
atic way to assess and select appropriate assistive technology
devices to accommodate the specific needs of their clients
(Escorpizo et al., 2013; Jette, Tao, & Haley, 2007; Kostanjsek
et al., 2011). The ICF model not only depicts the older adult
and his or her performance of tasks or activities in a state of
health rather than disability but also delineates and conceptu-
alizes functional performance into three classification levels—
body structure/function, activity, and participation—before
adding in disease or disorder. The ICF model can be used as a
guide for the provision of medical and therapeutic intervention,
including evaluating and selecting assistive technology, at each
classification level for a particular individual given their health
or disability, as well as environmental and personal factors.
Assistive technology evaluation, provision, training, and
follow-up is guided by the environmental factors component
of the ICF model. Specifically, the environmental factors
component constitutes the physical, social, and attitudinal
environment in which people live and includes five areas:
1. Products and technology
2. Natural environment and human-made changes to
environment
3. Support and relationships
4. Attitudes
5. Services, systems, and policies (Escorpizo et al., 2013;
Kostanjsek et al., 2011)
According to the ICF, assistive technology would be in-
cluded under the area of products and technology: “natural
or human made products or systems of products, equipment,
and technology in an individual’s immediate environment,
CHAPTER 21 ■ Environment, Products, and Technology 331
that are gathered, created, produced or manufactured” (p. 591).
Selecting and providing appropriate assistive technology
devices for an older adult depends on the number and type
of classification levels affected by that person’s disease, con-
dition, or disorder. Devices used to compensate for impair-
ments at the body structure/function level include hearing
aids, pacemakers, and prosthetics. Technology solutions at
the activity level can be low tech or high tech. Some low-tech
solutions are utensils with built-up or weighted handles,
reachers, and sock aids. Several high-tech examples include
environmental control units and specialized computer hard-
ware or software. Assistive technology used to compensate
for limitations in participation often overlap with the devices
recommended for the body structure/function and activity
levels. For example, an older adult with a mobility impair-
ment may use a powered wheelchair to compensate for an
inability to walk as well as to accomplish specific tasks or
actions, such as cleaning the kitchen. In short, classification
levels impacted by a disease, condition, or disorder will deter-
mine the amount and type of assistive technology devices
needed to function independently.
Assistive technology, both low tech and high tech, is avail-
able for people with hearing, vision, memory, communication,
and movement impairments. It is important to point out that
high-tech is not synonymous with complicated. In fact, high-
tech devices may be easier to use than traditional devices
designed for the same purpose. That is, they may be “smarter”
and save the user steps. A good example of this is the voice
recognition capabilities of popular smartphone platforms such
as Android and Apple. Assuming that the technology has
been carefully designed and tested with typical users—a design
process that is not always implemented—simple and intuitive
voice commands can enable an older person with a visual
impairment, for example, to obtain useful information with
the push of a button.
Determining Assistive Technology
Needs Using the ICF and Practice
Framework
Both the ICF (WHO, 2013) and the “Occupational Therapy
Practice Framework” (American Occupational Therapy
Association [AOTA], 2014) can guide the practitioner
throughout the assistive technology process from assess-
ment to follow-up. Specifically, the ICF model provides the
underlying foundation of the process by giving the practi-
tioner a picture of the client in a healthy and an unhealthy
state at various levels of functioning and contextual factors.
The Practice Framework likewise provides a conceptual
model for various occupations and the personal and environ-
mental factors that support those occupations. It delineates
the procedures to follow during each step of the interven-
tion process. These models allow occupational and physical
therapists to gain an understanding of a person’s “typical”
functional performance and contextual factors without a
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332 PART III ■ Active Aging: Supporting Client Activities and Participation
disease, disorder, or condition, and, in turn, use this infor-
mation to determine the client’s functional needs, abilities,
limitations, and impact of various contextual factors. They
provide the practitioner with a framework for gathering
necessary information about the client—needs, abilities,
and limitations—before and after the onset of a disease,
condition, or disorder. Particularly relevant to the use of
technology is its emphasis on environmental factors, which
are seen as potential facilitators or hindrances to function
(Arthanat, Nochajski, & Stone, 2004).
Physical therapists often frame their intervention in the
context of the ICF. Their emphasis is on body structure/body
function and on activity and participation with an eye toward
the physical capacity and functional mobility that enable
activity and participation. Their intervention may emphasize
assistive devices like canes, walkers, and wheelchairs (discussed
later in the chapter) that support mobility in individuals who
require such help. These devices require training for effective
and safe use, for example, ensuring that an individual using a
cane knows which hand to hold it in and how to make sure
it does not create a tripping hazard.
According to the Practice Framework (AOTA, 2014),
any occupational therapy evaluation, including the assistive
technology assessment, involves constructing an occupational
BOX 211 Applying Principles for Selecting Assistive Devices
Consider this example: Person 1 is a community-dwelling older man
who enjoys golfing, meeting with his friends to play cards, reading the
newspaper, and doing crossword puzzles. He has recently developed
an age-related eye condition called presbyopia that affects the accom-
modative power of his intraocular lens causing decreased visual acuity
at near distances. He has noticed increased difficulty reading the news-
paper, filling out crossword puzzles, and reading road signs when
driving. He does not have any difficulty performing any other ADL or
IADL. According to the ICF model, the condition, presbyopia, directly
affects the body structure/function level and indirectly affects the
other levels as noted by only minor activity limitations and participa-
tion restrictions mentioned above. Although this is not a typical client
seen for occupational therapy services, this client does represent a
person on the high functioning end of the continuum; that is,
the client has a condition that affects one level on the ICF model with
minimal impact on the others and only requires low-tech assistive
technology (i.e., eyeglasses) to remediate these limitations and restric-
tions. A physical therapist may also assess mobility issues, perhaps in
the context of a cane or other mobility device that can assist the indi-
vidual in moving through the environment while also identifying to
others the fact that the individual has a visual impairment.
Person 2 is an older woman with mild dementia who resides with
her daughter’s family. Before developing dementia, she lived inde-
pendently and had no difficulty performing her ADL and IADL. She
is beginning to have difficulty remembering to take her medica-
tions and to turn off the stove after cooking. Occasionally, she also
profile that reflects the client’s needs and wishes with regard
to occupations. After that profile is determined, the practi-
tioner analyses the client’s occupational performance. This
includes evaluating the person’s performance skills (e.g.,
motor and process skills), performance patterns (e.g., habits
and roles), and performance in areas of occupation (e.g.,
activities of daily living [ADL] and instrumental ADL
[IADL]). Impairments, limitations, restrictions, and barriers
in any of these areas are explored to determine which thera-
peutic strategy or combination of strategies—therapeutic
intervention, compensatory techniques, assistive technology,
or environmental modifications—would give the client the
most independent level of functional performance. Assistive
technology should be selected when the other strategies are
not adequate or sufficient in helping the client achieve his or
her full functional potential, and for energy conservation,
joint protection, or to reduce repetitive motion. An outcome
assessment is performed after assistive technology provision
and training to determine whether the technology was
successful in helping the client reach the desired goals. The
following section explores the appropriate application of
technology for people given the number and type of classifi-
cation levels affected by that person’s disease, condition, or
disorder (Box 21-1).
gets confused when performing certain self-care and home man-
agement tasks, as well as getting disoriented when walking in the
neighborhood. Her family is concerned for her safety because she
is home alone while they are working or going to school. In this
case, the condition affects the body/structure level of the ICF model,
as well as the activity and participation levels. The client appears to
have many positive environmental factors (e.g., good social support
network) but also several negative environmental factors that
endanger her safety (e.g., stove burners without automatic shutoff).
Interventions cannot be implemented at the body structure/
function level to alleviate problems in the other two levels. Because
the evaluation results show no other impairments except for
memory and cognitive-processing skills, intervention focuses on
environmental modifications, compensatory strategies, and family
education. An outcome assessment performed by the occupational
therapist determines that the goals relating to the patient’s safety
and medication management have not been fully met. Thus, the
therapist begins to explore assistive technology options with the
client and her family, taking into account her strengths, limitations,
and acceptability of the devices. The client, her family, and the
therapist decide on the following devices: burners with automatic
shutoffs, electronic pill organizer and reminder, an electronic note-
book that provides audible reminders, and a bracelet locator for
when she gets disoriented (http://www.abledata.com/products-
by-category). A follow-up evaluation found that with the interven-
tion and assistive technology, the client successfully met her goals
and will be able to continue to live with her family members.
4605_Ch21_327-340 31/10/17 12:35 PM Page 333
Assistive Technology for Older Adults
There are more than 40,000 products in 20 categories listed
in Abledata (http://www.abledata.com), a computerized data-
base of assistive devices supported by the Department of
Health & Human Services (HHS) National Institute on
Disability, Independent Living, and Rehabilitation Research
(NIDILRR). This section covers assistive devices that might
be useful for older adults, including devices for persons with
movement impairments and those with vision, hearing,
cognitive, and communication limitations. Therapists must
keep in mind that older adults often have more than one
chronic condition and resultant impairments and may benefit
from devices in several categories. Multiple impairments may
also require modification of devices.
Devices for Persons With Mobility or Motor
Impairments
Walking Aids and Wheelchairs
Walking aids are among the most common of all assistive
devices (Karmarkar, Cooper, Wang, Kelleher, & Cooper,
2011). The cane, second only to eyeglasses in popularity and
numbers, is also one of the oldest assistive devices. Older
adults experiencing some loss of balance may decide, on their
own, to purchase a cane. For those with more serious gait
impairments, perhaps due to stroke or Parkinson’s disease, a
variety of canes and walkers are available to make mobility
easier and safer. Walker types vary in design and functional-
ity. They range from regular walkers and canes to ones with
built-in seats that allow a person to sit and rest when tired.
Wheelchairs offer another option for independent mobil-
ity, as well as making assisted mobility possible. Advances in
wheelchairs have led to lighter, more comfortable designs
allowing the user to achieve different positions, including tilt,
recline, and, more recently, passive standing. Depending
on the needs of the person who will use the wheelchair, ther-
apists must make recommendations involving cushions,
armrests, wheels, tires, hand rims, and power. Therapists also
make recommendations for wheelchair accessories including
transfer boards, lapboards and trays, safety belts, clothing
guards, and bags and pockets. Several references provide
detailed information on wheelchairs, useful for therapists
working with older adults who may need a wheelchair
(Gebrosky, Pearlman, Cooper, Cooper, & Kelleher, 2013).
Environmental Control Units
Although environmental control devices were designed prima-
rily for persons with physical disabilities, they often benefit
people with cognitive or visual impairments as well. For older
adults, whether living at home or in a nursing home, an envi-
ronmental control device can increase the ability to operate
almost any device that runs on electricity: radios, computers,
phone, lights, and security systems, to name just a few. A
handheld television remote control could be considered an
CHAPTER 21 ■ Environment, Products, and Technology 333
environmental control device, one that reaches a much broader
market than older adults with disabilities. Originally, handheld
remotes were designed for young people with excellent fine
motor control, excellent vision, and a love for “bells and whis-
tles” because of the small size of the buttons, the small print
on or under each button, and the various complicated features.
However, there are several handheld remotes now that incor-
porate universal design features for older adults (Zhou, Rau,
& Salvendy, 2012), like larger buttons, more room between
buttons, more simplified layouts, and easy-to-read print.
As noted earlier, smart homes are increasingly popular
for everyone, but particularly for older people or those with
disabilities. The increase in development and availability of
sophisticated environmental sensors and controls has made
such technology more widely available (Cook & Polgar
2014). In a systematic review investigating outcomes of
environmental control systems and smart home technology
(Brandt, Samuelsson, Töytäri, & Salminen, 2011) the authors
reported that these technologies tended to increase study
participants’ independence, instrumental activities of daily
living, socializing, and quality of life. In several included stud-
ies, participants noted that environmental control units were
used to perform the following functions: increase and main-
tain independence, control devices for entertainment, and
communicate basic needs.
Abledata contains a section dedicated to environmental
control units with a brief description of each, the manufac-
turer, and the cost. In helping a person select an environmental
control device, Dickey and Shealey (1987) offered several
questions to consider: Will the system be difficult (how diffi-
cult) to operate? How reliable and durable is the system?
How will the system be installed? How easy is it to install?
How portable is the system, especially if it will need to be
moved? Who is the manufacturer, and has the company been
in business long enough to inspire confidence they will still
be in business when support or repair is required? Are the
features of the device appropriate for the intended user? How
much training will be required to ensure that the user will be
successful with its operation?
Robots
Environmental control devices “operate” on the electrical
environment. An environmental control device could be used
to operate a mechanical device such as a lift (Figure 21-2),
but the combination of electronics and mechanical functions
falls into the area of robotics. Robots have been developed to
assist people with performing industrial, military, personal,
and medical tasks (Davenport, 2005). Personal robot research
and development has lagged behind the advances made with
industrial robots because personal robots have to “operate in
a semiautonomous to autonomous state in changing environ-
ments while industrial robots function in fixed environments”
(p. 76). However, development of personal robots is expected
to increase in the near future due to less expensive robotic
components, recent advances in power consumption, and
better sensor technology. Current personal robot use and
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334 PART III ■ Active Aging: Supporting Client Activities and Participation
FIGURE 212 Overhead lift operated by a remote control device.
development is in the following areas: mobility devices, ex-
oskeletons, powered wheelchairs, entertainment, household
assistance, and telepresence.
Some household assistance robotic devices are already
reaching a large number of consumers. Robotic vacuum
cleaners can be seen now in many households of the devel-
oped countries. Likewise, robotic toys are now entertaining
children and adults. Robotic pets have also been tested in
older adults with cognitive deficits (Klein & Cook, 2012).
Although the research literature is scarce, preliminary results
suggest that this is a viable intervention to enhance social
interaction for individuals with dementia.
Devices for Persons With Vision Impairments
Vision loss is common among older persons. In fact, age-
related vision loss and blindness affect 4.9 million Americans
aged 65 and older (American Foundation for the Blind
[AFB], 2012). Additionally, about 1.8 million noninstitu-
tionalized older adults state they have difficulty performing
basic ADL such as bathing, reading, and dressing because
of a severe visual impairment (Desai, Pratt, Lentzner, &
Robinson, 2001). Vision loss may lead not only to difficulties
in performing activities but also to decreased activities (Rovner
& Casten, 2002), dependency (Wang, Mitchell, Smith,
Cumming, & Attebo, 1999), and social isolation (Wallhagen,
Strawbridge, Shema, Kurata, & Kaplan, 2001). Furthermore,
vision loss has been associated with depression (Augustin
et al., 2007; Evans, Fletcher, & Wormald, 2007) and emo-
tional distress (Wiliams, Brody, Thomas, Kaplan, & Brown,
1998) and decreased health-related quality of life (Langelaan
et al., 2007). Visual loss may be caused by diabetic retinopathy,
cataracts, glaucoma, and macular degeneration, and normal
aging.
Eyeglasses are the most common assistive device, and they
are typically provided by an optometrist. For individuals
who require other devices or devices that provide stronger
magnification, occupational therapists often participate in
providing assistive devices. There are a wide variety of
low-cost, simple assistive devices for persons with visual
impairments. These include magnifying glasses, pens that
write with a bold line, and writing guides. Materials prepared
in large print are available in many bookstores and libraries.
Banks can print checks with large characters, and games can
be bought with enlarged boards. Most electronics stores carry
phones with large buttons and large numbers. Thermometers,
clocks, watches, and blood sugar monitors are all available
with either large-print or voice-output features.
Today, various hardware and software solutions and
video-based technology have increased the number and type
of products available for persons with visual impairments. The
features offered by these devices make them appropriate for
older adults. These products are categorized by the features
they offer.
Screen Enlargement Software
Many software programs magnify the image on the computer
screen, allowing older adults with low vision to read what is
on the screen. All of the current Microsoft operating systems
provide free magnification of the computer screen through
its accessibility options. Many other software programs, such
as Microsoft Word, Microsoft Excel, and Adobe Acrobat
Reader, have free limited character enlargement features by
increasing the viewing size of the page. This can also be done
with most current browsers. In addition, smartphones and
tablets with Android or Apple software can enlarge text and
images by simply pinching and separating your fingers over
the screen. These free built-in features found in the above
applications are also another example of universal design. A
list of screen enlargement software can be obtained from
Abledata.
Closed Circuit Televisions
Closed circuit televisions (CCTVs) increase the size of any
written material or picture. The systems include a monitor
and a viewing table where the book or other materials are
placed. Some viewing tables are automated and can be
controlled with a foot pedal. For older adults with visual
impairments, a CCTV could make the difference in being
able to read the newspaper and books.
Braille Output Devices
Most of us are familiar with braille printed on heavy paper.
Software is available that, together with a braille printer,
permits braille printing of text produced on a computer with
a word processor. “Refreshable braille displays” attach to the
4605_Ch21_327-340 31/10/17 12:35 PM Page 335
computer and use tiny pins that move up and down to produce
braille characters that represent a portion of the computer
screen. Various refreshable braille display models exist
and are available in 20-, 40-, and 80-character-long strings.
Although a smaller percentage of visually impaired persons
are now learning braille, a significant portion of older adults
who have been blind since youth are benefiting from these
computer-based braille output devices. However, those who
acquire vision loss later in life often have difficulty learning
to read braille due to sensory loss in the fingers.
Screen Reading Software and Voice Recognition
Screen reading software is now fully integrated in modern
computer operating systems. It allows the words on the
computer monitor to be read out loud through the computer
speakers. Existing files can be read to the visually impaired
person. Voice recognition is also fully integrated in modern
operating systems, including those running tablets and smart-
phones. Using voice commands, a person can navigate the
computer, tablet, or phone desktop; access files and docu-
ments; and use various word processing, e-mail, scheduling,
and spreadsheet software. Together with an optical character
recognition system (described in the following section),
which takes text that is already printed and converts it into a
computer file, virtually any printed material becomes available
to the person with a visual impairment. For older adults with
severe vision loss, a talking computer may make it possible
to continue working, leisure reading, and carrying out house-
hold tasks that require writing and reading. The advent of
social networking sites has increased the value of computers
as a way to maintain social ties (Figure 21-3).
Optical Character Recognition System
Optical character recognition software can read text from a
document that has been scanned into the computer. Once
the software has recognized the text, the user can read it with
FIGURE 213 Computers can help clients with limited mobility
maintain social ties. Jack Hollingsworth/DigitalVision/Thinkstock
CHAPTER 21 ■ Environment, Products, and Technology 335
enlargement software or can use the screen reading feature of
the computer. Although the process can be time-consuming
and require some technical expertise, this solution can be
useful for old text from a book or document that does not
exist in electronic format.
Mobile Devices
Smartphones are rapidly becoming the standard in voice
communication and portable computing. These devices can
be completely operated using voice commands, which makes
them ideal for individuals with visual impairments. Users
not only can make phone calls using voice commands but can
also create appointments, dictate e-mails or text messages,
participate in social media sites, get weather information, or
navigate the Internet. Furthermore, the devices allow text
and image enlargement and full customization of the home
screen. Both Android and Apple platforms come with a com-
plete suite of accessibility features preinstalled in the devices,
and various aftermarket apps can further enhance the usabil-
ity of these devices for people with a visual impairment. For
example, Magnify by Appd Lab turns a phone into an instant
digital magnifying glass. Using the camera in a smartphone,
the app will amplify any images captured by the camera. This
app is currently available for Android users. BlindSquare,
available from the Apple app store, uses GPS in the device
to provide voice street navigations and points of interest to a
person with a visual impairment.
These mobile devices have provided those with visual im-
pairments an increased independence and freedom in both
the home and community environments that was unheard of
even a few years ago. It is, however, important to note that
older adults are less likely to adopt smart phones (Duggan et
al., 2015). Only 18 percent of those over age 65 own a smart
phone, and many older adults do not see their value or rele-
vance. In addition, they tend to be more concerned than
younger individuals about learning to use them.
Devices for Persons With Hearing Impairments
Hearing impairment is common among older adults: As
reported in Chapter 9, about 17 percent of older adults in
the United States have some degree of hearing loss (National
Institute on Deafness and Other Communication Disorders,
2016). Hearing loss can impact on communication, which in
turn can result in isolation and depression (McDonnall,
2009). Hearing loss affects health and safety in other ways,
such as not being able to understand instructions for taking
medications or being unable to hear fire alarms.
The first step in addressing hearing impairment is to seek
medical advice. Surgery is employed for some types of hearing
loss; age should not be the determinant in considering a
surgical approach (Capella-McDonnall, 2005). Cochlear
implants, developed initially for profoundly deaf individuals
involve implanting electrodes that bypass damaged hair
cells surrounding the cochlea. An implant does not restore
normal hearing. Instead, it can give a deaf person a useful
4605_Ch21_327-340 31/10/17 12:36 PM Page 336
336 PART III ■ Active Aging: Supporting Client Activities and Participation
representation of sounds in the environment and help him or
her to understand speech. Cochlear implants are not yet widely
used for older adults, although there is evidence that they do
improve communication, especially for elders who are younger
and still have a reasonable degree of speech recognition before
implantation (Lin, Chien, Li, Niparko, & Francis, 2012).
✺ PROMOTING BEST PRACTICE
Cochlear Implant and Quality of Life
The literature examining cochlear implants is extensive. In a
review paper Berrettini et al. (2011) found conclusive evidence
of improved quality of life and perceptive abilities after cochlear
implants. These benefits were seen even in individuals older
than age 75.
Approximately 14.3 percent of older adults between the ages
of 60 and 69 years experience tinnitus (Shargorodsky, Curhan,
& Farwell, 2010). The rate declines after 69 for unknown
reasons, possibly related to comorbid conditions associated
with tinnitus. There is no cure for this condition, but “maskers”
are sometimes used to provide a more acceptable sound than
that produced by the tinnitus. Hearing aids are often used to
offset the effect of the hearing loss that can accompany tinnitus.
Surgery is sometimes used to reduce tinnitus, as are drugs,
relaxation techniques, and biofeedback (Desai et al., 2001).
Hearing Aids
Many assistive devices are available for people with hearing
impairments, the most common of which is the hearing aid,
typically prescribed by an audiologist. Therapists encounter
many older adults who use hearing aids, but because of
fine motor or vision impairment, have difficulty replacing
batteries, positioning the device, or adjusting the controls.
Working with older adults, the therapist often establishes
a goal of improved fine motor performance that can lead to
independence in use of the hearing aid. The therapist might
also assist a person in finding “tools” for working the controls
or replacing the batteries more easily.
Assistive Listening Devices
When hearing aids do not provide adequate sound amplifi-
cation, assistive listening devices (ALDs) may be used. ALDs
include microphones for the person speaking, amplifiers to
capture the sounds, and, for the person with the hearing loss,
a headset or ear receiver. ALD systems are hardwired or use
either FM radio waves or infrared signals. Many churches,
schools, and theatres have ALD systems, usually FM and
infrared systems. The hardwired system is more often used
in a home.
Amplification Devices and Other Communication
Supports
Electronics and phone stores carry phones that offer ampli-
fied sound and devices that can be added to an existing
phone to provide amplification. In addition, closed-captioned
television provides text at the bottom of the screen on tele-
visions equipped with a special decoding device. All new
televisions with a screen greater than 13 inches now have
this feature installed in the factory. Other devices include
smoke detectors that provide a visual alert such as a flashing
light or vibration. A number of these devices can make it
possible for older adults with hearing loss to continue their
involvement in important life roles. They have the advantage
of being relatively low cost, as well, with smoke detectors
often provided free by community organizations, and small
televisions available for a few hundred dollars.
Devices for Persons With Memory Loss
Memory loss can occur with various diseases associated with
aging. One low-tech solution to memory impairment is to
write notes on paper and post them in appropriate places. An
alternative, high-tech solution is to use a smartphone or
tablet. A number of applications exist to provide reminders
for taking medications, appointments, and other tasks.
Electronic memory devices can improve everyday memory
functioning in patients with memory impairments after
acquired brain injury. In one study, participants receiving
occupational therapy training in the use of the device improved
daily memory function more than standard rehabilitation
(de Joode, van Heugten, Verhey, & van Boxtel, 2010). How-
ever, caution must be exercised in recommending these
devices because some may be too complex for someone to
operate even in the early stages of Alzheimer’s disease.
Other Assistive Devices
Other helpful assistive devices include automatic turn-off
switches for stove burners, automatic timers for lights,
movement-sensitive light switches that turn lamps on when
a person enters a room, and security systems that can sound
an alarm or flash bright lights when someone attempts to
open a secured door.
Issues Relating to Use of Assistive
Technology With Older Adults
Repair and maintenance of assistive devices are important
concerns. What are the costs, will the device be available
when needed, and how long will the repair take? Lack of
repair and maintenance can be dangerous and may result in
the device failing to provide the optimal amount of assistance.
Abandoning devices is also a concern. A study of 227
adults with various disabilities found that 29.3 percent of all
devices were abandoned (Phillips & Zhao, 1993). Further-
more, this study found that device abandonment was signifi-
cantly related to one of four factors:
1. Lack of consideration of user opinion in selection
2. Easy device procurement
4605_Ch21_327-340 31/10/17 12:36 PM Page 337
3. Poor device performance
4. Change in user needs or priorities
Although computers have become ubiquitous in daily life
in the United States and many other countries, older adults
are not necessarily proficient in their use. The current cohort
of older adults who use computers learned to use them rela-
tively later in life and there is a larger group of individuals in
this age-group who do not have computer skills as well-
established habits (Boot et al., 2013). For these individuals,
some of the benefits of the technology may not be as robust
as they may be for future cohorts of older adults.
In recommending assistive devices, the therapist must first
give the client options of different assistive technology devices
and work with vendors to allow the client to try equipment
out before making the purchase, especially with more expen-
sive devices. After determining which device the client
prefers, the therapist should help the client identify funding
for the device. Last, the therapist should provide training in
the use of the device, and leave instructions regarding repair
and maintenance, either with the device user or with a care-
giver. Locating service providers capable of offering quality
assistive technology services is often difficult not only for the
older consumer but for other service providers who make
referrals. There is also some fragmentation of services due
to specialization. Experts in vision, hearing, and cognitive
disabilities may not be capable of working with the complex
interweave of factors that often are present in an older person.
Occupational therapists are often the most knowledgeable
about assistive technology services and either make an inter-
vention or refer the client to another provider. One source of
information on service providers is the lead agency in each state
under the Technology Related Assistance for Individuals with
Disabilities Act. The Society for the Advancement of Reha-
bilitative and Assistive Technology (RESNA) in Washington,
DC, provides technical assistance to the states and could be
contacted for information on your state’s lead agency.
Funding is another problem with assistive devices and the
services required for successful use (Lenker, Harris, Taugher,
& Smith, 2013). Even though many devices are low in cost
and can be covered by the user, many other devices are expen-
sive and not affordable to all who need them. Assistive devices
help people maintain or regain independence and, thus, can
reduce overall health care costs. However, access to assistive
devices is often blocked, restricted, or limited because third-
party payers do not cover them. Therapists can help ensure
access by providing careful evaluation data that make the need
clear. They may also participate in research that validates
important outcomes of AD use.
AROUND THE GLOBE: Unmet Need for Assistive
Technologies in Europe
Reports of unmet need for assistive technologies in Europe
suggest that from 17 to 45 percent of community-residing elders
in six countries have such unmet needs. Although these countries
CHAPTER 21 ■ Environment, Products, and Technology 337
provide assistive devices free of charge, differences in the systems
by which individuals are evaluated and devices funded may
account for the different levels of need (Gramstad, Storli, &
Hamran, 2013).
Acceptability of the device to the individual is a crucial
factor (Lin & Wu, 2014). The person’s needs and wishes
must be considered. Some people may find the devices unac-
ceptable cosmetically, and some may resist being “dependent”
on these devices. Furthermore, “high tech” is intimidating
to some older adults. The therapist can address the issue of
acceptability in a training program for the use of a certain
device; however, it is still possible that the device will be left
in a closet to collect dust or, worse, that it will get in the way
and make function more difficult.
✺ PROMOTING BEST PRACTICE
Reasons for Failure of Assistive Device Use
In a recent review study published by the International
Journal of Audiology, the authors investigated reasons why
older adults do not wear prescribed hearing aids. The most
common reasons included were hearing aid value and/or
fit and comfort of the hearing aid. Other reasons included
maintenance, cost, and cosmetics (McCormack & Fortnam,
2013).
Although there are problems related to assistive technol-
ogy and environmental interventions, these tools offer great
potential for helping older adults maintain independence and
lead satisfying lives. Occupational and physical therapists, as
well as other service providers, often play an important role
in identifying the appropriate technology, in training older
persons in how to use it, and in providing follow-up support.
Occupational therapists provide devices to support an array
of activities, including self-care (both ADL and IADL),
work, and leisure. Physical therapists work to provide mobil-
ity devices while audiologists deal with devices that are related
to hearing. Ophthalmologists, optometrists, or opticians may
be knowledgeable about vision aides. Social workers are vital
in identifying sources of financing for all these devices and
services.
Effective therapeutic use of technology is by its nature
interdisciplinary (Schulz et al., 2015). Team efforts are typi-
cally needed to evaluate individuals and identify technologies
that might be of value. But the interdisciplinary nature of
assistive technologies goes beyond work with individuals.
Therapists work closely with engineers to evaluate existing
technology and develop new mechanisms for addressing
problems. Given the complexities of doing research in a realm
that changes rapidly, working with research methodologists
and statisticians is another important collaboration (Schulz
et al., 2015). And the entire team has a role in advocating for
clients to ensure access to those technologies that can truly
improve their quality of life.
4605_Ch21_327-340 31/10/17 12:36 PM Page 338
338 PART III ■ Active Aging: Supporting Client Activities and Participation
SUMMARY
Technology has the potential to solve problems and con-
tribute to well-being for older adults whether they are dealing
with the everyday issues that result from normal age-related
changes in function or the chronic diseases that contribute to
significant functional decline. Such technology can range
from the very low tech, a cane or walking stick, to very high
tech, a robot to serve as a social surrogate. Thoughtful evalu-
ation to identify specific needs and careful matching of need
with technology will increase the prospects for successful use
and accompanying improved function. However, technology
is not always the solution to a problem. Expense, ease of use,
and acceptability all influence the success of technological
interventions.
Therapists have important roles in evaluating individuals,
training them in the use of devices, and monitoring out-
comes. They also serve as advocates for their patients to
ensure they can acquire the equipment they need. Therapists
also have an important role in research to evaluate existing
technologies and develop new ones.
CASE STUDY
Mrs. Mittie Jones is an 87-year-old woman who had a
right cerebrovascular accident (CVA) and left hemiple-
gia several years ago and uses a manual wheelchair for
all of her mobility needs. She lives alone in the commu-
nity but has family members who live next door and
come and check on her at least once a day. She also
has home health nurses come by once a week to check
on her and nursing assistants that come by three times
a week to assist her with bathing, dressing, and light
house chores. Recently, the client has reported increased
difficulty moving around her house and operating
appliances.
Questions
1. What is the first step for an occupational therapist?
2. What would be important areas of emphasis for a
physical therapist?
3. On the basis of the occupational therapy assessment,
how would you evaluate her difficulties at each level
of the ICF? What environmental factors might affect
her performance?
4. What kinds of assistive devices might be most
helpful?
Critical Thinking Questions
1. What makes universal design important to all older
adults—that is, including those who have only
minimal functional limitations?
2. Mrs. A is a 67-year-old widow with mild arthritis
and mild presbycusis. How might environmental
control devices assist her in maintaining independ-
ence in her apartment?
3. Mr. Y is in the early stages of macular degeneration.
What assistive devices might a therapist consider to
help him as his vision declines?
4. Therapists have a role in making the environment
more accessible. What are some assistive devices that
might be provided in the community to facilitate
participation?
5. You want to recommend a device for a client but are
not sure how he will be able to pay for it. What are
some strategies for exploring payment options?
6. A therapist has provided an environmental control
device for Ms. D. On a home visit, she notes that the
device is sitting on the table, collecting dust. What
are the possible reasons that Ms. D might not use
the device, and what could the therapist do?
7. How might therapists contribute to urban planning
based on their understanding of universal design?
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“With full-span lives the norm, people may need to learn
how to be aged as they once learned to be adult.
LEARNING OUTCOMES
By the end of this chapter, readers will be able to:
1. Describe the national statistics on older adult drivers and
the types of motor vehicle violations most commonly
performed by older adults.
2. Define driving as an occupation using the Occupational
Therapy Practice Framework.
3. Explain the age-related physiological changes and disease-
related changes associated with driving difficulties among
older adults.
4. Identify the clinical assessment and interventions used
in driving rehabilitation programs for older drivers using
evidence-based practice.
5. Discuss the psychosocial implications of driving and the
inability to drive.
Clinical Vignette
Mr. Olsen is a 72-year-old executive who has some
arthritic changes in his right leg. He has driven to work
for the past 20 years and plans to continue to do so. How-
ever, he notes that the pain and stiffness in his leg make it
more difficult to move quickly from the gas pedal to the
brake. He has no other physical limitations, and he is cog-
nitively quite sharp. He wears bifocals, and his corrected
vision is 20/20.
Because of the arthritis in his leg, he keeps a greater dis-
tance between himself and the next vehicle, realizing that it
takes slightly longer for him to react and brake for sudden
stops.
1. On the basis of the information here, do you believe
that Mr. Olsen is safe to continue driving? Why or
why not?
2. What suggestions might you have for making Mr. Olsen
a safer driver given his current physical status?
CHAPTER 22
Driving
Wendy Stav ■ Beth A. Ekelman
—Ronald Blythe (1979, p. 22)
”
A lthough there are alternative means to move about
in the community, 90 percent of older adults prefer
accessing the community via the private automobile
(Rosenbloom, 2004; Stav, 2008). Driving is a valued occu-
pation as it is crucial to continued independent living and
maintaining ties to society (Stav, 2008). Many older adults
work past retirement age, engage in volunteer work, or stay
involved in organized community activities (Kartje, 2006;
Stav, 2008). They assume multiple roles, such as a spouse,
caregiver, grandparent, friend, worker, or volunteer, all of
which dictate the needs of the older driver (Kartie, 2006).
In this chapter, the meaning of driving for older adults,
its contribution to meaningful occupational profiles, and
the skills needed to be able to drive safely are considered.
Evaluation of driving and interventions to support driving
are reviewed.
Overview of National Statistics on
Violations, Crashes, and Fatalities
According to the most recent report by the National High-
way Traffic Safety Administration (NHTSA; 2013), there
were 35 million licensed drivers aged 65 and older in the
United States, representing a 21 percent increase from 2002
to 2011. The total number of licensed drivers increased only
9 percent during the same time period. It is projected that
the number of older drivers will continue to grow as the Baby
Boomers continue to age.
In 2011, 5,401 people aged 65 and older were killed in
motor vehicle crashes (MVCs) (NHTSA, 2013). Of those
killed, 3,402 were driving. A total of 185,000 adults in this
age-group were injured in MVCs. While the incidence of
older driver fatalities is decreasing, older adults are still over-
represented in the crash and fatality data as they comprise
only 14 percent of the population and driver far fewer miles
341
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342 PART III ■ Active Aging: Supporting Client Activities and Participation
compared to their younger counterparts. When placed in the
context of all MVCs, older adults are not necessarily more
likely to crash, but they did constitute 17 percent of all traffic
fatalities and 8 percent of all people injured in MVCs. The
high rate of injuries and fatalities among older adults is likely
caused by the inability to sustain the energy forces of a crash
due to age-related frailty and fragility (Langford & Oxley,
2006).
Driving as an Occupation
Driving is an activity in which many people participate on a
regular basis to which they ascribe meaning based on personal
and cultural values. Driving has value as a means of trans-
portation to a destination, and it has value and meaning as
an occupational enabler (Stav, 2015) by facilitating engage-
ment in other occupations in the community, including shop-
ping, social participation, and self-care.
The occupation of driving is complex and requires one
to receive multiple sensory stimuli simultaneously from the
environment through visual, auditory, proprioceptive, kines-
thetic, and vestibular functions. Extraneous stimuli must be
filtered so that only relevant stimuli are attended to. Process-
ing of relevant stimuli leads to the identification of objects
and events, and a perception of their relationships in space
to one another and the overall environment. Integration of
this information with past experience provides meaning and
context in relation to driving. Cues may be detected that are
associated with overlearned behaviors, which may result in
the automatic and habitual performance of that behavior. For
example, when one drives to work daily on a familiar route,
the process of driving becomes routine and automatic. At the
same time, higher level processing skills regulate the perform-
ance of automatic behaviors and are necessary to learn new
skills or deal with situations that are not routine, such as
driving an unfamiliar car to a new destination.
The American Occupational Therapy Association’s
(AOTA) Practice Framework (third edition; AOTA, 2014)
is used as a guideline to describe how the various client fac-
tors, performance skills, performance patterns, environments,
and contexts influence one’s ability to participate in the
occupation of driving. The Driving as an Occupation model
(Figure 22-1), adapted from Mitchell’s Neurosensory Model
of Driving (Ekelman, Mitchell, & O’Dell-Rossi, 2000), is a
systems-based approach that provides a comprehensive
overview of the relative contributions of the motor, process,
and communication/interaction skills, as well as client factors
that are required for safe driving. Figure 22-1 represents the
multidimensional construct of engagement in the occupation
of driving. According to the AOTA Practice Framework, the
occupation of driving is one aspect of community mobility
classified within the Instrumental Activities of Daily Living
domain of Occupation.
At the center of the engagement in driving are client fac-
tors that represent foundational capacities, including mental
functions (attention, memory, and visuospatial perception),
Client
factors
Performance
skills
Performance
patterns
Contexts
FIGURE 221 Driving as an occupation model.
sensory functions (vision), and neuromusculoskeletal and
movement-related functions. People enact their client factors
into small units of performance called performance skills.
Performance skills include motor and process skills and allow
for the ability to operate a vehicle safely, interpret objects
within the environment, and respond to environmental stim-
uli. Performance occurs in specific ways called performance
patterns that include automatic habitual behaviors associated
with driving. Performance patterns can be safe habits (putting
on seat belt or using a turn signal), routine (taking the same
route to volunteer at the hospital), and facilitate role perform-
ance (a husband fulfills the role of primary driver in a married
couple). Not all performance patterns are positive, and some
can be portrayed as negative habits (speeding) or unsafe rou-
tines (completing weekly business calls on the cell phone
while driving). All of this performance takes place within
contexts that
■ culturally determine the value of driving;
■ physically dictate where one will drive;
■ temporally identify when one drives with regard to time of
day, in the life span or along the continuum of a progress-
ing illness;
■ socially provide networks to support alternative methods
of driving; and
■ control how safely or accurately driving occurs.
The aging process and age-associated conditions may lead
to declines in any of the client factors and performance skill
areas represented in the model. Because these client factors
and performance skill areas are interdependent, dysfunction
that exists in one client factor or skill area may influence the
demands placed on other skill areas. At the same time, the
therapist must be cognizant of the individual’s context or
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CHAPTER 22 ■ Driving 343

contexts and performance patterns, particularly life roles.
Therefore, clinical evaluation of driving ability requires one
to be aware of potential dysfunction that may exist in all of
these areas. To be able to evaluate and diagnose dysfunction
formally in the various areas, the health-care professional
needs to understand each of these areas and how they are
interrelated.
that have functional purposes (AOTA, 2014). One needs
certain performance skills to operate vehicles and equipment
and to navigate through their environment. Examples of
requisite performance skills are depicted in Table 22-2. Of
course, certain contexts, such as size of the vehicle, terrain,
traffic patterns and so on, may alter the extent to which
specific performance skills are required.

Client Factors Performance Patterns

According to the Occupational Therapy Practice Framework
(AOTA, 2014), client factors consist of values, beliefs, and
spirituality; body functions; and body structures. Client
factors “reside within the client … and influence the client’s
performance in occupations” (AOTA, 2014, p. S22) specific
to their interest in and capacity to drive. Central to individ-
uals’ interest in driving is values, which guides the recognition
of independent travel via automobile as a very important area
of engagement, particularly in the United States, which is an
automobile-dependent culture.
Body functions most relevant to driving are the mental, sen-
sory, and neuromusculoskeletal and movement-related func-
tions. The body structures that support these body functions
include the eye, ear, and related structures, as well as structures
related to movement. Table 22-1 provides details about the
factors that contribute to ability to drive effectively and safely.
Performance Skills
Performance skills include motor, process, and social inter-
action skills. These are observable features of performance
Performance patterns “are the habits, routines, roles, and
rituals used in the process of engaging in occupations or
activities that can support or hinder occupational perform-
ance” (AOTA, 2014, p. S8). Habits and routines such as
placing car keys in a specific place can be useful in promoting
safe performance, or detrimental, such as inconsistently look-
ing both ways when crossing an intersection. Examples of
habits, routines, and role are presented in Table 22-3.
Contexts
The Occupational Therapy Practice Framework describes
seven types of contexts in which clients engage in driving
including cultural, physical, social, personal, spiritual, tem-
poral, and virtual. Environmental and contextual considera-
tions in driving are delineated in Table 22-4. Cultural contexts
may be a special consideration as they are imposed by family,
society, and one’s culture (AOTA, 2014). For example, in
the United States, driving is valued and viewed as a symbol
of independence. In many cultures, men are the primary
drivers, and women are the passengers.

TABLE 221 ■ Summary of Client Factors That Affect Driving Performance: Body Functions and Structures

FACTORS IMPACT ON DRIVING PERFORMANCE

Mental functions
Sensory functions and pain
Neuromusculoskeletal and
movement-related functions
Other functions, such as cardiovascular,
hematological, immunological,
respiratory, digestive, metabolic,
endocrine, genitourinary, reproductive,
skin and related structures
Body structures
Global mental functions, such as global attention, consciousness, orientation, emotional stability,
and impulse control are needed to drive.
Specific mental functions, such as attention, memory, visuospatial perception, higher level cognitive
functions for judgment, and the ability to plan, impact motor and process skills.
Visual acuity and visual field functions are important for driving performance. The ability to hear
sounds and horns, as well as ability to maintain balance are important. Appreciating pain and
whether it interferes with driving performance is important to consider.
It is important to consider an individual’s ability to move his or her joints and bones to maneuver
a vehicle safely and whether he or she has the strength to operate the controls. Individuals also
need to have good voluntary motor control and reactions to drive.
These functions should be considered if they interfere with performance skills and participation
in driving, especially as these relate to safety and energy levels.
It is important to consider which anatomical parts of the body are needed to drive: eyes, ears,
structures related to movement, and structures of the nervous system are the primary structures.
Other structures need to be considered in relation to how may affect performance skills they
necessary for safe driving.
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344 PART III ■ Active Aging: Supporting Client Activities and Participation

TABLE 222 ■ Summary of Performance Skills That Affect Driving Performance: Motor Skills and Communication/Interaction
Skills

EXAMPLES OF PERFORMANCE SKILLS USED IN DRIVING

Motor Skills
Posture Able to maintain trunk control and balance while driving; maintains an upright sitting position; and is able
to position body, arms, and legs in relation to the driving controls to promote efficiency in movement
during performance.
Mobility Able to reach for controls within the vehicle and flex, rotate, and twist trunk to operate the vehicle
safely.
Coordination Able to coordinate both sides of body (arms and legs) to safely operate the vehicle. Able to grasp and
release vehicle controls, and movements are smooth and fluid during performance.
Strength and effort Able to move vehicle controls and regulate the force, speed, and grade of movement to operate vehicle
controls safely. Able to properly grip controls.
Energy Able to participate in driving without obvious fatigue and is able to maintain a consistent tempo of
performance throughout the entire driving process.
Process Skills
Energy Able to maintain a consistent tempo of performance throughout the entire driving process and
maintain focused attention throughout the task when presented with extraneous auditory or
visual stimuli.
Knowledge Operates the vehicle safely and appropriately, adheres to goal-directed plans of action (able to follow
directions, stay on designated route), asks questions or reads directions using map, road signs,
and does not ask unnecessary information questions, such as how to turn on the car or put the
car in gear.
Temporal organization Able to initiate the process of driving, follow appropriate steps in proper order to safely operate the
vehicle, and appropriately terminates or stops the vehicle in the designated location when destination
is reached.
Organizing space and objects Able to locate and store keys, vehicle, and safety items (spare tire, jack, flashlight); aware of where all
controls and safety items are located; able to maneuver vehicle around obstacles and on the road safely
while adhering to driving laws.
Adaptation Able to notice/respond to environmental cues while driving and makes an effective and efficient
response, makes appropriate accommodations and adjustments in anticipation of environmental
stimulus, anticipates and prevents undesirable circumstances from recurring or persisting. Able to
problem solve.
Communication/Interaction Skills
Physicality Appropriately makes eye contact, gestures, and assumes appropriate physical postures necessary for
participation in driving.
Information exchange Able to effectively communicate (give and receive) information when communicating with others during
driving (e.g., asking for directions, paying toll, communicating with police officer).
Relations Able to follow the rules of driving and respectfully interact with others on the road.

TABLE 223 ■ Summary of Performance Patterns That Affect Driving Performance

PERFORMANCE PATTERNS EXAMPLES OF PERFORMANCE PATTERNS RELATED TO DRIVING

Habits Automatic behaviors associated with driving (e.g., “autopilot” driving on a familiar route, putting car keys in the
same place so they can be found easily). Some habits are not safe or impoverished, (e.g., talking on the cell
phone while driving, putting on makeup while driving, inconsistently looking both ways when crossing an
intersection, driving while intoxicated, etc.).
Routines Examples of driving routines are common routes taken, time of day one usually drives.
Roles The individual may be the only driver in the household, responsible for carpooling, providing transportation for
members of the household, or drives as a part of his or her work.
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CHAPTER 22 ■ Driving 345

TABLE 224 ■ Summary of Contextual Issues That May Affect Driving Performance

CONTEXTS EXAMPLES OF CONTEXTS RELATED TO DRIVING

Cultural Expectations to drive imposed by family, society, and culture, (e.g., in the United States, individuals may obtain a license at age 16,
and driving is valued and viewed as a way of achieving independence). Why must the individual drive (e.g., go to the grocery
store for food, the bank for money)? Are there opportunities to explore alternative methods of community transportation or
access to food, banking, and so forth?
Physical What is the environment like where the individual will be driving (e.g., highway, country, suburbs)? What is the physical layout of
the vehicle and adaptations? What distances does the person drive or need to drive?
Social Are others in the family or social network available to drive? Are others depending on the individual to drive? Does the inability
to drive impact social participation opportunities?
Personal Age, gender, socioeconomic status, and educational status of client.
Temporal When did the individual learn to drive, how long has he or she driven, what time of day does he or she drive?
Virtual Does the individual use any voice-activated systems or other environmental controls to operate the vehicle? How does the
client perform on the driving simulator?

AROUND THE GLOBE: Driving in Saudi Arabia
Different cultures hold different views about the ability to drive.
For example, in Saudi Arabia, women are prohibited from driving
because of rigid perceptions of female roles. Even such strategies as
using taxis can be problematic because of the cultural proscription
against being alone with a male who is not a family member. Thus,
women in Saudi Arabia must rely on other community mobility
strategies such as walking or being transported by a male relative.
Age-Related Physiological and Disease-
Related Changes Affecting Driving
Performance
Driving safety and driving performance are the two main out-
comes used in driving research (Owlsey & McGwin, 2010).
Safety involves avoidance of such adverse driving events as
MVCs, whereas performance refers to driver behavior when
operating a motor vehicle. Physical driving behavior measures
usually include speed, braking, lane keeping, and visual scan-
ning. Driving performance is measured by ratings given by a
trained evaluator who rides in the vehicle and uses a stan-
dardized scale. Evidence is beginning to emerge that links
driving performance with driving safety, although more work
needs to be done in this area. Lane maintenance, yielding,
and gap acceptance errors predicted crash related injuries with
approximately 50 percent probability among older drivers in
a study conducted by Classen, Shechtman, Awadzi, Joo, and
Lanford (2010).
As can be seen in Table 22-5, age-related changes, com-
mon medical conditions, and medications can affect a driver’s
client factors and performance skills, thus compromising
driving safety. Chapters 7 through 17 describe age-related
changes in important functions, both typical and associated
with disease processes, related to aging.
Sensory Functions
Visual Function and Driving
The literature that focuses on visual function associated with
aging and driving includes impairments in visual acuity, con-
trast sensitivity, visual field, color vision, and visual processing
speed (NHTSA, n.d).
Desapriya and colleagues (2014) concluded that visual
acuity alone is not an appropriate method for assessing fitness
to drive. Rubin and colleagues (2007) and Cross and col-
leagues (2009) conducted well-designed cohort studies with
adequate sample sizes (1,801 and 3,158 participants, respec-
tively) and found that there was no significant relationship
between visual acuity and collision rates (Owsley & McGwin,
2010).
Several studies consistently indicate a relationship between
impaired contrast sensitivity and reduced driving perform-
ance (Owsley & McGwin, 2010; Owsley, Stalvey, Wells,
Sloane, & McGwin, 2001). In general, higher driving per-
formance scores in closed-road circuits were correlated with
better contrast sensitivity (Owsley & McGwin, 2010; Wood
& Troutbeck, 1995). In addition, contrast sensitivity is a bet-
ter predictor of recognition of road signs, obstacles and
pedestrians during night driving than photopic visual acuity
(Owsley & McGwin, 2010; Wood & Owens, 2005). Wood
and Carberry (2006) noted that improvement in contrast sen-
sitivity was predictive of improvements in driving perform-
ance among individuals after cataract surgery. Although a
preponderance of the evidence suggests that screening for
contrast sensitivity may be beneficial, more population-based
studies are needed (NHTSA, 2009).
Studies generally suggest that visual field impairment
may elevate crash risk when the impairment is serious and
when it is binocular (Haymes et al., 2007; NHTSA, 2009;
Owsley & McGwin, 2010; Rubin et al., 2007). The NHTSA
(2009) recommends that drivers with visual field impair-
ment should be referred to a driving specialist to evaluate
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346 PART III ■ Active Aging: Supporting Client Activities and Participation

TABLE 225 ■ Summary of Skill Areas and Changes Affecting Driving Performance of Older Adults

SKILL AREA AND DISEASES AFFECTING SKILL AREA
Visual input (cataracts, glaucoma with peripheral
field loss, macular degeneration, diabetic
retinopathy)
Other sensory input (peripheral vascular disease)
Cognitive function (Alzheimer disease, multi-infarct
dementia)
Parkinson’s disease, diabetes with transient cognitive
impairment, cerebrovascular accident
SUBSKILL
Dynamic visual acuity
Peripheral vision
UFOV
Hearing
Tactual
Memory, attention,
judgment, central
information processing
DRIVING PERFORMANCE
Difficulty distinguishing fine detail (reading road signs),
problems with glare in bright sunlight
Difficulty at intersections and changing lanes
Failure to identify potential hazards, failure to yield the
right of way, failure to heed a stop sign, inadequate
stopping distance
Difficulty hearing sirens, horns, and whistles
Difficulty feeling pedals and modulating pressure on pedals
Slowed reaction time
Difficulty with traffic sign recognition, searching for
hazards, executing evasive actions, identifying hazards
Difficulty aligning car with side of road, entering and
leaving the highway, dealing with traffic in roundabouts,
performing two tasks at the same time in an emergency

their driving skills under a variety of on the road driving
conditions.
Color vision has been tested by many state licensing agencies
to ensure that drivers can obey color traffic control devices and
other color signals, such as traffic lights and tail lights. However,
the literature notes that there is no link between color deficien-
cies and MVC involvement (Atchison, Penderson, Dain, &
Wood, 2003; NHTSA, 2009; Owsley & McGwin, 2010).
Although the NHTSA (2009) recommends that drivers should
be able to discriminate between different traffic lights, color
vision deficiency by itself should not prevent a driver from
obtaining a license for a personal vehicle.
Several studies have shown that there is a relationship be-
tween slowed processing speed and driving safety (Anderson
et al., 2012; NHTSA, 2009; Owsley & McGwin, 2010).
Poor performance on the Useful Field of View (UFOV),
shown to be sensitive to attentional and visual processing speed
(Matas, Nettelbeck, & Burns, 2014), was associated with a
history of an increased number of motor vehicle accidents
among older adults (Ball et al., 2006; Owsley & McGwin,
2010; NHTSA, 2009; Rubin et al., 2007). The NHTSA
(2009) recommends that jurisdictions should consider imple-
menting a screening test for licensure that assesses processing
speed.
Changes in Other Functions
Age-associated medical conditions and changes in mental
function can result in impairment in driving abilities. For
example, diabetic neuropathy and peripheral vascular disease
may result in impairment in distal lower extremity sensation,
which may make operating the pedals of the vehicle danger-
ous. Age-related changes in mental function that can affect
driving ability in older adults are memory loss, diminished
attention, impaired judgment, and slowed central informa-
tion processing (Underwood, 1992). Of particular interest is
psychomotor slowing or reaction time. The literature on
movement slowing with age indicates that alterations in
motor and process skills are due to
1. failure to use advance preparatory information,
2. difficulty in processing stimuli and making responses
that are spatially incompatible,
3. initiation deficit in dealing with increased task com-
plexity, and
4. inability to regulate performance speed (Stelmach &
Nahom, 1992).
Dementia and Driving Performance and Safety
According to the NHTSA (2009), dementia can reduce
driver performance and increase driving errors that lead to
vehicle crashes. There is significant evidence that individuals
with dementia have a higher risk of MVCs (Dickerson, 2014;
Dubinsky et al., 2000). Yet it is unclear how progression rates
of dementia impact driving safety (Dickerson et al., 2008;
Eby, Silverstein, Molnar, LeBlanc, & Adler, 2012.
Available empirical evidence support the conclusion that
dementia is accompanied by increased crash risk. Problematic
behaviors include becoming lost in familiar places, incorrect
turning, impaired signaling, decreased comprehension of traf-
fic signs, and lane deviation (Duchek et al., 2003; Eby et al.,
2012; Hunt, Brown, & Gilman, 2010; Ranchet, Broussolle,
Poisson, & Paire-Ficout, 2012; Uc, Rizzo, Anderson, Shi,
Dawson, 2004, 2005). The majority of experts suggest that
the diagnosis of Alzheimer’s disease alone is not sufficient to
cause the immediate withdrawal of driving privileges. Not
only is there a possibility of misdiagnosis, particularly in the
early stages of dementia, but driving performance in some
persons in the milder stages of Alzheimer’s disease may still
be satisfactory (Eby et al., 2012). There is strong Level I evi-
dence that individuals with moderate to severe dementia
should not drive (Brown & Ott, 2010; Chee et al., 2017;
4605_Ch22_341-358 31/10/17 12:34 PM Page 347
Wheatley et al., 2014). Some, but not all, drivers with very
mild to mild dementia may be able to continue driving. Lon-
gitudinal studies have shown that many of these individuals
are able to pass formal road tests (Duchek et al., 2003; Ott
et al., 2008; Wheatley et al). However, these individuals
should be referred for further testing when risk factors for
unsafe driving exist (Dickerson, 2014; NHSTA, 2009;
Wheatley et al., 2014). Physicians should refer clients with
very mild and mild dementia for a driver performance evalu-
ation by a certified examiner and reassessment every 6 months
(Dubinsky et al., 2000; Duchek et al., 2003; Dickerson, 2014),
or more often if families report concern or dementia is rapidly
progressing (Adler, Rottunda, & Dysken, 2005). Iverson and
colleagues (2010) from the American Academy of Neurology
also recommend on-road performance, cognitive testing, driv-
ing simulation, crash data, and caregiver report as important
factors to consider when making driving recommendations
(Dickerson, 2014).
The use of copiloting, where a passenger assists the driver
with how to operate the vehicle, is not supported by the
evidence, and the need for such assistance is an indication the
individual with dementia should stop driving (Wheatley
et al., 2014). The need for navigational assistance is not con-
sidered an indication of being unfit to drive, and these types
of verbal prompts may be helpful (Wheatley et al., 2014).
Assessments of attention, executive functioning, visu-
ospatial skills and memory are useful to assist in the driv-
ing assessments of individuals with Alzheimer’s disease
(NHTSA, 2009). The UFOV, Trail Making A and B, and
similar tests are useful in predicting driving performance.
However, these alone cannot be used for licensing deci-
sions (NHSTA, 2009).
In summary, moderate to severe dementia is incompat-
ible with safe driving (NHSTA, 2009; Wheatley et al.,
2014). Those with very mild to mild dementia may be
safe to drive; however, individual functional assessments
of driving skills should be done to determine driving safety.
Reassessment is required based on the progression of demen-
tia. The practice of copiloting the driver with dementia is
not recommended.
Other Medical Conditions Affecting Driving
Performance and Safety
Parkinson’s disease is another cause of dementia and, com-
bined with bradykinesia, can lead to an increased risk for
MVCs (Keplinger, 1998; Wood et al., 2005). Ranchet and
colleagues (2012) conducted a systematic review examining
the relationship between cognitive functioning and driving
behaviors of individuals with Parkinson’s disease. Common
at-fault errors occur in lane observation and stop signs, diffi-
culty driving in urban settings and conditions involving in-
tersections and roundabouts, hesitating longer before turning,
not accelerating to the proper speed, driving more slowly with
speed variability when distracted, and a decreased awareness
of how their driving may affect others (Amick, Grace, & Ott,
2007; Uc, Rizzo, Anderson, Sparks et al., 2006; Uc et al.,
CHAPTER 22 ■ Driving 347
2007, 2009; Wood et al., 2008). Classen (2014) recently
completed a review of the evidence concerning driving in
individuals with Parkinson’s disease. Drivers with mild motor
disability may be fit to drive and should have a baseline
comprehensive driving evaluation performed, consider having
annual driving evaluations, begin planning for driving cessa-
tion, develop a plan for use of alternative transportation
options, and talk with family about driving retirement. Those
with severe motor impairment and disease severity and
multiple risk factors, such as decreased information process-
ing and impaired contrast sensitivity, should stop driving and
seek out consultative services to address transportation issues.
Individuals with mild to moderate motor disability and a
few risk factors should receive a comprehensive driving eval-
uation and opportunities for rehabilitation, learn strategies to
address transitioning to nondriving, and develop a mobility
plan for driving cessation.
Cerebrovascular disease is another cause of cognitive dys-
function. Legh-Smith, Wade, and Hewer (1986) conducted
a study that concluded that individuals who have had a stroke
may display difficulty aligning their cars with the side of the
road, entering and leaving the highway, dealing with traffic
in roundabouts, and performing two tasks at the same time
in an emergency (Keplinger, 1998).
Individuals who have diabetes, especially those needing
insulin or oral hypoglycemic drugs, have a higher risk for
MVAs (Holmes, 1990; Keplinger, 1998; Koepsell et al., 1994).
Because these individuals have more severe diabetes, they are
at risk for hypoglycemia, which can cause transient cognitive
impairment.
Neuromusculoskeletal problems such as arthritis are
common in older adults. Functional implications of arthritis
as these relate to driving are limited ability to operate the pri-
mary controls of the vehicle, such as the foot pedals, steering
wheel, ignition, gear selector, safety belt, and other controls
that require reaching, strength, or leverage (NHTSA, 2009).
Medications
Certain medications that affect the central nervous system
reportedly can impair psychomotor function and place older
adults at increased risk for injurious motor vehicle collisions.
For example, drivers using benzodiazepines for anxiety
and insomnia had a 50 percent higher accident rate than
nonusers (Morgan & King, 1995; Ray, Fought, & Decker,
1992). The American Medical Association identifies
several medication categories, including anticholinergics,
anticonvulsants, antidepressants, antiemetics, antihistamines,
antihypertensives, antiparkinsonians, antipsychotics, benzo-
diazepines, sedatives, muscle relaxants, narcotic analgesics, and
stimulants, that can affect driving ability (American Geriatrics
Society & Pomidor, 2016). It is important for drivers to dis-
cuss with their doctors how new medications and interactions
with existing medications may impact their ability to drive.
Therapists should be alert to changes in performance that
may be medication related, and report these to the physician
as well.
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348 PART III ■ Active Aging: Supporting Client Activities and Participation
Clinical Assessment and Intervention
Clinical practice with a focus in the area of driving rehabili-
tation is considered a specialized area of practice. Because of
the complexities of diagnosis, equipment, policies, stake-
holder involvement, and high risk to the client and the public,
driving rehabilitation is not entry-level practice. Efforts to
distinguish practitioners who specialize in driving rehabil-
itation from generalists have resulted in two certification
programs. Although there are practitioners who choose to
specialize in driving rehabilitation and may earn an additional
certification credential, there continues to be a role for the
generalist practitioner to address driving in practice.
The discussion here of evaluation and intervention to
support driving for older adults emphasizes the role of occu-
pational therapy. This is due to the reality that driving is
largely within the professional scope of OT due to the focus
on motor performance, sensory perception, cognitive abilities,
as well as person–environment fit. In addition, the NHTSA,
the American Medical Association, and the American
Geriatric Society have identified occupational therapy as the
principle health-care discipline to address driving (American
Geriatrics Society & Pomidor, 2016). Physical therapists
can become certified driving specialists but are less likely than
occupational therapists to do so. However, physical therapy
often works closely with occupational therapy to ensure that
issues related to physical capacity are addressed adequately.
If an older adult’s driving issues are the result of limited range
of motion or strength, physical therapy intervention may be
able to ameliorate the problem.
INTERPROFESSIONAL PRACTICE
Driving Rehabilitation Specialists
The Association of Driver Rehabilitation Specialists (ADED),
an interprofessional organization, enacted the first certification
program in 1995 (ADED, 2006). The program designates
individuals as certified driver rehabilitation specialists (CDRS)
and awards a credential of CDRS. The CDRS credential identifies
health-care providers, driver educators and instructors, and
equipment dealers who have met the certification requirements
to plan, develop, coordinate, and implement driver rehabilitation
services for individuals with disabilities (ADED, 2006).
Certification through the American Occupational Ther-
apy Association (AOTA) is available only to occupational
therapists and occupational therapy assistants. It designates
individuals as Specialty Certified in Driving and Commu-
nity Mobility and awards a credential of SCDCM or, for
occupational therapy assistants, SCADCM (AOTA,
2006). The SCDCM or SCADCM is a portfolio-based
certification program involving professional development
activities grounded in the AOTA Standards of Continuing
Competence (AOTA, 2015). Neither the CDRS nor the
SCDCM/SCADCM is required to practice clinically in
the area of driving rehabilitation, but they demonstrate
focused knowledge, skills, and experience and add credi-
bility when working with other team members and state
agencies.
Few tools exist that directly predict the risk of MVC
among older adults (Dickerson, Meuel, Ridenour, &
Cooper, 2014); Woolnough et al. (2013). Typically, clinical
screenings consist of an overview of motor function and
reaction time, a screening of visual skills, and various tests
to determine possible cognitive-perceptual dysfunction.
There is no assessment tool that can definitively determine
safe driving; however, there are several instruments that
show some correlation to scores on the tests and increased
driving risk (Dickerson et al., 2014). Woolnough and col-
leagues (2013) determined that there is no association be-
tween performance on the Assessment of Driving Related
Skills (ADReS) and history of crash in the previous 2 years.
The ADReS is a test battery recommended by the American
Medical Association to measure vision, cognition, and motor/
somatosensory functions related to driving. However, neu-
ropsychological assessments that measure speed of process-
ing, visuospatial abilities, and memory (Anderson et al.,
2012), and those that provide a composite cognitive score
have been shown to predict safety errors in older drivers
(Dawson et al., 2010).
INTERPROFESSIONAL PRACTICE
The Interprofessional Team in Driving Assessment
and Intervention
Formalized assessment of each skill area can be accomplished
by an interprofessional team including neuropsychologist,
ophthalmologist, physiatrist, and occupational therapist; and
can determine whether an individual has sufficient function
in a given skill area to drive. Each professional focuses on the
skills or functional areas aligned with his or her discipline in
consideration of ability and safety. For occupational therapy
practitioners in general practice, it is important to implement
the same clinical reasoning skills when determining safety
to bathe alone, cook independently, or live without
assistance when determining the ability to drive or travel in
the community safely. When a concern for performance
or safety is present, a referral to a driving rehabilitation
specialist should follow. Practitioners who specialize in
driving rehabilitation have acquired additional training to
be able to assess areas that are beyond the scope of their
particular discipline.
Clinical determinations based solely on screening tools
are usually made with a degree of certainty when a relatively
severe degree of impairment exists. When there is lesser
dysfunction in the evaluated skill, the impact on driving
performance may not be clear. Although some driving reha-
bilitation programs may make a determination based solely
on clinical data, most programs use this information to
4605_Ch22_341-358 31/10/17 12:34 PM Page 349
identify areas of concern that may need to be ruled out during
a behind-the-wheel assessment.
Medical and Driving History and Performance
Patterns
Clinical assessments generally start with a medical and driv-
ing history, which may consist of a questionnaire or be part
of the initial interview. By the conclusion of the interview
and history, the evaluating professional should have obtained
an impression about the older driver’s general medical status,
FIGURE 222 Summary and recommendations.
CHAPTER 22 ■ Driving 349
his or her driving experience, the role of driving in fulfilling
life roles, any significant on-road incidents, and self-awareness
of limitations and the impact of these factors on driving
patterns. Figure 22-2 shows a summary of the recommenda-
tions based on a comprehensive driving assessment.
Medical information obtained as part of the medical
history should include any diagnosed medical conditions,
including psychological diagnoses, that could have implica-
tions for driving safety, including those already discussed here.
The examiner also should inquire about prescription medica-
tions currently being taken by the individual to determine
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350 PART III ■ Active Aging: Supporting Client Activities and Participation
whether any might make driving hazardous. The driving
evaluator should never hesitate to discuss medications with
the physician to ensure that driving performance will not be
compromised by a particular medication. A summary of
medical information that should be obtained can be found in
the online ancillary materials.
The driving history should include basic information about
the individual’s driving record. With the exception of a
person’s years of driving experience and any formal driver’s
education, the driving history should generally be limited
to the previous 3- to 5-year period and should focus on the
person’s behavioral patterns with respect to driving, any means
of self-regulation, and on-road incidents, crashes, or moving
violations or near misses.
The Driving Habit Questionnaire by Owsley, Stalvey,
Wells, and Sloane (1999) is a valuable tool that can determine
whether the client is currently driving, how often he or she
drives, and the approximate annual mileage accrued. An occu-
pational profile also should be gathered to determine the client’s
interest and needs related to driving as well as other occupa-
tional engagement that is dependent on driving. Destinations
to which the individual drives on a regular basis should be iden-
tified, along with any driving conditions that may be of partic-
ular concern to the individual. The examiner should identify
conditions that might create excessive anxiety for the individual
so that these can be avoided during a behind-the-wheel assess-
ment. The development of new activities of daily living (ADL)
dependencies may provide strong evidence that an individual
with a dementing illness may encounter difficulty driving.
Another key objective is to determine the level of insight
the person has into his or her limitations and the effects of
those limitations on driving performance. Particular attention
should be paid to whether the individual self-regulates his or
her driving in any way (e.g., he or she avoids expressways,
rush-hour traffic, left-hand turns, or unfamiliar areas). Com-
plete reliance on the older driver’s self-perception of driving
ability may not be a reliable way to verify whether problems
will manifest themselves in driving ability. Without aware-
ness of potential risks, the older adult has a poor prognosis
for correcting or compensating for problems identified later
in the evaluation. If the client consents, obtaining input from
family members may help clarify these issues. Even the seem-
ingly innocuous observation that the client needs assistance
in filling out the questionnaire and medical forms can be an
indicator of visual or cognitive deficits.
In addition to medical and driving history, the clinician
should spend time in this portion of the evaluation simply
getting to know the client. The clinician should explore why
driving is important to the client, where he or she needs to
drive, and what alternative means of transportation are avail-
able to this person.
Clinical Assessment of Movement
Key questions to answer during assessment are whether the in-
dividual possesses adequate sensory and neuromusculoskeletal
functions and motor performance skills to safely drive a vehicle
or access transportation systems. The clinician needs to assess
the client’s mobility, posture, coordination, strength, effort,
energy, and knowledge in relation to the activity demands of
driving. Typical protocols for assessment of these areas should
be followed with selection of tools relying on evidence in sup-
port of prediction of driving safety or performance outcomes.
The first criterion to explore is the client’s functional
mobility. Factors to consider are the client’s ability to travel
to and from the vehicle; whether the client uses an assistive
device for mobility, such as a wheelchair, walker, or cane; and
whether he or she needs assistance from another person
to travel to the vehicle. The Rapid Pace has been found to have
moderate evidence linking poor performance to decreased fit-
ness to drive (Classen et al., 2011; Edwards, Bart, O’Connor,
& Cissell, 2010; Stav, Justiss, McCarthy, Mann, & Lanford,
2008). Increasingly, studies are offering little or weak evi-
dence for assessment of physical abilities or skills as predictors
of driving performance (Carr, Bart, O’Connor, & Cissell,
2011; Cordell, Lee, Granger, Vieira, & Lee, 2008; Kantor,
Mauger, Richardson, & Unroe, 2004; Ott et al., 2008;
Staplin, Gish, & Wagner, 2003). Although no single mea-
surement can determine fitness to drive (Dickerson et al.,
2014), these data are important because observation of motor
skills and performance paints a picture of what the therapist
can expect during the behind the wheel assessment.
Another issue to consider is whether the client can transfer
the mobility device in and out of the vehicle independently.
Any unresolved issues regarding mobility outside the vehicle
will need to be a part of the intervention plan.
The clinician also needs to evaluate the client’s posture and
trunk stability. To efficiently reach the gas, brake, and steering
wheel and to provide a stable platform from which to operate
the equipment, one has to have sufficient posture and trunk
stability. If this is an issue, seating options will need to be-
come part of the intervention plan. Many postural deficits
can be overcome with the correct seating.
Coordination and strength/effort play a key role in successful
driving. Driving requires the smooth coordination of move-
ments of both the upper and lower extremities, frequently
simultaneously.
Functional limitations in active range of motion should be
determined for neck, trunk, and upper and lower extremities.
Detail about what factors to examine can be found in the
online ancillary materials.
The clinician also needs to assess whether the client has
the energy required to participate in all aspects of driving. The
successful driver or traveller has to be capable of tolerating
extended periods of physical and mental “work.”
Clinical Assessment of Visual Functions
The primary purpose of the vision screening should be to
determine the possible presence of visual dysfunction that
may have the potential to affect driving ability. It is not
diagnostic in nature because there is strong evidence that
4605_Ch22_341-358 31/10/17 12:34 PM Page 351
visual acuity has little or no relationship to crashes or driving
performance, unless visual acuity is significantly impaired at
less than 20/70 or the client has additional visual issues (Carr
et al., 2011; Edwards et al., 2008; Stav et al., 2008; Wood,
Anstey, Kerr, Lacherez, & Lord, 2008).
At a minimum, distant visual acuity, visual fields, contrast,
and oculomotor control should be screened. In her review
of visual dysfunction on the ability to drive, Strano (1989)
described the objective of an evaluation of visual skills with
respect to driving in terms of two distinct tasks: (1) to deter-
mine whether vision meets legal visual requirements and
(2) to determine what additional problems exist and what
effect they may have on driving ability. Baker (2006) provided
an extensive review of the visual system and the evaluation
and treatment of potential dysfunction relevant to driving.
The ability to renew one’s driver’s license does not repre-
sent proof of adequate vision for safe driving as standards and
training of licensing staff vary widely. The International
Council of Ophthalmology (2006) recommends that a mea-
surement of 20/40 distant acuity or better should be the stan-
dard for unrestricted driving, and that acuity measurements
worse than 20/40 to 20/200 should be individually consid-
ered. Peripheral field recommendations state that 120 degrees
horizontally and 40 degrees vertically should be the minimum
standard, with peripheral fields less than this left to individual
consideration. Visual functions may be assessed using various
methods as described in the online ancillary materials.
Common industrial vision-screening devices such as the
OPTEC (www.stereooptical.com) or Titmus Vision Screener
(www.titmus.com) are used in many driver assessment pro-
grams. These machines facilitate easy screening of distant
visual acuity, color perception, and the oculomotor skills
responsible for alignment of the eyes and depth perception.
They can also screen peripheral vision in temporal and nasal
fields if equipped with optional perimetry modules. Depth
perception can be assessed functionally. Color perception
screenings are frequently included with many industrial
vision-testing devices. Whatever the method used to assess
vision clinically, the evaluator should remember that these
tests are given under more or less “optimal” conditions.
During the behind-the-wheel assessment, the evaluator
should be observant of how the client’s vision affects his or
her driving ability. Visual field deficits in upper or lower
quadrants can be screened via confrontation testing or by
acknowledgment of stimuli presented by a laser pointer.
Functionally, the evaluator should observe how well the client
identifies relevant information in the periphery, including
incorporation of cervical rotation to check blind spots while
lane changing.
Contrast sensitivity is the measure of the ability of the
visual system to distinguish various shades of gray or shades
of colors. Most printed material is (more or less) black print
on a white background. Visual acuity tests are given using
black symbols on a white background with optimal lighting.
Functional activity is rarely completed in “optimal” conditions,
especially when pertaining to driving. Lighting conditions and
CHAPTER 22 ■ Driving 351
the backdrop of what is before the driver change continually.
Even the color of other vehicles can have some impact on the
ability of drivers to see them efficiently. Persons with cataracts,
glaucoma, optic neuritis, or other diseases affecting the cornea,
lens, or retina of the eye may have increased difficulty with
poor lighting conditions, even when they test well for acuity
clinically. Contrast sensitivity testing is conducted using a
vision chart similar to a Snellen chart with color of the text
in decreasing shades of gray. Another method of testing
contrast sensitivity is the Functional Acuity Contrast Test
(FACT). The FACT chart, developed by Arthur Ginsburg,
tests five spatial frequencies (sizes) and nine levels of contrast.
Because these devices often are used by state licensing agen-
cies, they also may indicate whether the person will be able
to renew his or her license. Because of the design of these
devices, it is difficult or impossible to assess depth perception
and contrast when the client has monocular or biocular
vision, that is, vision with one eye or two eyes, respectively.
There are various handheld charts that can address contrast,
such as the LEA Low Contrast Flip Chart. There are currently
no standardized limitations for driving with reduced contrast,
but there is evidence that impaired contrast sensitivity related
to the normal process of aging is linked to increased crash
risk (Amick et al., 2007; Keay et al., 2009; Selander, Johansson,
Lundberg, & Falkmer, 2010; Stav et al., 2008). Therefore,
the evaluator should discuss limitations in contrast with the
client, and the relevance to driving. Reductions in contrast
sensitivity can be a symptom of eye diseases, such as cataracts
and glaucoma. Sometimes the client may be unaware of these
conditions, so the clinician should refer the client to his or
her eye specialist for follow-up.
Clinical Assessment of Other Client Factors
and Performance Skills
The objective of the cognitive-perceptual screenings is to
determine the potential presence of dysfunction in mental
functions, such as attention and memory or processing skills
that may potentially affect driving ability. Although there are
multiple ways of assessing for potential dysfunction in pro-
cessing skills that are necessary for driving, no single test or
combination of tests can predict with certainty whether the
degree of dysfunction measured will adversely affect driving
ability. Unless test results indicate a severe degree of dys-
function, any concerns identified during the process skills
screening should either be confirmed or ruled out during
a behind-the-wheel assessment. In addition, results from
processing skill screenings are used to determine whether
significant errors committed behind the wheel are consistent
with clinically noted concerns and whether these errors are
amenable to treatment. These are described in greater detail
in the online ancillary materials.
The specific tests constituting the mental functions and
process skills component of clinical driving assessment vary
from program to program but typically include assessments
from three general categories: psychometric tests, driving
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352 PART III ■ Active Aging: Supporting Client Activities and Participation
simulators, and a separate category of “functional” assess-
ments. A battery of tests should be diverse enough to assess
as many cognitive-perceptual skill areas as possible. However,
no screening will be perfect. One must understand both the
strengths and limitations of the particular mental functions
and process skills assessments and account for any identified
dysfunction during the behind-the-wheel assessment.
Psychometric Tests
Psychometric tests have been found in various combinations
to correlate with driving ability. It should be noted that even
with the extensive use of psychometric tests, the occupa-
tional therapist or driving rehabilitation specialist is using
them only as screening tools. Any indications of cognitive
deficits should be reported to the referring physician, or a
referral made for follow-up with an appropriate medical
doctor.
As with other types of assessments, psychometric batteries
should not be used as the sole determinant of an older per-
son’s driving ability. In fact, psychometric tests may be of less
value when determining the driving potential of older drivers
than that of younger populations. One factor that limits the
utility of many psychometric tests concerns the poor quality
of normative data with respect to older age-groups because
norms may be available only for younger individuals or may
reflect age ranges of 10 to 15 years—too large a span to be
sensitive to change in older individuals. It may be difficult to
link results to driving performance. For example, researchers
have reported inconsistent results of the utility of the
Motor-Free Visual Perception Test (MVPT) in predicting
driving performance. Some studies have linked MVPT per-
formance with driving performance outcomes (Edwards,
Bart, O’Connor, & Cissell, 2010; Korner-Bitensky, Kua,
von Zweck, & Van Benthem, 2000; Oswanski et al., 2007),
whereas other researchers report no relationship with fitness
to drive (Carr et al., 2011; Kantor et al., 2004; Stav et al.,
2008; Zook, Bennett, & Lane, 2009). A list of psychometric
tests frequently used in driving rehabilitation settings and
that have been found to correlate with behind-the-wheel
performance can be found in the online ancillary materials.
The Trail Making tests in particular identify at-risk drivers
if they complete the measure with slowed processing speed
(Amick et al., 2007; Carr et al., 2011; Classen et al., 2008;
Grace et al., 2005; Keay et al., 2009; Munro et al., 2010; Ott
et al., 2008; Wood et al., 2008; Zook et al., 2009). When an
individual takes longer than 2 minutes or cannot complete
the test, evidence suggests that the individual is at significant
risk for being unfit to drive. However, there is insufficient
evidence for exact cut-off scores of either Trails A or Trails B.
The one assessment that has consistently shown to be
predictive of driving performance and crashes is the UFOV
(Amick et al., 2007; Edwards et al., 2008; Owsley et al.,
1998; Stav et al., 2008; Wood et al., 2008). Although the
UFOV has been shown to be predictive, Subtest 2 in par-
ticular has shown the most predictive validity of driving
performance (Classen et al., 2011; Edwards, Bart, O’Connor,
& Cissell, 2010; Wood et al., 2008).
On-the-Road Assessment of Cognition
Experienced drivers in their 50s and 60s may notice some
physical or visual changes in function that affect driving, but
they may be able to compensate for these due to their exten-
sive driving experience. The older driver may report limiting
driving at night, travelling only to familiar places, or accept-
ing rides from others when possible. Unfortunately, when
cognition becomes an issue of driving performance, clients
commonly have decreased insight into actual functional
performance. Adult children of older drivers report forget-
fulness (e.g., failing to turn off the stove or lock the house)
and unexplained dents and scrapes on their parent’s vehicle.
The parent vehemently denies these reports or tries to dismiss
them as unimportant. Persons with memory deficits, almost
by definition, do not remember what it is they are forgetting.
Drivers with cognitive deficits may not notice or recall near
misses, difficulty maintaining lane position, or difficulty
interpreting navigational signs.
Evidence-Based Practice
The AOTA has published in-depth guidelines for evalua-
tion and intervention of driving. Within this guideline is a
review of the evidence relevant to driving and the older
adult. Level I, II, and III studies focused on five different
intervention approaches:
1. Skills-based intervention (Golisz, 2014)
2. Education (Golisz, 2014)
3. Modification to the vehicle
4. Policy (Stav, 2014)
5. Physical infrastructure (Bohr, 2008)
Studies focusing on skills-based intervention looked at
visual training, psychomotor ability such as response time
and anticipation time, and range-of-motion home exercise
training (Arbesman, Lieberman, & Berlanstein, 2014). In
general, UFOV intervention using a computerized visual
attention analyzer seems to be effective in improving per-
formance on a behind-the-wheel assessment (Ball, Edwards,
Ross, & McGwin, 2010; Cassavaugh & Kramer, 2009;
Edwards, Delahunt, & Mahncke, 2009; Edwards, Myers,
et al., 2009). In addition, after 18 months, the effect of the
UFOV persisted but the effect of the simulator training did
not (Roenker et al., 2003). Another study (Klavora et al.,
1995) examined older adults poststroke who had impaired
visual attention, using a Dynavision apparatus and behind-
the-wheel driving test as the outcome measure. Six of the
10 participants earned a rating of safe to resume driving or
to receive driving lessons. Finally, another study determined
that older adults who participated in the exercise program to
improve head and neck flexibility were more likely to have
improved on handling position and observing while driving
4605_Ch22_341-358 31/10/17 12:34 PM Page 353
(Ostrow, Shafron, & McPherson, 1992) and stabilized driving
performance (Marottoli, Allore, et al., 2007). Education-
based interventions were studied and found that classroom
sessions combined with on-road training improves driver
performance (Bédard et al., 2008; Korner-Bitensky, Kua, von
Zweck, & Van Benthem, 2009; Marottoli, Ness, et al., 2007).
Arbesman and Justiss (2013) reviewed studies that exam-
ined modification to the vehicle, looking at window tinting,
windshield glare, and use of adapted cruise control system.
These studies concluded that tinted windows negatively
affect the older adult’s ability to see low-contrast objects
and maneuver the vehicle backward (Burns, Nettelbeck,
White, & Wilson, 1999; Freedman, Zador, & Staplin, 1993;
LaMotte, Ridder, Yeung, & De Land, 2000). In addition,
decreased contrast sensitivity due to the angle of the windshield
and dashboard reflectance is an important factor to consider
when recommending the type of car that best meets the needs
of the older driver (Schumann, Flannagan, Sivak, & Traube,
1997). Other studies have shown that older drivers take longer
to locate controls and display systems (Laux, 1991), and they
favored the use of an adapted cruise control device, especially
to allow for more space between cars (Fancher et al., 1998).
Studies of vehicle technology and modifications concen-
trated on driver assistance systems such as intelligent trans-
portation systems, adaptive cruise control, and navigation
systems (Arbesman & Justiss, 2013). The evidence revealed
mixed results on the benefits of vehicle technologies with
some improving performance including homogeneity of speed
with intelligent speed limit system (van Nes, Brandenburg, &
Twisk, 2010) reduced stress with adaptive cruise control
(Stanton & Young, 2005), and improved safety with collision
avoidance systems (Fitch, Kiefer, Hankey, & Kleiner, 2007;
Kramer et al., 2007). Other studies found the technology to
have negative safety effects including Blanco and colleagues
(2006).
Infrastructure studies focused primarily on signage, specif-
ically color, reflectiveness, location, fonts, and familiarity
(Stav, Hunt, & Arbesman, 2006). The evidence supports
specific colors and fonts (Carlson, 2001; Chrysler, Carlson,
& Hawkins, 2002; Ho, Scialfa, Caird, & Graw, 2001), but
the studies were not conducted in real-life driving environ-
ments. Kline, Buck, Sell, Bolan, and Dewar (1999) deter-
mined that legibility thresholds were lower for familiar signs
compared to unfamiliar signs and that older drivers used
compensatory strategies to read signs.
Policies concerning license renewal usually include one
or more of the following: vision testing, in-person renewal,
and medical review (Stav, 2014). Studies suggest that as driv-
ers age, renewal criteria should increase as a way to reduce
motor vehicle accidents (Grabowski, Campbell, & Morrisey,
2004; Hakamies-Blomqvist, Johansson, & Lundburg, 1996;
Marshall, Spasoff, Nair, & Walraven, 2002; Shipp 1998).
Efforts to improve safety through licensing restrictions have
yielded inconsistent results with a studies by Braitman
Chaudhary, and McCartt (2010) and Nasvadi and Wister
(2009) finding positive safety outcomes, whereas Langford
CHAPTER 22 ■ Driving 353
and colleagues (Langford, Bohensky, Koppel, & Newstead,
2008; Langford & Koppel, 2011) and Dobbs (2008) found no
positive benefits.
AROUND THE GLOBE: Improving Driving Conditions
In Canada, Tuokko and McGee (2002) conducted focus groups
with older adult drivers and individual interviews with health-care
professionals to identify ways to improve the driving condition for
older adults. Although participants identified that there needs to
be a societal shift in attitude toward the acceptance of alternative
modes of transportation, as well as improved road engineering
and transportation methods, education of the general public and
professionals was identified as a priority. The group recommended
that a mandatory defensive driving course should be offered
through senior centers and that health-care professionals could
recommend nonmandatory self-assessments that would alert
people of factors that may have an impact on driving safety and
provide suggested actions people could take.
Suggestions for Clinicians in Geriatric
Practice
By interviewing the older client or the client’s family mem-
bers or caregiver, the geriatric clinician can determine
whether a referral to a driver rehabilitation specialist is indi-
cated. Several factors should be considered as signs that the
older adult may be experiencing difficulties in driving. If any
of the following factors are present, the geriatric clinician
should recommend that the older adult undergo a formal
driving evaluation:
■ If the client is experiencing difficulties performing ADL,
there is a good chance that driving is problematic as well.
■ Although the self-report of an elderly driver is not usually
reliable, the individual may have his or her own concerns
about driving safety.
■ Certainly, the family or caregiver should be asked if they
have any concerns about the client’s ability to drive.
■ If the client reports episodes of getting lost on the way to
appointments or meetings or an increased incidence of
other drivers honking at him or her, a driving evaluation
should be conducted.
■ Physical limitations such as neck pain or limited upper or
lower extremity range of motion are indications that the
driver may have difficulty operating a motor vehicle safely.
■ If any of these indicators are reported or apparent clinically,
the geriatric clinician should recommend that the older
adult receive a driving evaluation from a driver rehabilita-
tion specialist.
■ Under no circumstances should a geriatric clinician recom-
mend adaptive equipment for a motor vehicle without
having the older adult undergo a thorough driving evalua-
tion and training in the use of the equipment. Even the
simplest adaptive device requires training to use safely
4605_Ch22_341-358 31/10/17 12:34 PM Page 354
354 PART III ■ Active Aging: Supporting Client Activities and Participation
because the slightest modification may require a more
complex adjustment by the driver to ensure the safe oper-
ation of the vehicle. The geriatric clinician also needs to
consider alternative solutions available to the client should
driving privileges be taken away and how the inability to
drive may impact the client’s ability to participate in valued
activities.
SUMMARY
Driving is an important occupation, as well as a symbol of
freedom and independence. As the elderly population ages,
difficulties in driving arise due to normal physiologic and
disease-related changes affecting the skills necessary to drive
safely. Assessment of the elderly driver’s functions, client fac-
tors, performance skills, performance patterns, and contexts
is necessary to help determine whether the driver will be safe
on the road. Ultimately, a behind-the-wheel assessment may
be necessary to help identify skill-area deficiencies and to pro-
vide future recommendations. Psychosocial implications must
be considered as well when evaluating and determining
whether the elderly driver should continue to drive with re-
strictions or cease driving altogether. Ultimately, the practi-
tioner must consider the balance between independence and
safety for the client and other road users.
CASE STUDY
Mr. Albert Smith, age 80, occasionally forgets where the
keys are or what day it is. One day, Mr. Smith drives his
daughter and his wife to the grocery store. During the
ride, Mrs. Smith directs her husband while he is driving
because he has difficulty remembering the route to take.
Mr. Smith’s daughter is concerned, so she makes an
appointment with her father’s physician to assess his cog-
nitive skills. She tells the physician that her father has
forgotten to turn off the stove, forgets to take his medica-
tions, never knows what the date is, and occasionally asks
for directions to what should be familiar places. Mr. Smith
has never had an accident or ticket and feels he is a safe
driver. He drives alone to the hardware store and to a local
restaurant to “meet the boys” for breakfast. He and his
wife go to the grocery and drug stores; he takes her to the
beauty parlor and to church—“Not at night, mind you”—
and avoids “downtown.” He reluctantly agrees to come in
for an occupational therapy driving evaluation.
The occupational therapist completes several types of
assessments. At the end of the testing the OT notes that
Mr. Smith has some arthritis, which slows his walking
but otherwise does well physically. He is independent in
all his self-care. He has less than ideal vision but within
the parameters set by the state driving licensing agency,
and he appears to have some mild cognitive issues. From
Mr. Smith’s perspective, he is faced with the prospect of
not driving and loss of independence. As driving is such
an integral part of our society, loss of driving privileges is
a very real sign of “getting old,” a prospect few people care
to face.
Questions
1. How do you communicate your recommendations
to Mr. Smith or his family (remember patient
confidentiality)?
2. What if Mr. Smith does not have any family members
to bring him to a driving evaluation?
Critical Thinking Questions
1. Describe the different aspects of the Driving as an
Occupation model specific to how the different
constructs of the model may limit an older adult’s
ability to drive safely.
2. How do the normal aging process and disease
processes affect the elderly driver’s ability to
drive?
3. What information is important to obtain during the
initial interview portion of a driver evaluation?
4. What are the pros and cons of functional measures
used to assess driving performance?
5. Which is the most effective way to assess a driver’s
abilities: a driving simulator or a behind-the-wheel
assessment? When is either of these assessments
indicated?
6. What issues are of concern when a recommendation
to suspend driving must be made?
7. How can interprofessional interactions improve the
evaluation and intervention processes as related to
driving for older adults?
Acknowledgment
The authors wish to thank Aaron Zinck for assisting with the
Driving as an Occupation model graphic, and Steven Mitchell
for contributing the illustrations regarding occupational therapy
driving evaluations. Patrick Baker, Pamela O’Dell Rossi, and
Steven Mitchell are thanked for their contributions to an earlier
edition of this chapter.
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“I think the only way we can grow and get on in this world isperfect
LEARNING OUTCOMES
By the end of this chapter, readers will be able to:
1. Identify the implications of driving cessation for the older adult.
2. Explore alternative methods of community mobility
recommended for the older adult.
3. Identify assessment and intervention options for the geriatric
practitioner to support community mobility for the individ-
ual client as well as the community and population.
Clinical Vignette
Mrs. Conchita Sanchez is a 69-year-old retired teacher who is
experiencing vision and functional difficulties secondary to her
progressing macular degeneration. She has remained active in
her retirement as a volunteer in the local elementary school and
as a story reader in the children’s section of the local library. In
addition to being independent in self-care and driving through-
out her adult life, Mrs. Sanchez serves as the primary caregiver
to her husband who has Parkinson’s disease. She has been the
sole driver in her household for more than 5 years and has been
responsible for all shopping, transport to medical appointments
for both herself and her husband, and has assisted her daughter
with afterschool pickup of the grandchildren 2 days per week
at school. Now, however, her vision has deteriorated to the
point that she can no longer drive.
1. On the basis of the brief occupational profile of
Mrs. Sanchez, what areas of occupational engagement
will be most influenced by her inability to drive?
2. What suggestions might you have for facilitating con-
tinued occupational engagement and fulfillment of her
roles as volunteer, spouse, caregiver, and grandparent?
Losing the Ability to Drive:
A Psychosocial Perspective
In Western industrialized society, the ability to drive and
hold a driver’s license is very important both psychologically
and functionally because it is equated with freedom, choice,
CHAPTER 23
Community Mobility
Wendy Stav
to accept the fact we’re not
and live accordingly.
—Ray Bradbury, The Illustrated Man
”
identity, independence and autonomy, and status (Portegijs,
Rantakokko, Mikkola, Viljanen, & Rantanen, 2014). Func-
tionally, having a driver’s license means you can go shop-
ping, visit a friend, keep appointments, go to your place of
worship, or just take a drive whenever and wherever you
choose. Community mobility is recognized as an occupation
in the Occupational Therapy Practice Framework (3rd ed.;
American Occupational Therapy Association [AOTA],
2014), defined as “planning and moving around in the com-
munity and using public or private transportation, such as
driving, walking, bicycling, or accessing and riding in buses,
taxi cabs, or other transportation systems” (p. S19). In addi-
tion to being an occupation, community mobility is an
“occupation enabler” because mobility in the community
serves as a conduit to engagement in many other occupa-
tions including work, leisure, and instrumental activities of
daily living (Stav, 2015). Due to the occupation and occupation
enabler status of community mobility, one’s ability to access
and be mobile in the community has significant implications
for the health and well being old older adults (AOTA, 2010;
Oxley & Whelan, 2008; Satariano et al., 2012).
AROUND THE GLOBE: Community Mobility in India
Community mobility issues are not unique to the United States
and other Western countries. In the city of Chennai in India, older
adults report spending about 10% of their time moving around
the community, mostly by walking (Ramachandran & D’Souza,
2016). These elders feel unsafe because of uneven pavement,
failure of drivers to obey traffic rules, and crowded roads. However,
they also do not find public transportation accessible because of
difficulty boarding, inadequate seating, and crowding.
Residential and commercial development, as well as the
increase in populations living in suburban residential com-
munities, has led to the idea that owning an automobile and
being able to drive are essential to the enjoyment of daily life
(Hare, 1992). Grocery stores, leisure venues, and houses of
359
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360 PART III ■ Active Aging: Supporting Client Activities and Participation
worship are often not within walking distance making mo-
torized mobility using a private automobile or public trans-
portation critical to community engagement. For older adults
who are no longer able to drive or not comfortable operating
an automobile, identifying and accessing transportation
options becomes a priority.
Before giving up driving altogether, most older adults
restrict themselves to driving under certain conditions (Ross
et al., 2009). However, these modifications have differing
levels of effectiveness in enhancing safety or performance
depending on consistency in use of the modification, the
context, or the driver’s capabilities. As described in Chapter 22,
examples of self-regulation techniques employed by older
drivers include driving only during daylight hours and on
familiar streets, or avoiding inclement weather and heavy
traffic times. Some older adults report they do not want
passengers with them because either the conversation is dis-
tracting or they are fearful they may injure a family member,
especially a grandchild. Others prefer to have a second per-
son in the car with them believing that two sets of eyes are
better than one. This shared responsibility of driving in
which one physically operates the vehicle while the other
navigates or points out obstacles is considered “copiloting”
(Shua-Haim, Shua-Haim, & Ross, 1999) and is not con-
sidered safe and therefore not recommended.
Source of Decision to Stop Driving
The decision to stop driving has both emotional and prac-
tical consequences (Chihuri et al., 2016). There may be dif-
ferences in those consequences depending on the sources of
the decision. In instances when older adults decide for
themselves to cease driving, they may feel empowered as
they initiated the transition from driving to improve safety.
These older adults also have the opportunity to explore op-
tions and experiment with their use prior the fully relying
on alternate transportation services for community mobility.
In addition, older adults who make the choice themselves
are able to slowly transition from driving in phases over a
period of time to become accustomed to the new services.
On the other hand, older adults who must stop driving be-
cause they are not medically fit to drive have very different
experiences. The transition is abrupt and immediate with
no opportunity to consider the implications for accessing
the community and desired occupations. Older adults who
have the decision imposed on them often feel a sense of pro-
found loss and may even experience the traditional stages
of grief (Kübler-Ross, 1969). They may feel overwhelmed,
frustrated, or anxious at the prospect of using novel trans-
portation systems that they never learned how to navigate.
As a result, the likelihood of a smooth transition to resuming
community mobility and engagement within community is
limited. The result of these unsupported transitions can in-
clude decreased community mobility with detrimental health
outcomes.
Implications of Driving Cessation
Driving cessation can decrease a person’s social network,
thereby increasing both isolation and loneliness; an increase
in depression is a particularly notable negative health out-
come of the decision (Chihuri et al., 2016). Chihuri and col-
leagues noted that in addition, driving cessation results in
decline in health and function in most spheres, and increases
the risk of nursing home placement. Marottoli et al. (1997)
demonstrated that driving cessation has been associated with
depressive symptoms, which, in turn, are associated with dis-
ability and mortality. Legh-Smith, Wade, and Hewer (1986)
studied patients who stopped driving after having a stroke.
These ex-drivers did less local shopping and traveling and
decreased their social interactions, resulting in an increased
likelihood of experiencing depressive symptoms. Through
a qualitative study, Johnson (1998) demonstrated that the
decision to stop driving was not only depressing but also
stressful and that this decision process and outcome could
cause anxiety and decreased morale. In general, “life-space
mobility”—the area in which one moves in daily life—is
associated with quality of life, and driving cessation limits
this mobility (Rantakokko et al., 2016)
In an effort to ease the transition from driving, studies have
been conducted to examine the effect of support groups and
group intervention to provide education and facilitate identi-
fication of alternatives (Dobbs, Harper, & Wood, 2009; Stern
et al., 2008). In both of these studies, the group intervention
had positive outcomes on alleviating the negative consequences
associated with driving cessation, reduced depression, and im-
proved quality of life (Dobbs et al., 2009) and self-efficacy,
communication. The program assisted clients diagnosed with
dementia and their families (Stern et al., 2008). When educa-
tion to prepare for driving cessation is suggested to older adults,
many are unaware that this is an event they should anticipate,
and roughly half indicate they would participate in educational
programs (Bryanton & Weeks, 2013).
Because driving is associated with autonomy and compe-
tence, giving up a driver’s license can make a person feel em-
barrassed, inadequate, and incompetent. Driving cessation
threatens one’s self-esteem and personal dignity because it
implies social disability and dependency on others. There is
also a sense of loss of power, especially when having to use
alternate forms of transportation. Gillins (1990) notes that
losing the ability to drive is usually associated with other
losses as well, such as vision, cognition, or limb function. This
adds to the person’s feelings of anger and helplessness as he
or she has lost an important piece of his or her identity.
INTERPROFESSIONAL PRACTICE
The Role of the Physician
A study of perceptions of patients about the role of physicians in
helping elders plan for transitions such as driving cessation and
alternate modes of transportation, roughly half of respondents
indicated they would be open to discussion with a physician
4605_Ch23_359-366 31/10/17 12:32 PM Page 361
(Lum, Brown, Juarez-Colunga, & Betz, 2015). One-third preferred
that family members make the decision about when they should
stop driving.
Family Involvement
Family members and caregivers find the issue of driving cessa-
tion to be a difficult topic to discuss with a loved one, especially
if the reason the family member needs to stop driving is related
to impaired cognition. Family members may develop excuses to
keep an older loved one off the road (Gillins, 1990). Some family
members have resorted to hiding the keys and disabling the car
or actually selling it to keep a family member from driving. Other
caregivers have solicited expert opinions by having their loved
one assessed by a driving rehabilitation specialist, believing that
their family member may heed that advice more readily.
Several resources have been developed to support family
members in identifying when an older adult is having difficulty
driving, initiating the discussion, and assisting with the transi-
tion from driving. The first step when confronted with the pos-
sibility of an older adult having difficulty is determining whether
an issue actually exists. There are several self-assessment screens
available, but few possess the psychometric rigor to determine
fitness to drive. However, the Fitness-to-Drive Screening
(http://ftds.phhp.ufl.edu) was developed and studied by an oc-
cupational therapist and has the capacity to determine whether
further investigation of performance should be pursued
(Classen, Velozo, Winter, Bedard, & Wang, 2015). This tool
is a Web-based survey that gathers characteristics and patterns
of an older driver’s behavior as reported by a family member
or someone who has seen the person drive. The result of the
Fitness-to-Drive Screening may suggest the person should
transition from driving, which then becomes the next obstacle
for the family to overcome. The Hartford worked in collabora-
tion with the MIT AgeLab to develop a comprehensive re-
source for just these circumstances. The resulting book, titled
We Need to Talk … Family Conversations With Older Drivers,
includes strategies for who should approach the older driver,
the best times for the conversation, preparing for the conversa-
tion, implications when the driver has dementia, as well as
worksheets of driving behavior warning signs and transportation
cost worksheets (The Hartford & MIT AgeLab, 2012). Asso-
ciated online seminars have also been developed to support fam-
ily members during the difficult transition (The Hartford &
MIT AgeLab, 2015). These kinds of assessments can help ease
the conversation, as they present both the older adult and the
family with concrete data about the driver’s safety.
Identification of older adults who need to transition from
driving and discussion the concerns is typically just the be-
ginning of journey for these older adults and their families.
Transition from driving often means the end of freedom and
spontaneity to travel throughout the community. New bar-
riers now exist for older adults who want or need to travel to
the grocery store, the doctor’s office, a friend’s home, a leisure
CHAPTER 23 ■ Community Mobility 361
activity, the beauty salon, or to a volunteer location. In addi-
tion, the older adult who just ceased driving may have been
a source of community mobility for friends, neighbors, a
spouse, or grandchildren. Driving cessation of one person
may ultimately limit the community mobility of several in-
dividuals and thus may have far-reaching effects. It is impor-
tant to work with the older adult as well as the family
members to identify community destinations frequented as
well as frequency of travel and duration of trips to assist with
filling the gaps with other modes of mobility.
Suggestions for Clinicians in Geriatric
Practice
By interviewing the older client or the client’s family mem-
bers or caregiver, the geriatric clinician can determine
whether alternate transportation options are indicated. Most
often, such an interview would be conducted by an occupa-
tional therapist; occasionally, social workers or psychologists
might take the lead. Several factors should be considered as
signs that the older adult may be experiencing difficulties
accessing the community. If any of the following factors are
present, the geriatric clinician should recommend that the
older adult explore transportation options as well as service
delivery availability in the local community:
■ Difficulties performing activities of daily living, suggesting
that there is a good chance that community mobility is
problematic as well.
■ Recent health episode or disease progression resulting in
driving cessation.
■ Expression by the individual or family members about
community mobility concerns.
■ Physical limitations causing deficits in ambulation and
transfers as indications the older adult may have difficulty
accessing and using transportation resources.
■ Visual and cognitive deficits causing limitations in reading,
environmental awareness, problem solving, planning, money
management, or safety suggesting the older adult may have
difficulty accessing and using transportation resources.
■ Report by the individual or his or her family about social
isolation and resulting depression.
If any of these indicators are reported or apparent clini-
cally, the geriatric clinician should recommend that the older
adult receive a community mobility evaluation from an oc-
cupational therapist who is familiar with local transportation
options and necessary performance skills to access and use
those transportation systems. Assessment and intervention
should focus on community resources that are easily accessi-
ble to the client. Therapists need to be creative in identifying
options. Among those that may work in specific situations:
■ Public transportation (buses, subways)
■ Community-responsive public transit (buses specifically for
individuals with disabilities and older adults)
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362 PART III ■ Active Aging: Supporting Client Activities and Participation

■ Taxi services can be difficult. Although buses may not be a good alterna-
■ Uber/Lyft tive to driving, special transportation designed for elderly
■ Private drivers (professionals, college students) persons, such as taxi or van services, is often too expensive,
■ Community transit (vans provided by specific localities) and most people can use this mode of transportation only
■ Walking for trips they consider critical, such as medical appoint-
■ Biking ments. Issues with community mobility for older individuals
■ Family members as drivers can vary greatly depending on where the person lives. Rural
elders are the most likely to feel isolated when they can no
Each of these options has benefits and limitations. Cost,
longer drive compared with their urban and suburban coun-
access, convenience, and physical requirements may all be
terparts. Communities that are disadvantaged economically
factors in evaluating which would be most helpful to specific
may have far fewer options than more affluent ones.
individuals.
Studies have shown that few older adults use public trans-
Optimally, a program should exist to help the older adult
portation. The majority of elders use their driver licenses as ev-
explore alternatives and to develop new skills necessary to
idenced by a reported 89% of older adults trips made via private
successfully use alternative community mobility options. This
automobile (Rosenbloom, 2012). There are, however, as many
type of client-centered and community-based practice will
as 7 million adults aged 65 and older who do not drive (Houser,
help ensure the safety of the older adult and facilitate suc-
2005). Adapted vehicles can make public transportation more
cessful participation in meaningful occupations within the
accessible for older (and disabled) individuals (Figure 23-1).
community. If needed, consultation with a physical therapist
Exposure to inclement weather is a concern for elderly
might be warranted to identify and remediate physical
adults when using public transportation. Both walking to and
mobility concerns that might affect balance required to walk,
waiting for the bus in bad weather can lead to health prob-
range of motion and strength required to step onto a bus, and
lems. Also, if an individual is unable to operate a motor
other physical capacity concerns that can affect use of alter-
vehicle because of a physical impairment, chances are good
native transportation.
that he or she will be unable to ambulate the distance neces-
In the course of all these discussions, it is important to
sary to get to the bus stop or carry purchases home from the
acknowledge the psychological consequences of being unable
bus stop. Gillins (1990) noted that many elderly people are
to drive. There are certainly many ways to support mobility
concerned about their personal safety and fear harassment
through means other than driving, but none provides the
when taking public transportation.
same level of independence. Damage to self-esteem and per-
The U.S. Department of Transportation (2003) recog-
sonal identity may occur. For some people, acceptance of
nized the challenges of safe mobility for the aging population
these new limitations raises anxiety about other significant
in the United States. In its 2003 vision statement, the U.S.
losses, including the prospect of one’s own death. Addressing
Department of Transportation placed a focus on safe and re-
these feelings openly and directly may offer some comfort to
liable mobility for the aging population.
the individual.
A transportation system that offers safe mobility to
all people and allows older persons to remain inde-
Community Mobility: Some Alternative pendent and to age in place. Investments in highway
Solutions and pedestrian infrastructure and public transporta-
tion services support independence. Medical and social
More than 30 years ago, the White House Conference on
Aging recognized that transportation was the third greatest
problem for elders after poor health and poverty. Access to
public transportation for older adults continues to be a major
challenge. Affordable, accessible, and flexible transportation
options are essential for older adults so they can get to health-
care appointments and services, continue to independently
obtain groceries and other household items, and maintain
contacts with family, friends, and social organizations to pre-
vent isolation and depression (Bailey, 2004).
For people who have used a car as their sole source of
transportation, being forced to use alternative forms of
transportation can be challenging, frustrating, and anxiety-
provoking. Seeking and using alternative transportation op-
tions requires mastery of new skills, which may elicit even
more fear and frustration. For example, if an elderly person
has never taken a bus, learning to read the schedule, finding FIGURE 231 Adapted vehicles can improve accessibility in public
the bus stops, and managing entering and exiting the bus transportation. monkeybusinessimages/iStock/Thinkstock
4605_Ch23_359-366 31/10/17 12:33 PM Page 363
service communities, transportation managers, motor
vehicle administrators, and caregivers work together
to extend safe driving and to offer other convenient
and affordable transportation options when driving
and walking must be curtailed. Public and private
organizations form new partnerships to enable all cit-
izens to enjoy safe mobility for life. (p. 6)
Stated goals to achieve this vision include the following:
1. Safer, easier-to-use roadways and walkways
2. Safer, easier-to-use automobiles
3. Improved systems for assessing competency of older
drivers and pedestrians
4. Better, easier-to-use public transportation services
5. Targeted state and local action plans
6. Better public information
7. Basic and social policy research (U.S. DOT, 2003)
An important role for health-care and other professionals
is in ensuring the development of supportive environments
(Kochtitzky, Freeland, & Yen, 2011). Both social and physical
environments have an impact on community mobility (Gardner,
2014). In particular, amenity diversity (availability of parks,
food retail, service retail such as banks, recreational facilities,
leisure services such as theaters) is associated with enhanced
mobility (Rosso, Grubesic, Auchincloss, Tabb, & Michael,
2013). In contrast, environments that have been allowed to
deteriorate can interfere with mobility (Figure 23-2). Occupa-
tional and physical therapists can both assist urban planners
and architects in design of such neighborhoods and advocate
for support in their development.
FIGURE 232 Deteriorated infrastructure, including broken sidewalks,
can interfere with mobility. SBSArtDept/iStock/Thinkstock
CHAPTER 23 ■ Community Mobility 363
INTERPROFESSIONAL PRACTICE
Addressing Environmental Issues in Support
of Community Mobility
Kochtitzky and colleagues (2011) recommend that a wide array
of professionals should be involved in design of supportive
environments to enhance mobility for older adults. These
include architects, building and housing inspectors, safety
personnel, occupational therapists, urban planners, and
many others. These various professionals contribute differing
perspectives about physical characteristics (e.g., types of
materials used in construction), appearance of buildings
(fit with the natural environment, for example), and probable
use (e.g., socialization or to address instrumental needs).
Pilot programs have begun to emerge which attempt to
address community mobility issues of the older adult. For
example, the American Public Transportation Association
(APTA) launched the Easy Rider Program in 2005. The
focus of this program was to improve community mobility of
America’s aging population. The program includes the fol-
lowing components:
1. New service designs and infrastructures
2. Application of new technologies
3. Transit user training and outreach programs
4. Strategies for engaging allies and supporters
5. Execution of broad-based communications activities
6. Strategies for engaging the media on behalf of mobility
for seniors (APTA, 2005)
Another successful program piloted and now replicated in
other cities in the United States is the Independent Trans-
portation Network (ITN; http://www.itnamerica.org). Origi-
nally piloted in Portland, Maine, the ITN has been financially
viable through a collaborative model involving donated vehi-
cles, volunteer drivers, local businesses, and voucher programs.
The comprehensive program is partially supported by local
businesses allowing riders to use vouchers to travel to commu-
nity partner businesses and receive a discount on purchases
made in these establishments. All parties involved benefit when
an older adult can travel to a local pharmacy using a safe and
personal transportation system and receive discounts on pur-
chases, while the pharmacy generates a stream of clients and
revenue by supporting the ITN. The program has instituted
other innovative programs, such as voucher packages in which
adult children can purchase a night out package including
transportation to a restaurant, dinner for the traveller, trans-
portation to the theater, tickets, and transportation home.
Again, all parties benefit from this program: the business by
making a sale, the older adult by maintaining the ability to
engage with the community, and the gift purchaser by provid-
ing a gift that will be used and appreciated. The ITN business
model has been so successful federal funds have been made
available to replicate ITN in cities nationwide. Affiliated com-
munities across the United States now include ITNBluegrass,
ITNCentralCT, ITNCentralOklahoma, ITNCoastalCT,
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364 PART III ■ Active Aging: Supporting Client Activities and Participation
ITNGreaterSanDiego, ITNLanier, ITNMemphis, ITN
MontereyCounty, ITNNorthJersey, INTOrlando, ITNSouthern
Delaware, ITNStCharles, ITNSunCoast, and ITNTwinCities
(ITNAmerica, 2016).
Not all older adults are fortunate enough to have an ITN
in the vicinity, so other means of community mobility must
be identified. The obvious on-call choice of mobility would
be cab service, but depending on the frequency of travel and
population density of the area, cab service may not be the best
option. It is important for geriatric practitioners to be aware
of resources in their area that may be available to older adults
wishing to travel. Practitioners can explore the local Area
Agency on Aging, senior centers, senior housing complexes,
community transit agencies, local churches, and hospitals.
Larger scale projects have compiled statewide transportation
resources using state grant funding. An example of one such
endeavor is the Florida Senior Safety Resource Center (http://
fssrc.phhp.ufl.edu/content/find-transportation). The website
serves as a searchable database of transportation services by
county or municipality. Within each county or municipality,
services are searchable by type of route, type of schedule, and
type of service. Once the search is complete, all applicable
services are listed with name, contact information, eligibility,
hours of operation, cost, route, and other relevant informa-
tion. The database is inclusive of medical transportation systems,
wheelchair transport, community transport, public transit, senior
center transport, and private transportation companies. Prac-
titioners should compile a list of locally available resources
with hours of operation, cost, eligibility for use, and range
of travel for dissemination to clients in need. With careful
planning, seniors may be able to meet most of their trans-
portation needs; however, it is probable that they will not
have the level of independence and convenience they expe-
rienced when they could drive.
Facilitating Change in Transportation Services
Urban and suburban areas will likely have more transportation
services available, but compilation of available services in any
area will assist the practitioner in understanding where the
gaps exist to begin collaboration with local agencies to estab-
lish services. Public education to transportation providers,
social service agencies, and local businesses is critical in creat-
ing a network supportive of community mobility.
Older adults need education to encourage planning
ahead and identification of strategies to manage without a
vehicle to ultimately lessen the impact of driving cessation.
Older adults and their family members themselves can be
catalysts to development of transportation resources and
systems in any community as consumer demand for services
can spawn innovative transportation programs. Important
to the success of any community mobility program would
be promotion of new skills to allow older adults to partici-
pate in activities involving the use of available transportation
and community resources. The Well Elderly Program, de-
veloped by Jackson, Carlson, Mandel, Zemke, and Clark
(1998), would be appropriate as a method of supporting
community mobility of elders through the acquisition of new
skills within contexts. Using occupation in lifestyle redesign,
these researchers enabled the participants, community-
dwelling older adults, to explore community transportation
options by discussing individualized obstacles and inhibitory
fears regarding the use of transportation. After gathering
practical knowledge about their traveling options, the par-
ticipants embarked on several trips using buses, cabs, and the
Metro subway system. They shared their experiences, traded
tips, and motivated each other to continue using the avail-
able transportation options. These activities were completed
with trained occupational therapists throughout. Noting that
many of the participants also were afraid to even walk across
the street to the market to buy food or to the library a few
blocks away, the Well Elderly Program had the participants
practice safe community mobility techniques within the
security of occupational therapy outings. This type of pro-
gramming is essential to the successful community integra-
tion of older adults who cannot drive.
Much of the therapeutic services provided in the area of
community mobility should consider the client or beneficiary
of services at the community or population level. The system-
atic and infrastructure changes as facilitated by a geriatric cli-
nician can have far reaching benefits beyond an individual
client. There services can include the following:
■ Environmental assessment for accessibility of buses, trains,
bus stops, subway stations, crosswalks, sidewalks, and pub-
lic commerce areas
■ Consultation with automobile manufacturers to include
seating height, seating planes of movement, and handles to
enhance transfers in and out of automobiles for passengers
■ Vehicle modifications or inclusion of modifications for new
transit vehicle purchases such as kneeling buses, convertible
seating on buses, wheelchair tie-downs, and ramps
■ Modification to scheduling including longer “layovers”
between bus or train transfers to allow for transitions, later
operating hours to allow for nighttime access to the com-
munity, larger fonts on printed schedules and maps, and
app-based routing for use of technology while traveling
■ Assistance with development of paratransit eligibility
guidelines and evaluation protocols
■ Facilitation of interagency collaboration for mutually ben-
eficial transport of older adults (e.g., senior housing, local
businesses, and cultural arts venues)
Evidence-Based Practice
The AOTA has conducted systematic reviews on driving and
community mobility and one area of specific focus has been
on community mobility programs. The review of the evidence
relevant to community mobility and the older adult identi-
fied Level I, II, and III studies of the effectiveness, use, and
acceptance of community mobility training and programs.
Relatively few studies have been conducted concerning the
effectiveness of community mobility programs for older adults
compared with the volumes of studies on assessment of fitness
4605_Ch23_359-366 31/10/17 12:33 PM Page 365
to drive and improving driving safety. One study (Freund,
2002) supports the use of an integrative transportation pro-
gram for seniors designed to meet the needs of the older
adult, family members who were concerned about community
mobility, and merchants. Paid transportation services were
provided to transport older adults to area businesses. Partici-
pants were satisfied with the program (Freund, 2002). In a
study of the effectiveness of travel training programs, Stepa-
niuk, Tuokko, McGee, Garrett, and Benner (2008) found that
older adults who received group transit training use the bus
more frequently compared with those who received classroom
training. More needs to be done in this area to explore different
models of community mobility programs and the efficacy on
how these impact the quality of life, community integration,
and social participation of the older adult (Stav, 2014).
There is also at least some evidence that various other forms
of direct intervention can support community mobility. For ex-
ample, a systematic review by Ross, Schmidt, and Ball (2013)
found that cognitive and exercise-based interventions can en-
hance community mobility. There was mixed support for the
value of educational interventions. Many sources ranging from
medical professionals and health-care providers, to social sci-
entists, policy makers, and government officials note, that the
transportation and mobility needs of an ever-increasing aging
population has emerged as an issue that demands well-designed
and purposeful solutions. Despite the overwhelming need, there
is evidence of only slight change and progress on this issue.
Consideration of how any solution would be administered and
paid for are of paramount concern, but perhaps the greater chal-
lenge will be confronting the fact that we live in a society and
culture that is built around private-car ownership. Our roadways
and communities have been designed with the assumption that
Americans own and operate their own vehicles. Addressing the
community mobility issues of the older adult will call for a major
paradigm shift. The costs involved in these changes are relatively
small compared with the cost of providing transportation for
this growing segment of the population. These types of im-
provements would help preserve the aging person’s independ-
ence and dignity and, at the same time, allow them a more
active role in society.
SUMMARY
Community mobility is an important occupation because it
allows for older adults who do not wish to or can no longer drive
to continue to access the community. Community mobility and
transportation alternatives become increasingly important as the
population ages and individuals experience difficulties related
to functional declines and must transition from driving. Assess-
ment of the older adult’s ability to access and use transportation
in addition to assessment of the community environment is
necessary to determine whether the older adult can travel in the
community safely and independently. Clinical assessments
may be used, but in vivo assessments in the community will ide-
ally identify the ability to use transportation resources. Services
provided by a geriatric practitioner may focus on an individual
client but may also be organization, community, or population
CHAPTER 23 ■ Community Mobility 365
based to modify the system, infrastructure, or available resources
in support of community mobility for all older adults and those
active in the community.
CASE STUDY
Arthur McCall is an 80-year-old retired machinist. He
lives alone following the death of his wife 2 years ago.
Mr. McCall’s married daughter lives about an hour away;
his married son lives abroad with his family. Mr. McCall
has been in good health until fairly recently and has par-
ticipated in a rich array of activities. He goes to the local
senior center twice a week to play bingo, meets friends at
McDonald’s every morning to have a cup of coffee, and,
since his wife’s death, he has learned to grocery shop.
Recently, he began to have significant difficulty with
his vision. His ophthalmologist diagnosed cataracts, which
the physician indicated could be removed surgically.
Mr. McCall has also developed considerable neck stiffness
and, quite recently, has begun to forget to eat and grocery
shop. He has had several recent “fender-benders” and his
daughter is concerned about his safety driving.
Questions
1. How would you know if Mr. McCall is able to drive
safely?
2. If the results of Mr. McCall’s evaluation suggest he
should stop driving, what would be appropriate next
steps?
3. What are some potential resources that might help
Mr. McCall continue the activities he values?
Critical Thinking Questions
1. In what ways might the need to give up driving affect
an older individual’s emotional status?
2. What other consequences might an older adult be
affected by the need to stop driving?
3. How might driving cessation have differing effects
for individuals who live in urban, suburban, and rural
settings?
4. What other environmental barriers might make
alternative means of community mobility difficult?
5. How might new technologies contribute to main-
taining community mobility?
6. What are reasonable expectations for family participa-
tion in solving an older adult’s community mobility
concerns?
7. What specific research would be helpful in informing
policy planning with regard to community mobility?
4605_Ch23_359-366 31/10/17 12:33 PM Page 366
366 PART III ■ Active Aging: Supporting Client Activities and Participation
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Interactions, Relationships, and Sexuality
Bette Bonder
“Those who love deeply never grow old; they may die of old age, but—Arthur
LEARNING OUTCOMES
By the end of this chapter, readers will be able to:
1. Discuss the importance of social occupations in the lives
of older adults.
2. Describe typical social networks of older adults.
3. Discuss the concept of reciprocity.
4. Describe typical family occupations in later life.
5. Identify cultural myths about sex and older adults.
6. Describe how demographics, health status, and health care
affect the sexual activity and sexual satisfaction of older
adults.
7. Describe strategies for responding to clients’ concerns
about sexual issues.
8. Discuss the nature and processes of informal caregiving.
9. Discuss strategies for establishing therapeutic interactions
with elders and families.
Clinical Vignette
Manny Alvarez is a 72 year-old retired postal carrier. He lives
in a well-tended bungalow in a suburb of a large Midwestern
city, the same house in which he and his wife of 40 years
(now deceased) raised their four sons. Mr. Alvarez spends a
good bit of time sitting on his front porch chatting with his
neighbors. The 93-year-old woman right next door has been
the beneficiary of his handyman efforts, and he usually cuts
her grass in the summer. Of his four sons, two live in the
same city, and they stop by frequently with their children to
visit. From time to time, Mr. Alvarez looks after the grand-
children while his sons and their wives take vacations or when
the boys are out of school on a workday.
1. What strengths do you see in Mr. Alvarez’s social net-
work? How do these strengths contribute to his quality
of life?
2. What concerns might you identify in thinking about
Mr. Alvarez’s current and future social needs?
S ocial interactions and occupations play a prominent role
in the lives of elders. A huge body of literature discusses
CHAPTER 24
■ Cynthia Hovland-Scafe
they die young.
Pinero
”
the importance of family and friends in promoting positive
aging, quality of life, and well-being (Chappell & Funk,
2011). To be effective in providing services for older adults,
it is essential to understand the diversity of social networks
and families that include older adults, both in terms of structure
and occupations. Factors associated with positive social in-
teraction in later life include long-standing good relationships
with family and friends (Choi, Yorgason, & Sohnson, 2016;
J. K. Wolff, Lindenberger, Brose, & Schmiedek, 2016), abil-
ity to help others (Bulanda & Jendrek, 2016; Greenfield,
2009), sense of spirituality (Krause, 2003), and established
intergenerational networks (Bulanda & Jendrek, 2016).
It is clear that elders with strong social networks age best,
but it is also clear that they face various challenges in main-
taining satisfying relationships and coping with the inevitable
changes wrought by the aging process. Friends and family
move away or die. Elders become more limited in the abilities
required to sustain relationships, including community mo-
bility that facilitates interaction and hearing required to com-
municate effectively. Increased societal mobility means that
adult children may live far away. Financial limitations that
result from policy and pension changes may lead to reduced
opportunities for interaction.
There are many misconceptions about the relationships
between older adults and younger people (Binstock, 2010).
Dependency ratios (i.e., the number of older people depend-
ent on younger adults) are often used as a way to indicate who
provides help and who receives it. Some projections indicate
that as the population ages, the dependency ratio will grow.
This assumes, however, that everyone older than 65 years of
age is dependent, an assumption that is patently false. In fact,
individuals now reaching their later years are healthier and
more functional than those who preceded them (Velkoff, He,
Sengupta, & DeBarros, 2006). If this trend continues, the
dynamics of family interactions will also continue to change.
Family relationships are most typically characterized by
reciprocal roles. Older adults provide considerable care for
younger generations in terms of financial, emotional, and
instrumental support (Bonder, 2006). Family members who
provide care may find their contributions to the well-being
367
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368 PART III ■ Active Aging: Supporting Client Activities and Participation

of elders to be emotionally satisfying because this provides
an opportunity for more balance in relationships (Roth,
Dilworth-Anderson, Huang, Gross, & Gitlin, 2015). In
spousal caregiving relationships, women caring for a spouse
reported enhanced well-being, signifying they may derive an
increased sense of “meaning and accomplishment” from care-
giving, whereas men did not associate caring for a spouse with
well-being (Freedman, Cornman, & Carr, 2014, p. 861).
There is growing recognition of the importance of the role of
custodial grandparents and grandparents as occasional care-
givers and the contribution they make to the functioning of
the family (Hayslip, Blumenthal, & Garner, 2015; Laughlin,
2013; Musil, Warner, Zauszniewski, Jeanblanc, & Kercher,
2006).
The importance of family to all generations is reflected in a
large body of research (cf. Becvar, 2013; Rowland, 2012).
However, there is a temptation for health-care providers and
researchers to focus on caregiving, usually framed in terms of
care received by the older adult and provided by adult children
or spouses (Binstock, 2010). Although at some point in the
life cycle elderly persons may require care due to growing de-
pendency, they also provide care for each other and for younger
generations (Thomas, 2010). Furthermore, although demo-
graphically many middle-aged individuals are “caught in the
middle,” in point of fact, relatively few are providing active care
for their older family members at any given time (Brody, 2004).
Because social interaction generally, and family in partic-
ular, is so central to older adults, effective care can be pro-
vided only when social interactions and their dynamics are
well understood. This chapter considers the research on social
and family constellations and occupations in later life. This
includes a discussion of spousal relationships and sexuality
in later life, as well as the therapeutic interventions that can
support positive interactions.
Social Relationships in Later Life
As people age, their social networks shift, although it
seems that most elders maintain dense and diverse relation-
ships (Cornwell et al., 2008). Litwin (2001) described a
model including five network types: diverse, friends, neigh-
bors, family, and restricted (Table 24-1). Diverse networks
reflect the widest array of relationships among friends, family,
and neighbors and are associated with high morale, as are
friend networks. Individuals who have exclusively family net-
works or restricted networks have the lowest morale. These
findings support the importance for elders of establishing a
variety of relationships (Figure 24-1).
Social networks are important both because of the
support they can provide for the elder and because of the
opportunities they afford for elders to help others (Bulanda
& Jendrek, 2016; Greenfield, 2009). Such opportunities
contribute to elders’ self-esteem. This mutuality or reci-
procity is an important component of social occupations
both with family members and with other social contacts
(Gruenewald, Liao, & Seeman, 2012; Thomas, 2010), a
TABLE 241 ■ Family Network Typology
NETWORK TYPES DESCRIPTION
Diverse Social network includes a wide array of individuals
with varying relationships to the individual
Friends Social network includes primarily unrelated
friends
Neighbors Social network includes primarily unrelated
individuals living in close proximity
Family Social network includes primarily related
individuals (blood relations, in-laws)
Restricted Social network is limited, without relationships
to friends, neighbors, or family
Source: Litwin (2001).

Social networks are vital in later life (Miche, Huxhold, &

Stevens, 2013; Windsor, Fiori, & Crisp, 2011). Adequate
social support is important to avoiding depression (Djundeva,
Mills, Wittek, & Steverink, 2015; Greenfield, 2009) and
loneliness, assistance with instrumental needs, sustaining a
sense of connection through the ability to provide reciprocal
support, and personal control (Cornwell, Laumann, &
Schumm, 2008). Elders who have strong social networks
enjoy better health (Greenfield, 2009). They are less likely to
experience cognitive and functional decline and more likely
to live longer (Chappell & Funk, 2011). Social relationships
can ameliorate some of the negative effects of low socioeco-
nomic status, even though there is evidence that individuals
from lower socioeconomic circumstances have somewhat
smaller networks than better educated and more affluent
FIGURE 241 Intergenerational activities can be meaningful for
individuals (Ajrouch, Blandon, & Antonucci, 2005), but they everyone involved. Photo courtesy of Benjamin Rose Institute,
also report more positive characteristics of the caregiving Cleveland, Ohio. Reprinted with permission. Lucky Business/iStock/
experience (Roth et al., 2015). Thinkstock
4605_Ch24_367-382 31/10/17 12:32 PM Page 369
finding that is consistent across cultures (cf. Antonucci,
Ajrouch, & Abdulrahim, 2014; Samanta, Chen, & Vanneman,
2014).
Building and sustaining social relationships require various
skills that ideally have been acquired over the life course.
However, late life presents unique challenges, particularly
in terms of ongoing loss. As discussed later in this chapter,
interventions to assist elders in adding to their social networks
as they cope with loss can be a meaningful and sometimes
vital contribution of occupational therapy. Furthermore,
families must be taken into consideration in developing
intervention plans for occupational therapy, physical therapy,
and other disciplines working with older individuals because
family support and assistance can be the difference between
success and failure of those plans.
Elders look to family for a variety of important purposes
(Bonder, 2006). They value opportunities to pass along a
legacy, to enjoy time together, and to continue to feel valued
and useful. They tend to look first to family at times when
they need emotional or instrumental support. On the other
hand, not all family interactions are positive, and in some
circumstances, family can be a source of considerable stress.
Family relationships in later life are affected by individual
histories with family, gender, cultural values, and many other
factors.
Gender differences in roles and experiences are impor-
tant issues for aging families (Carstensen, 2001). Over their
life span, women tend to experience more personal disabil-
ity and need more personal assistance than their male
counterparts (Brody, 2004). They are also more likely to
be sole caregivers for spouses, grandchildren, and other
family members and less likely to hire assistants to help
with these tasks. Although role flexibility has increased
in the United States, women still experience considerable
role strain and conflict as they juggle responsibilities
as workers, parents, and caregivers for their own parents.
Remarkably, while social relationships and support advan-
taged men during middle age, women experience significantly
more social support and connection in later life (Fischer &
Beresford, 2014). As women’s roles continue to evolve, it
will be important to continue the process of identifying
emerging concerns.
Other social issues change the nature of family interactions
and social support. The growth of new family constellations
including stepfamilies has increased the complexity of family
dynamics (Ganong & Coleman, 2006). It is increasingly
common for elders to marry or remarry, introducing new
relationships to the family late in life (Wu, Schimmele, &
Ouellet, 2015). Another trend that alters family dynamics is
the increase in cohabitation among older adults (Noël-Miller,
2011). Some elders choose this option because of policy
limitations on pension funds from a previous marriage if a
remarriage takes place. Others do so because they worry
about the estate implications of a remarriage. Adult children
and other family members may be uncomfortable or even
hostile about the arrangement.
CHAPTER 24 ■ Interactions, Relationships, and Sexuality 369
Culture and Family
Cultural and ethnic backgrounds also affect family dynamics
and expectations (Mahoney, Cloutterbuck, Neary, & Zahn,
2005). For example, the norm in the United States is to have
nuclear families co-reside, with elders living elsewhere, some-
times even at considerable distance. In contrast, in Maya
villages in Highland Guatemala, extended families live to-
gether in homes that are expanded to accommodate multiple
generations. Elders in these settings have responsibility for
assisting with child care and household tasks for as long as
they are physically able to do so. When they become unable
to contribute, their adult children and grandchildren provide
the care they need.
The belief that many Asian cultures revere elders is accu-
rate historically (Sung, 2000). Family networks are associated
with psychological well-being for Chinese elders (Cheng &
Chan, 2006). This sense of well-being is improved in situations
where there are intergenerational transfers of resources
and support (Antonucci et al., 2015; Samanta et al., 2015),
emphasizing the importance for older adults of being able
to do for others. Current social trends have altered family
dynamics, requiring adaptation on the part of each generation
(Brown & Lin, 2012). For example, in 2000, Japan intro-
duced a long-term care insurance system rendering long-term
care a right for elders regardless of family readiness or
finances (Tsutsui, Muramatsu, & Higashino, 2013). Analysis
of this movement indicates a decreased sense of “filial obli-
gation, or perceived norms of children’s duties toward their
aging parents” (Tsutsui et al., p. 797).
In Scandinavia, by contrast, the existence of a social
welfare system has reduced the extent to which family mem-
bers may feel responsible for caring for family members
(Lin, 2005).
AROUND THE GLOBE: Social Networks
■ Compared with European, non-Mediterranean countries, older
adults in Mediterranean countries had larger families and more
social exchange (Litwin, 2009).
■ Social support delayed the trajectory to frailty among older
Mexican Americans (Peek, Howrey, Ternent, Ray, & Ottenbacher,
2012).
■ Older adults in the Netherlands spent comparable amounts of
time with their adult biological and stepchildren (van der Pas &
van Tilburg, 2010).
■ In China, there is a growing trend toward “skip” households in
which elders live with their grandchildren (Korinek, Zimmer, &
Gu, 2011).
Family Constellations
Among the relationships that must be considered for older
adults are spousal units, siblings, nuclear families including
adult children and grandchildren, extended family (nieces,
cousins, aunts), and fictive kin (neighbors and friends who
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370 PART III ■ Active Aging: Supporting Client Activities and Participation
have both instrumental and emotional relationships with the
individual; Suanet, van Tilburg, & van Groenou, 2013). In
some cultures, family may include honorary members with
particular roles—godparent, for example.
In addition, family structures are not static. New people
enter families through marriage, birth, and expanding net-
works of friends. At the same time, people die, divorce, and
drop out of sight. Such losses are characteristic of the family
lives of elders and can be quite stressful for the individual,
although memories of important loved ones can also be a
source of comfort.
Growing older does not alter long-standing family inter-
actions (Percy, 2010). Families that were characterized by
close relationships will continue to have such interaction, even
when they are geographically distant. In families in which
conflict has been long-standing or interpersonal relationships
strained, these difficulties will persist and will characterize
family relationships in later life as well, unless active steps
are taken by family members to resolve them (Table 24-2
summarizes family structures).
The trend toward having fewer children also has an impact
on family functioning. The current generation of elders often
had three or more children, but the more typical pattern for
the baby boom generation is one or two children, meaning
fewer adult children are available to provide care. Of course,
this also means fewer adult children and grandchildren to
whom elders may be responsible. As was noted in Chapter 1,
the impact of these kinds of societal trends is difficult to
ascertain because many factors interact. The reduced avail-
ability of adult children to provide care may well be counter-
balanced by the increased physical health and reduced
disability of the generation about to enter later life.
The increasing geographic mobility of individuals and
families has significant consequences for family interactions.
Older adults may migrate to more moderate climates or may
choose to live in two places (e.g., “snowbirds”). Some elders
also migrate back to their original places of residence when
it becomes necessary to secure instrumental support because
families are so often seen as the first resort when such care is
needed. Adult children also move as educational and work
TABLE 242 ■ Family Relationships
FAMILY STRUCTURE DESCRIPTION
Nuclear Parents and their children
Extended All relatives, including grandparents, siblings,
nieces and nephews, in-laws, and so on
Fictive Individuals who assume family-like interactions
by choice, through long-standing friendships
and other close interaction
Family of origin One’s parents, siblings, and other older
relatives, living and dead
Source: Karuza et al. (1982).
opportunities require. Thus, families may be quite far-flung,
and whatever geographic realities are true at a given point in
time may change.
Family Occupations
In the United States, elders engage in a wide array of occu-
pations with their families (Bonder, 2006). These incorporate
most performance areas as well as the patterns in which these
occupations are clustered. In all of these, there is the potential
for exchange and reciprocity. So, for example, in activities of
daily living, elders might help their grandchildren learn to
manage self-care. An older adult might need help washing
his or her hair or cutting toenails, with an adult child (most
often a daughter or daughter-in-law) providing this assis-
tance. In the area of instrumental activities of daily living, an
elder might rely on adult children for transportation or to
manage home maintenance. The same elder might teach an
adult child to cook a favorite family recipe. Shopping together
might be considered an instrumental activity of daily living
or might be a leisure or social outing for both the elder and
his or her family members.
Play and leisure occupations are common among families.
Spending time together in pleasurable activities is a frequently
identified occupation mentioned by family members of
every generation. Going to movies, traveling, playing games
with grandchildren, and sharing holiday meals are all areas
of occupational performance that are often shared. These
performance areas offer many opportunities for reciprocity
because the elder may host a gathering or may be invited to
join children and grandchildren on an outing.
Social participation is an aspect of all these occupations,
and it is one of the most salient elements of family engage-
ment for each generation. Interaction with younger family
members can ameliorate the sense of loss when contempo-
raries die. Here, too, there is the opportunity for reciprocity
because children and grandchildren may benefit from the
wisdom and experience of their older family members.
Grandparenting may be enacted in unique ways in different
cultures (Hayslip, 2009). In Native American families, an
important role is as a “ceremonial grandparent” (Weibel-
Orlando, 2000), whereas in Mexican American families, the
grandparent may label himself or herself a “provider” rather
than a grandparent (Williams, 1998).
Many of these occupations carry elements of habits and
routines (Silverstein, 2006). For every generation, important
family traditions provide emotional comfort and an element
of predictability and safety in an unpredictable world. Family
gatherings for holidays, for example, are frequently treasured
by family members of every generation. Even family dis-
agreements may carry an element of tradition. So a holiday
spent together, complete with family friction, can be deeply
meaningful to each generation.
Family occupations require shifting roles over time.
Becoming a grandparent, a caregiver, or a widow all convey
particular meanings. Some of these roles must be learned
4605_Ch24_367-382 31/10/17 12:32 PM Page 371
through experimentation or observation. The observational
aspect of this learning may reflect family members long dead,
as new grandparents remember their own grandparents and
the ways in which they interacted.
In modern times, a wide array of new family constellations
has arisen. Some individuals have chosen to raise children
outside of marriage (Johnson & Favreault, 2004), a decision
that can have long-term negative consequences for financial
stability. Some individuals never have children—sometimes
by choice, sometimes not (Koropeckyj-Cox & Call, 2007).
Family also includes siblings, and elders may have positive
social relationships with siblings and may be called on to
provide care.
Some older adults do not have adequate support from
family (Cramm, van Dijk, & Nieboer, 2012). Adult children,
if any, may be at an emotional or geographic distance. The
older individual may live in Florida, while their adult children
live in Nebraska. Individuals who do not have family to
provide support must look to neighbors, friends, and social
service agencies. Many moderating factors related to the
individual, his or her culture, societal conditions, and other
factors affect social interaction in later life.
Grandparenting
As briefly discussed earlier, grandparenting is a unique family
role for older adults. There is no question that it is a role that
has great importance in the lives of elders and that this occu-
pation may encourage well-being for grandmothers and
grandfathers alike (Reitzes & Mutran, 2004). Grandparent-
ing takes many forms (Bulanda & Jendrek, 2016; Devine &
Earle, 2011), offering opportunities for meaningful leisure
and enjoyable interaction. Grandparents may take children
on outings or travel with them or may enjoy playing with
them and telling stories (Bonder, 2006).
In many families, grandparenting involves providing a
direct service through child-care activities. This may be in-
frequent, as in the case of one woman who looked after her
grandchildren when they had snow days at school (Bonder,
2006), or the grandparent may provide child care on a regular
basis while adult children are at work.
The most intensive grandparenting comes in those cases in
which the grandparent is raising a grandchild or grandchildren
(Minkler & Fuller-Thomson, 2005). More than 2.7 million
grandparents have grandchildren living with them (U.S.
Census Bureau, 2011). Of these 51.1 percent are white not
Hispanic, 24.2 percent are African American, and 18.7 per-
cent are Hispanic/Latino. Almost 20 percent live in poverty
(GrandFacts, 2010).
Elders from minority or disadvantaged backgrounds are
more likely to be custodial grandparents and also to lack
wide social networks that might provide support. Custodial
grandparenting carries both costs and benefits (Laughlin,
2013), and although it can promote a sense of well-being, it
can be problematic in families already struggling with dys-
function. There is little training for custodial grandparents;
CHAPTER 24 ■ Interactions, Relationships, and Sexuality 371
occupational therapy intervention may provide mechanisms
for building skills.
AROUND THE GLOBE: Culture and Grandparenting
■ In the United States, justifications for caregiving among white,
Asian American, and Native Hawaiian grandparents raising their
grandchildren differed, with Hawaiian grandparents more
focused on custom than whites or Asian Americans and more
focused on responsibility than Asian Americans (Yancura, 2013).
■ In China, high-intensity care for young grandchildren
accelerated health decline for the elders, whereas light-intensity
care had a protective effect (Chen & Liu, 2012).
Special Circumstances
Not every older adult has a traditional family structure. Gay
elders are less likely than others to have children. For these
individuals, family networks include extended family and
fictive kin (Suanet et al., 2013). As is true for other childless
individuals, there is an increased risk of loneliness and
depression. However, childlessness is not necessarily a cause
of isolation or sadness. Perhaps a more important issue is the
presence or absence of a long-term partner because gay indi-
viduals are affected by absence or loss of a partner in much
the same way as other individuals who become widowed.
Another unique concern is present in families with adult
children with developmental disabilities (Decker & Hull,
2005). Elders may have ongoing responsibility for providing
financial, instrumental, and emotional support for their
children. They may find this to be particularly stressful if there
are no extended family members whom they feel they can
count on to provide support. In addition, some individuals
with developmental delay start to show signs of aging, in-
cluding dementia, at a younger age than is typical for others.
Thus, parents who are themselves aging may have to help
adult children who are dealing with the same issues.
Spousal Relationships and Widowhood
One of the most important social relationships in later life is
that with one’s spouse. The vast majority of today’s cohort
of elders is or has been married. Spousal relationships provide
companionship and emotional and instrumental support
(Szinovacz & Davey, 2004) and can be extremely reward-
ing in later life. Marriage is associated with better health
(McFarland, Hayward, & Brown, 2013) and less loneliness
and depression (Bookwala & Jacobs, 2004; Pinquart, 2003).
Of course, not all marriages are created equal, and where
long-standing problems exist, they are not likely to disappear
in later life (Gierveld, van Groenou, Hoogendoorn, & Smit,
2009). Divorce is not unheard of late in life (Avison &
Davies, 2005; Cummings, 2005), and it can bring financial
and emotional stress. In addition, developmental changes
like retirement can lead to challenges in establishing new
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372 PART III ■ Active Aging: Supporting Client Activities and Participation
patterns in relationships. A nonworking spouse may struggle
to adjust to having a retired spouse at home and (potentially)
underfoot.
Without doubt, however, the greatest challenge in the
marital relationship is death of a spouse. The initial adjust-
ment is fraught with difficulty (Utz, Caserta, & Lund, 2012).
For both men and women, the loss of companionship and
instrumental support can be devastating, at least initially.
During the initial adjustment, newly widowed individuals
report poor health and swings in emotional well-being
(Schaan, 2013). Widowhood increases the risk of nursing
home admission (Noël-Miller, 2010). It is important for care
providers to realize that the duration of the adjustment is
highly variable, often taking a year or more.
Several factors predict adjustment and long-term well-
being (Black & Santanello, 2012), including the family
worldview that ascribes meaning to relationships. Higher
socioeconomic status, religious and spiritual resources, and
social resources are important in ensuring adaptation. Widowed
adults who are able to increase their reliance on other sources
of social support, such as volunteer activities, tend to fare better
(Donnelly & Hinterlong, 2009). High initial distress is associ-
ated with worse adjustment (Boerner, Wortman, & Bonanno,
2005). The quality of the marital relationship does not predict
the extent of initial grief or long-term adjustment (Gierveld
et al., 2009), reinforcing the finding that problematic relation-
ships can be better than none for some individuals.
The choice about whether to remarry carries its own
unique challenges (Koren, 2011; Wu et al., 2015). In most
developed countries, women are less likely to remarry because
of demographic realities. In addition, women are more likely
to eventually adjust to being alone, increasing their partici-
pation in other social activities (Donnelly & Hinterlong,
2009) and perhaps finding pleasure in a newfound freedom.
Men, in contrast, are very likely to remarry relatively quickly,
both because of social pressures and their own wish to have
a companion and helper.
Implications for Intervention
Given the centrality of social occupations to quality of life in
later life, therapists can be helpful in ensuring that older adults
have the skills needed to maintain and expand their social
networks. Such efforts have demonstrated value in supporting
positive aging both in the community (Clark et al., 2011)
and in long-term care facilities (O’Sullivan & Hocking, 2006).
These interventions can be provided through various strategies
identified in the Occupational Therapy Practice Framework
(3rd ed.; American Occupational Therapy Association, 2014),
including therapeutic use of occupations and activities, consul-
tation, education, and advocacy in Promoting Best Practice.
✺ PROMOTING BEST PRACTICE
Supporting Social Engagement
The Well-Elderly Study (Clark et al., 2011) was a randomized
controlled trial of a community-based intervention that
provided group sessions to address daily living topics (time use,
safety, personal finance, and social relationships, among other
topics). A total of 187 program participants and 173 control
group participants were evaluated in the 2011 wave of the
study. The trial showed positive outcomes in terms of mental
and physical well-being.
Sexuality and Aging
An important consideration in later life is the role of
sexuality. As is true for younger individuals, older adults
have varying wishes about their sexual activities. Although
some have diminished or absent interest, “older adults
consistently identify sexual well-being as integral to overall
quality of life” (Syme, Klonoff, Macer, & Brodine, 2012,
p. 232).
Views of late-life sexuality are often based on stereotypes
that sex after 50 either does not exist or that it is beset by
dissatisfaction and dysfunction (Sharpe, 2004). Older women
and men are seen as asexual or, if they do show an interest in
sex, as “dirty old men or women.” It is not only young and
middle-aged but also older people themselves who are often
negative about the prospects of continued sexual interest and
ability. Many simply assume that the game is over. The fact
is that we have lifelong sexual feelings, interest, activity, and
capacities (Waite, Laumann, Das, & Schumm, 2009).
Defining Sexuality
Sexuality includes the way we think about ourselves as sexual
beings and the corresponding gender roles and behaviors, the
need for intimacy, ideas about reproduction, and the feelings
of excitement and pleasure that are associated with sex
(Mohan & Bhugra, 2005). Sexuality also includes the entire
range of sexual behaviors as well as the decision to be celibate
and is an important aspect of activity and participation. Many
older adults spend more time hugging and cuddling, fondling,
and caressing to express their affection. In any discussion of
sexuality in late adulthood, we need to maintain a broad
definition of sexuality that will allow us to perceive existing
sexual behaviors more accurately and to provide appropriate
professional assistance. The couple in Figure 24-2 clearly
enjoys each other’s company, regardless of whether their
closeness involves sexual intercourse.
Unfortunately, the opportunity to develop or maintain
intimate relationships is a problem for many elders. There is
a significant gender imbalance in late adulthood, making it
difficult for older heterosexual women to find a sexual partner
(Waite et al., 2009). By age 75, only about 40 percent of
women have a current partner, compared with 78 percent of
men. Only half of older African Americans report having a
regular sexual partner compared with roughly two-thirds of
other racial/ethnic groups.
It should be noted that although there is relatively less
research on sexuality outside the United States, evidence from
China (Guan, 2004) and the United Kingdom (Gott, 2005)
4605_Ch24_367-382 31/10/17 12:32 PM Page 373
FIGURE 242 Couples who have been together for a long time
can find pleasure in a variety of close or intimate activities.
Witthaya/iStock/Thinkstock
suggests that many issues with regard to sexuality in later life
are universal.
Life-Stage Effects
Many older people find themselves alone after the death
of a longtime spouse or companion. This means that the
opportunities for sex, other than self-stimulation, may be
decreased.
The problem is even more pronounced in nursing homes,
where residents tend to be treated as sexless beings by staff,
and sexual activities may be actively discouraged (Regas,
2012). Although they may recognize the residents’ rights to
sexual expression, those in the nursing home industry have
pragmatic concerns that often take precedence. These include
privacy issues as well a concern that patients might physically
hurt themselves, a concern for what is acceptable to patients’
families, as well as concerns about the possibilities of litiga-
tion. When dementia is a factor, there also is a concern about
mutual consent (Tarzia, Fetherstonhaugh, & Bauer, 2012;
Wilkins, 2015).
Declining health with associated decrements in perform-
ance skills can be a significant barrier to sexual fulfillment for
older people (Syme et al., 2012). In fact, older men and
women report that better health for themselves and their
partners is among the most important factors for improving
their sexual satisfaction. Moreover, those who have a health
problem that negatively affects their sexual relationships do
not necessarily seek professional treatment.
Gays and Lesbians in Older Adulthood
Gay and lesbian elders struggle with the same issues about
sustaining sexual occupations in life that characterize other
populations (MetLife Mature Market Institute, 2010). Many
CHAPTER 24 ■ Interactions, Relationships, and Sexuality 373
older gay men maintain both their interest in sex as well
as their ability to function sexually (Kleinplatz, Ménard,
Paradis, Campbell, & Dalgleish, 2013). They may also have
unexpectedly restricted social networks because of the HIV
epidemic of the late 1980s and early 1990s (Rosenfeld,
Bertlam, & Smith, 2012). Lesbian women are also interested
in continuing their sexual activity but focus increasingly on
stability and continuity of the relationship overall (Averett,
Yoon, & Jenkins, 2012). It is important to remember that
elders have as many ways of demonstrating their personal
sexual choices as do younger individuals. An attitude of
acceptance is essential in working with elders, as is true in
any clinical situation.
Sexual Attitudes and Behaviors of Older Adults
The main predictors of sexual satisfaction for older adults
were being sexually active, having good mental health, and
having good functional health status. Among individuals
aged 57 to 64, 61 percent of women and 83 percent of men
were sexually active based on findings from one study (Waite
et al., 2009). By age 75, only 17 percent of women were
sexually active, compared with 38 percent of men. Sexual
expression was identified as a component of satisfaction with
partner relationships.
Age-Related Physical Changes and Sexual
Functioning
Certainly, older adults are more susceptible to many disabling
medical conditions such as cardiac problems and arthritis, as
well as normal aging changes that may make the expression
of sexuality difficult due to changes in performance skills as
well as body structures and body functions. In addition, the
treatments used for medical conditions may hinder the older
adult’s sexual response. Those in late adulthood may experi-
ence a decrease in physical energy, along with increases in
physical discomfort, which may affect the desire and capacity
for sexual activities (Karraker, DeLamater, & Schwartz,
2011). However, the need for intimacy, excitement, and
pleasure continues throughout the life span, and there is
nothing in the normal biology of aging that would preclude
the ability for sexual activity.
Physical Changes in Men
There are several sexual changes that occur as men age,
including a decrease in the production of testosterone. Men
in late adulthood may notice that it takes longer to get an
erection than when they were younger, and many older men
need more manual or oral stimulation of the penis to produce
an erection. Moreover, the erection may not be as firm or
as large as it was when the man was younger (Goldstein,
2004). A man also may experience a longer time before
ejaculating. The proportion of men who have tried potency-
enhancing medicines, hormones, or other treatments has
doubled since 1999.
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374 PART III ■ Active Aging: Supporting Client Activities and Participation

Physical Changes in Women

BOX 241 Some Illnesses That May Affect Sexual Arousal
The common physical changes that affect women’s sexuality or Desire
result from lowered levels of estrogen hormones after
menopause. Postmenopausal women usually experience ■ Testosterone or estrogen deficiency caused by aging,
a decrease in vaginal lubrication, which may make coitus disease, surgery, or injury
uncomfortable. Nonprescription vaginal lubricants are readily ■ Cardiac disease, including coronary artery disease,
available and effective for this problem. Moreover, women postcoronary recovery, high blood pressure
may experience orgasms that are less dramatic. A somewhat ■ Liver problems including hepatitis, cirrhosis
surprising result of more men using medication for erectile ■ Kidney problems including nephritis, renal failure, dialysis
dysfunction is the increased pleasure the men’s use of these ■ Pulmonary diseases
treatments is giving their female partners, no matter what ■ Degenerative diseases
their age—a finding that challenges the belief that older ■ Thyroid diseases
women are not all that welcoming of their partner’s new- ■ Head injuries
found ardor (American Association of Retired People, ■ Psychomotor epilepsy
2005). Table 24-3 summarizes age-related changes in sexual ■ Chronic obstructive pulmonary disease
response.

Effects of Disease and Other Factors

associated with arthritis may interfere with sexual activity
on Sexuality
(Abdel-Nasser & Ali, 2005). Pulmonary diseases are not
Many conditions and illnesses common among those in uncommon in later life. Individuals who have smoked are
late adulthood can affect body systems and body functions particularly at risk, but others may develop chronic obstruc-
necessary for participation in sexual activity (Karraker et al., tive pulmonary disease (COPD) as well. Individuals with
2011). Moreover, some chronic conditions slowly take their COPD are likely to tire easily, so that sexual activity may
toll on affected individuals’ capacity to enjoy certain sexual result in excessive stress or fatigue (Collins et al., 2012). Note
activities (Box 24-1). that many of these are issues that can be addressed in physical
Men who have vascular problems may not get enough therapy during intervention focused on physical capacity.
blood flowing to the penis, which can lead to erectile dys- Excessive alcohol consumption may adversely affect sexual
function. Men and women with diseases of the heart and arousal and sexual performance at any age. Although some
cardiovascular system (which include angina, high blood people report that the use of drugs and alcohol make them
pressure, heart failure, abnormal rhythms of the heart, and feel less inhibited and freer to enjoy sex, acute or chronic use
aortic stenosis) need to take reasonable precautions before of alcohol and drugs can inhibit sexual desire, performance,
resuming sexual activity. Cerebrovascular diseases may and satisfaction in men and women. Abuse of alcohol and
commonly result in sexual dysfunction, leading to a decrease drugs almost inevitably contributes to sexual problems not
in sexual activity. Psychological and social factors seem to only directly but also by affecting emotions and straining
exert a strong impact on sexual functioning and the quality relationships.
of sexual life after stroke (Bodenheimer, Roig, Worsowicz, As many as 400 prescription medicines are known to cause
& Cifu, 2004). The pain, stiffness, fatigue, and limited ability at least occasional problems with sexual desire and function.
Sometimes the problem is not with a single medication but
may be a reaction to two or more medications taken in com-
bination. Table 24-4 shows common medications with sexual
TABLE 243 ■ Normal Age-Related Changes in Sexual side effects.
Response Many types of surgery can cause short-term sexual difficul-
ties. Surgeries that involve sexual organs or glands may have
WOMEN OR FEMALE MEN OR MALE
long-term sexual effects; however, some common surgeries are
Arousal Delayed lubrication Delayed and less firm often inaccurately assumed to cause inevitable sexual impair-
Decreased Bartholin erection ment. Neither a hysterectomy nor a mastectomy should impair
gland secretion Longer interval to sexual functioning, although is not uncommon for women
Reduced vaginal ejaculation
expansion Less testicular elevation to feel less feminine or less desirable after such surgeries.
Decreased elevation A prostatectomy, the surgical removal of all or part of the
of the uterus prostate, does not necessarily end a man’s physical capacity for
Orgasm Fewer orgasmic Shorter ejaculation time sexual activity. Improved surgical techniques and alternative
contractions treatments increase the likelihood that patients will continue
Postorgasm No dilation of cervical os Rapid loss of erection to enjoy erections after treatment.
Longer refraction period Psychiatric illnesses, especially major depression and
dementia, are frequently associated with sexual dysfunction
4605_Ch24_367-382 31/10/17 12:32 PM Page 375
TABLE 244 ■ Some Prescription Medications With Possible
Sexual Side Effects
TYPE OF DRUG TRADE NAMES POTENTIAL PROBLEMS
Tranquilizer; Valium, Xanax, Changes in libido; erection
antianxiety Ativan problems; delayed
orgasm/ejaculation
Antidepressant Prozac, Zoloft, Changes in libido, delayed
Paxil, Effexor orgasm/ejaculation
Antihypertensive Clonidine, Erectile dysfunction,
beta-blockers decreased libido
Ulcer medication Tagamet Decreased libido, erectile
dysfunction
in late life. Decreased libido is a cardinal symptom of depres-
sion. Sexual dysfunction is a common side effect seen in
patients taking antidepressants, particularly selective sero-
tonin reuptake inhibitors (Paxos & Dugan, 2014).
Alzheimer’s and other dementias can have a profound
effect on sexuality (Ward et al., 2005). Sometimes sexual
desire increases and can result in unreasonable and exhaust-
ing demands, often at odd times, in inappropriate places
or with inappropriate people. Other individuals may lose
interest in a physical relationship and may become withdrawn.
Psychosocial stresses such as the loss of a partner due to
disability or death, fears of self-injury or death due to medical
conditions (e.g., history of myocardial infarction, shortness
of breath), or sensitivity to loss of personal appearance or
control of hygiene (e.g., due to incontinence or the presence
of a colostomy) can sometimes spell the end of an individual’s
desire for sexual activity.
Sexually Transmitted Diseases and the Elderly
Population
Older men and women are at significant risk for HIV/AIDS
and other sexually transmitted diseases. They may be at risk
because of a lack of information. In fact, older adults are one
sixth as likely to use condoms during intercourse compared
with those in their 20s (Gott, 2005; Goodroad, 2003). Syphilis,
genital herpes, and chlamydial infections do not appear to
present any differently or to be more severe in older persons.
Implications for Health-Care Providers
Clearly, there is a role for health-care professionals as
advocates to represent the right of those in late adulthood to
pursue sexual pleasure with other consenting adults. Provid-
ing for privacy, supporting relationships, and addressing
cultural stereotypes would have positive effects on the health,
self-esteem, and dignity of many elderly individuals. Open-
minded, nonjudgmental individuals who are comfortable with
their own sexuality are likely to approach the topic differently
from those who believe that sexuality is limited to genital
CHAPTER 24 ■ Interactions, Relationships, and Sexuality 375
contact between married heterosexuals under a certain age.
Older couples in new relationships may find their families
less than fully supportive; family meetings may help to open
up communication.
Assessing sexual concerns can be done in the context of
addressing limitations or changes in the patient’s lifestyle and
general health-care issues. The evaluation of these issues may
be done using a checklist or open-ended questions such as,
“What concerns you about your sexuality?” A list of specific
considerations can be found in the electronic support materials
that accompany this book. It is important to be aware of
potential impact of medical conditions and medications on sex-
ual functioning and to help patients by addressing issues like
positioning for comfort, energy conservation, alternative mech-
anisms for sexual satisfaction, and their own beliefs, values, and
needs as they affect participation in this important occupation.
Dealing with the sensitive area of sexuality also raises
ethical considerations. Health-care providers must be aware
of the limits of their own comfort, knowledge, and skills and
be prepared to refer to someone better qualified to help a
patient with a sexual problem. Most codes of ethical behavior
for health-care professionals explicitly prohibit sexual contact
between a health-care provider and a client, and for good
reasons. Boundaries are equally important if the professional
is faced with a patient who makes inappropriate sexual
remarks or sexual advances. In a firm but friendly manner,
the professional can acknowledge and redirect the patient’s
focus to more appropriate topics.
When Caregiving Becomes Necessary
At some point in the lives of many elders, it becomes neces-
sary to receive support and care in managing daily life. Care-
giving is an extension and expansion of the typical kinds of
social participation so essential in the lives of older adults
(Chappell & Funk, 2011). The vast majority of this care is
provided by family (Chappel & Funk, 2011). In the United
States alone, such care has an economic value of more than
$375 billion (Robison, Fortinsky, Kleppinger, Shugrue, &
Porter, 2009). Approximately 25 percent of adult children
are providing some care for elders. Where family is not avail-
able, fictive kin, including friends and neighbors (Suanet
et al., 2013) may step in. Wives and adult daughters most often
provide care, but husbands, sons, and daughters-in-law may
also be caregivers. Caregiving varies among ethnic groups,
with ethnic minority groups tending to provide more infor-
mal support (Pinquart & Sörensen, 2005).
Caregiving has consequences for the caregiver as well as
the care recipient (Hoffman, Lee, & Mendez-Luck, 2012;
Lee, Tang, Kim, & Albert, 2014). They may engage in poor
health behaviors and may experience high levels of stress
and depression. African American caregivers experienced less
depression, perhaps because of a relatively strong cultural
tradition of providing care (Dilworth-Anderson et al., 2005),
but ethnic minority caregivers from a variety of backgrounds
reported more physical illness (Pinquart & Sörensen, 2005).
4605_Ch24_367-382 31/10/17 12:32 PM Page 376
376 PART III ■ Active Aging: Supporting Client Activities and Participation
It is easy to forget that caregiving also has benefits (Roth
et al., 2015). Caregivers may find the role meaningful, par-
ticularly when they are close to the individual (McGraw &
Walker, 2004). This is especially true when opportunities for
reciprocity continue to be available (J. L. Wolff & Agree,
2004) and there are strong emotional ties between caregiver
and recipient of care (McGraw & Walker, 2004).
Informal caregiving is of particular importance for occu-
pational therapy intervention because it is most often a new
occupation that families must learn to manage (Figure 24-3).
Thoughtful assistance by the therapist can reduce the stress
that may be hallmark of this occupation (Dooley & Hinojosa,
2004) and can improve satisfaction both of the elder and the
family. It is not a given that caregiving will result in stress
(Robison et al., 2009), and thoughtful support from an occu-
pational therapist in structuring caregiving can help minimize
difficulties inherent in the role. In addition, an occupational
therapist can help families examine realistically their own
emotional and instrumental resources for providing care in
alternative living arrangements.
Physical therapists often rely on families to help elders
with home programs for strength and flexibility and as assis-
tants in safe transfers and use of mobility aides. These activ-
ities may be feasible but can also be perceived as burdensome.
Family members may need reassurance that deciding against
providing certain kinds of care does not mean they do not
love the elder (Kaufman, Shim, & Russ, 2004); allow them
to be realistic in identifying their resources. Assistance from
occupational therapy, physical therapy, and social work in
finding other caregiving strategies can help alleviate burden.
Discussion of strategies for assisting families is provided here.
The Intentional Relationship Model
The Intentional Relationship Model (IRM) provides a skills-
based conceptualization of the client-therapist relationship
that was developed based on the in-depth study of practicing
FIGURE 243 Clients and their caregivers should be consistently
involved in the design of interventions. monkeybusinessimages/
iStock/Thinkstock
occupational therapists worldwide (Taylor, 2008). The model
offers recommendations on how the therapeutic use of self
can be applied in therapy to foster client engagement and
support positive outcomes. According to IRM, the client is
the focal point of the therapeutic relationship process; the
therapist is responsible for maintaining an open and trusting
relationship with the client (Taylor, 2008). To do so, the
therapist must be aware of his or her own preferences for
interaction as well as those of the client to respond appropri-
ately to the inevitable interpersonal events that occur within
therapy. Interpersonal events occur naturally and have the
power to strengthen or challenge a therapeutic relationship
depending on how they are managed. Some examples of
interpersonal events include resistance and reluctance in
therapy, boundary testing, an intimate self-disclosure on
the part of the client, and power dilemmas, among others
(Taylor, 2008). An interpersonal reasoning process guides
how the therapist responds in an intentional way to the events
of therapy, based on the client’s interpersonal characteristics.
Although interpersonal events are unavoidable, the ther-
apist is urged to continually work on the application of
interpersonal reasoning to strengthen his or her own ability
to respond in the most optimal way to the client’s presenta-
tion (Taylor, 2008). This is done through development of
an interpersonal skill base and the appropriate and inter-
changeable application of one of six interpersonal modes. A
therapeutic mode is a specific way of relating to a client
within the boundaries of the professional therapeutic rela-
tionship. The six therapeutic modes of IRM include the
following (Taylor, 2008):
advocating—securing the client’s rights, raising the client’s
awareness of available resources, connecting the clients
with disabled peers, and advocating for the client with
external service providers and agencies;
collaborating—expecting the client to take an active role in
directing his or her own therapy process and outcomes,
with an emphasis on freedom, choice and autonomy;
empathizing—striving to understand the client’s perspec-
tive on the situation, and inquiring about his or her
thoughts, feelings and behaviors in a way that is free of
judgment;
encouraging—instilling hope in the client and commend-
ing their progress through positive reinforcement;
instructing—structuring therapy activities, providing clear
feedback, setting limits, and being explicit about events
and expectations in therapy; and
problem-solving—providing opportunities for strategic
thinking and analysis of the situation by providing
choices and posing strategic questions
A therapist’s ability to empathetically relate to clients, for
example, can have an impact on client outcomes, and the
therapists’ positive affect has been associated with a decrease
in clients’ confusion and improvements in activities of daily
living (Ambady et al., 2002). Although therapists have their
own personal tendency toward specific modes applied in
4605_Ch24_367-382 31/10/17 12:32 PM Page 377
therapy, they should be strategic in their mode use to best
align with client preferences and interpersonal style (Taylor,
2008).
Techniques for Practice
Therapeutic relationships with clients and their families are
a means to facilitate functional performance. In a partnership
between the family caregiver and the professional, the ther-
apeutic relationship illustrates compatible beliefs about the
source of the problem and the solution, a sharing of power
and control, and a sharing of perspectives. Such interactions
are a desirable goal for all therapeutic relationships. There
are specific methods by which such relationships can be
established, as described in the following sections.
Ethnographic Interviewing
In health-care situations, information solicited during
interviews with clients and their families is expected to relate
specifically to the purpose of intervention. As noted earlier,
perspectives and goals can be very different. The method
used in interviewing and the information obtained should
both incorporate a sense of the client’s and the family’s
understanding of the illness experience (Bonder & Martin,
2013).
One technique for gathering information and gaining
understanding of the illness experience of another person is
ethnographic interviewing (Bonder & Martin, 2013). Ethno-
graphic interviewing involves asking open-ended questions
and using responses to those questions to frame more detailed
questions that elaborate on specific issues (Skinner, 2012).
As needed the therapist moves through the array of possible
questions from very general, to multiple choice, to yes–no,
and from very broad topics to more specific information.
Whenever possible, the therapist should revert back to the
higher level of questioning in the interview, especially at the
start of a new topic (Box 24-2).
Identifying Goals and Negotiating Discrepancies
The next step in this therapeutic process is to engage in
negotiation with the client and the caregiver, actively seek-
ing compromise in areas of differences and conflict. The
therapist must recognize and accept that resolution and
compromise may be closer to the caregiver’s view or it may
be closer to the therapist’s view—either must be possible,
or it is not true negotiation. Bonder and Martin (2013)
describe this process as mutual cultural accommodation,
a process through which all parties arrive at a compromise
that preserves their most central beliefs but also supports a
decision that facilitates progress.
Families can be assisted through several strategies, including
instruction and demonstration on specific skills, emotional sup-
port, and educational programs offering skill-building and
problem-solving. As described in Promoting Best Practice:
Caregiver Programs, two of these programs have been evaluated
CHAPTER 24 ■ Interactions, Relationships, and Sexuality 377
BOX 242 Ethnographic Interview Techniques
1. Clarify your purpose. Ask permission.
2. Let the client know he or she can decide against answering
questions.
3. You might start either with a very general or a very specific
question.
4. Ask follow-up questions for greater depth of understanding.
5. Ask for clarification and details.
6. Ask stressful or highly personal questions later in the
interview.
7. Observe carefully.
8. Remember that reality is in the eye of the beholder, and
memory is unreliable.
9. Keep careful notes.
10. Ask each question in two or more ways.
Source: Bonder & Martin (2013).
for effectiveness and found to be helpful in improving care
and reducing problems. Work with informal caregivers often
requires interprofessional approaches, as described in Interpro-
fessional Practice: Care for Informal Caregivers.
✺ PROMOTING BEST PRACTICE
Caregiver Programs
Two treatment protocols, Reducing Disability in Alzheimer’s
Disease (RDAD) and STAR-Community Consultants (STAR-C),
have been shown to improve care and quality of life for
individuals with Alzheimer’s disease and reduce behavioral
problems, making informal caregiving both easier and more
rewarding (Teri et al., 2012). Each program is designed to train
caregivers to improve their interactions and to develop
problem-solving strategies. Both have been tested using
randomized, controlled studies.
INTERPROFESSIONAL PRACTICE
Care for Informal Caregivers
Programming and support for informal caregivers can be
most effective when provided by a team. For example, a social
worker can assist in identifying community programs for
older adults with dementia, sources for community transit,
and funding for in-home respite care. The occupational
therapist focuses on designing strategies to address daily
tasks such as bathing and dressing, as well as activities to
promote meaningful engagement in activities for both the
elder and the caregiver. The physical therapist emphasizes
mobility issues that can interfere with the elder’s function, as
well as those that affect the caregiver’s ability to manage the
physical demands of tasks. The nurse will emphasize strategies
for monitoring the health status of the elder and the caregiver.
4605_Ch24_367-382 31/10/17 12:32 PM Page 378
378 PART III ■ Active Aging: Supporting Client Activities and Participation
Addressing Family Issues in the Current
Health-Care Environment
Third-party payers typically require rapid termination of serv-
ices and tend to assume that the family will fill the breach
(Chappell & Funk, 2011). For a variety of reasons, this may
be an unrealistic assumption. Family may live far away. They
may have their own families and work to tend to. They may
have long-standing family tensions that interfere with the
provision of required services.
Such problems are not always easily resolved, and they
present significant ethical dilemmas for the practitioner. Can
a client be discharged to home when family members are
unable or unwilling to ensure the person’s physical safety?
Increasingly, negotiation with families must be complemented
by negotiation with insurers about alternative services.
Creative solutions must be considered, not all of which will
be acceptable. Therapists can assist families in interacting
with insurers, locating alternative resources, and working
toward changing unreasonable and unrealistic regulations.
As has been discussed throughout this chapter, social
interactions are highly meaningful and often include many
individuals beyond the family. Elders may struggle to build
and maintain social networks as they leave jobs where social
interaction was a daily part of life, as they move to new envi-
ronments, or as friends of long-standing move away or die.
Assisting elders in building social skills, problem-solving
about meeting new people, and other efforts to address social
needs can be vital to successful aging.
SUMMARY
Much remains to be learned about family life and social in-
teraction in later years. The circumstances of individual older
adults are complex, and their multiple relationships with fam-
ily and society add to that complexity. In addition, what is
understood about older population may change over time, as
societal and personal situations change (Velkoff et al., 2006).
It is essential that policy be based on the best available infor-
mation and that information be expanded, enhanced, and
updated as family and social circumstances change.
When health-care professionals work with older adults,
family issues cannot be ignored. Outcomes of treatment often
reflect the effectiveness with which concerns of the whole
family, not just the identified client, have been incorporated
into the intervention. Families have considerable import in
service provision for elders and represent a potential resource
to reduce costs while enhancing quality of care. At the same
time, professionals must take care to remember that elders
may also have other important responsibilities. Families must
determine how to fill the gaps caused by the older individual’s
illness or disability.
The ultimate objective of occupational and physical therapy
is to promote optimal performance in daily living activities.
In working with families of older people in the community,
an important goal is to support them in their efforts to reach,
in essence, the same objective for themselves and for the
person receiving the care.
CASE STUDY
Mrs. Jones is an 88-year-old woman whose husband died
10 years ago. Since then she has been living alone in a con-
dominium on the second floor of a 100-unit building.
Mrs. Jones has two daughters who live within 20 minutes
of her. They are both married, and each has two teenaged
children. She also has a son, an attorney, who lives at a
distance with his wife and three children.
Two months ago, Mrs. Jones fell on an icy sidewalk
and fractured her femur. She had surgery to repair the
fracture with a steel implant, and was then transferred to
a nursing facility for rehabilitation. It is now time to con-
sider discharge because the therapists believe she has made
maximal progress in their care.
Mrs. Jones wants to go back to her home; her daugh-
ters are concerned because they both work and fear that if
she returns home they will be pressed into service because
she is currently far from fully independent. Her son has
called the social worker to indicate that he wants his
mother discharged to an assisted living facility, threaten-
ing legal action if this is not done.
Questions
What family-related issues are evident here?
1. Whose values should be given precedence?
2. How might you work with the family to reach an
agreement about next steps?
Critical Thinking Questions
1. For elders, what kinds of occupational and emo-
tional needs are addressed through social and
family interactions?
2. In what ways is reciprocity important in the social
interactions of elders?
3. What are some ways that elders who do not have blood
relations meet family-focused occupational needs?
4. How do health status and social circumstances affect
sexual activity and satisfaction for older adults?
5. Discuss areas in which social and family interactions
can be problematic in later life.
6. Relate the concept of responsibility for problems and
solutions to the therapist–family caregiver relationship.
7. In ethnographic interviewing, what strategies can be
used to gather detailed and relevant information
about problems and solutions?
4605_Ch24_367-382 31/10/17 12:32 PM Page 379
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Vanina Dal Bello-Haas
“Anyone who stops learningstaysis old,young.whether at twenty or eighty. Anyone who keeps learning
The greatest thing in life is to keep your mind young.
LEARNING OUTCOMES
By the end of this chapter, readers will be able to:
1. Describe the age-related factors that influence learning
in older adults.
2. Identify key principles to consider when engaging older
adults in learning.
3. Distinguish the different types of memory and learning.
4. Identify effective strategies for facilitating learning in older
adults.
5. Develop effective educational materials for older adults.
6. Differentiate among formal, informal, and nonformal
learning.
7. List the reasons an older adult may engage in learning.
8. Summarize the benefits of learning for older adults.
9. Describe the connection(s) between education, learning,
older adult health, and health literacy.
10. List the key documentation elements that should be
included in the health record.
Clinical Vignette 1
Ms. Samantha Denning, age 83, and Mr. Bruno Gatto,
age 72, are the co-presidents of a local Seniors Council.
Ms. Denning and Mr. Gatto have contacted Patrick and
Kim Cuc, an occupational therapist and physical therapist
who co-own a private practice. Ms. Denning and Mr. Gatto
would like to provide a 2-hour “Age-wise, Health-wise”
educational session for older adults living the community
and have asked Patrick and Kim Cuc to develop and pre-
sent the session. The older adults comprise a diverse group
in terms of socioeconomic status, race and ethnicity, and
functioning.
1. What type of learning is the example in the clinical vi-
gnette? Why might an older adult attend the session?
2. What might Patrick and Kim Cuc do to ensure learn-
ing is maximized during the session? Are there any
learning-environment factors that need to be taken
into consideration as Patrick and Kim Cuc plan the
session?
CHAPTER 25
Learning in Later Life
■ Megan E. O’Connell
—Henry Ford
”
3. Are there any sociocultural factors that may influence
the teaching and learning process?
Clinical Vignette 2
Mr. Francisco de Ruiz is a 71-year-old man who recently had
a left total hip replacement (THR) and is to be discharged
home. Mr. de Ruiz and his wife, Rita (age 83), moved from
Central America 20 years ago, after their only son Roberto
died in a car accident. The de Ruiz’s are fluent in Spanish,
and English is their second language. Mr. and Mrs. de Ruiz
live in a small bungalow. Before Mr. de Ruiz’s THR, both
Mr. and Mrs. de Ruiz were independent in all activities of
daily living (ADL) and instrumental ADL, were driving,
participated in an aquatics exercise class 4 days per week,
and were active in their church and with the local immigrant
welcome center.
Sarah Redkin, physical therapist, and Scott Mussaid, oc-
cupational therapist, are planning a cotreatment session to
teach the de Ruiz’s car transfers and post-THR precautions
during a variety of activities.
1. What are some considerations for skills learning that
Sarah and Scott keep in mind?
2. Are there any strategies that Sarah and Scott can im-
plement to ensure learning is maximized during the
session? Are there any learning environment factors
that need to be taken into consideration as Sarah and
Scott plan the session?
3. Are there any sociocultural factors that may influence
the teaching and learning process?
A s described in Chapters 7 through 11, numerous
age-related changes are associated with decline in
neurological integrity and are therefore considered “nor-
mal” aging. The reader should refer to these chapters to
review relevant information and strategies for addressing
383
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384 PART III ■ Active Aging: Supporting Client Activities and Participation
these normal age-related changes to maximize communi-
cation with older adults, which, in turn, will enhance the
teaching and learning process.
Learning at any age involves the interaction of a multitude
of cognitive processes and sensory systems. Although many of
the changes that accompany aging may affect how efficiently
learning takes place, older adults can learn and do learn. Evi-
dence for this is robust: Despite well-documented declines in
normal cognitive aging abilities, healthy older adults rarely
demonstrate declines in real-world functioning. This is partially
because cognitive ability is only one of many determinants of
success in life. Personality is another major determinant, for
example. Another hypothesized reason age-associated cogni-
tive declines do not translate into functional declines is because
of accommodations made by older persons and society. Some
adaptations made by older adults to accommodate age-related
cognitive declines are conscious and some are unconscious—
that is, the brain will recruit additional resources to maintain
task performance (Salthouse, 2012).
Responsibility rests with occupational and physical ther-
apists to use their knowledge, skills, and attitudes to set up
an appropriate learning environment and implement effective
teaching and communication techniques to enhance and
maximize learning. To do this, it is important to understand
the multiple sensory and cognitive processes underlying
learning and to understand the different types of learning
related to memory theory. To learn and retain new informa-
tion, that information must first be processed by the relevant
memory system. Memory is like a bank—you cannot with-
draw if nothing was actually deposited in the first place. It is
not uncommon for many memory complaints from older
persons and their loved ones to be related to difficulties not
with the memory bank but with the depositing of informa-
tion into memory. Common difficulties that can, at least on
casual inspection, appear as problems with learning are actu-
ally problems with sensation and perception, such as the
common sensory declines of reduced visual and hearing acuity
associated with aging (see Chapter 9).
Gerogogy
It has been argued that teaching strategies for older adults
(65 years of age) are distinctly different from those for teach-
ing adults (andragogy; adults between the ages 18 and 65) or
children (pedagogy) and that a separate educational approach,
gerogogy, is warranted (Best, 2001). Gerogogy as an ap-
proach recognizes the special needs of older adults related to
learning and refers to the need to fine-tune adult teaching
and instructional styles and strategies to enhance the learning
experiences of older adults who are generally postwork and
are no longer raising families, and sometimes frail (Findsen
& Formosa, 2011). Because of the critical age-related tran-
sitions and the uniqueness of older adulthood as a develop-
mental stage, acknowledging and accommodating the normal
age-related physical, cognitive, and psychosocial changes are
key elements of gerogogy (Findsen & Formosa, 2011).
Impact of Sensory System Changes on Older
Adult Learning
The age-associated sensory system changes outlined in
Chapter 9 have a great potential to influence effective com-
munication with older adults during the teaching and
learning process. These changes need to be taken into con-
sideration when structuring the learning environment,
planning and implementing the learning intervention, and
when developing educational materials. For example, blue,
green, and lavender have been found to be difficult for
older adults to differentiate from each other (Griffiths,
Johnson, Piper, & Langdon, 2004). Readers interested in
learning more about the concept of readability should con-
sult the Web-based resources found in the ancillaries.
INTERPROFESSIONAL PRACTICE
Considerations for Occupational and Physical
Therapists When Developing Written Educational
Materials for Older Adults*
■ Ensure high contrast between background and text.
■ Use a nonglossy, nonglare background.
■ Use serif font (e.g., Times New Roman) rather than sans serif
font (e.g., Arial)
■ Increase font size. The smallest font size that should be used
for educational materials is 14 points.
■ Use a combination of upper and lower case. Avoid ALL
CAPITAL letters, italicized, and ornamental fonts.
■ Limit the amount of information provided to “need to know.”
■ Ensure information is relevant.
■ Present information sequentially, in a logical order.
■ Use active voice.
■ Use bullets and boxes to highlight key information.
■ Use underline or bold to highlight important ideas, concepts,
or terms.
■ Increase readability by using ample spacing and white space.
■ Use a simple image, picture, or figure to illustrate key points.
■ Pictographs may be effective.
■ Avoid the use of complex figures, charts.
■ Ensure material is written at a fifth- to eighth-grade reading
level for broadest applicability and to address low literacy
levels.
■ Use an index program (e.g., SMOG Readability Formula)
automated within a word processing application
(e.g., Flesch-Kincaid Index and FOG Index) to check
your material.
■ If referring older adults to a website, ensure the website is
“older-adult-friendly.”
For more information, see https://www.nlm.nih.gov/pubs/
checklist.pdf
From Bastable (2014); Doak, Doak, & Root (2007).
*Many of these considerations are applicable to a variety of popula-
tions, including those with low literacy levels, and are elements of
“best practice” client education design.
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✺
PROMOTING BEST PRACTICE
Patient Education Materials
Research has found that the majority of patient education
materials available through the National Library of Medicine
are written at reading levels considerably higher than that of
the average adult living in the United States (Stossel, Segar,
Gliatto, Fallar, & Karani, 2012).
A posttest comparison group study examined the effect of
pictograph-based discharge instructions on comprehension
and recall of older adults with low literacy skills. The older
adult patient sample ranged in age from 65 to 76 years
(mean age = 67.59 years), and a majority (83.3 percent) had an
education level of high school or lower. The pictographs, with
relevant captions, included discharge instructions post–total
hip replacement surgery, advice for home care, signs/
symptoms of complications, instructions for prescribed
medications, and guidance on when to seek medical
help. Significantly greater improvements in scores on
comprehension and recall were demonstrated by the
pictograph group compared with the text-only group,
suggesting that the pictograph-based educational materials
assisted with patients’ understanding of intended health-care
messages (J. Choi, 2016).
Impact of Psychological and Physical Changes
on Older Adult Learning
Occupational and physical therapists need to be cognizant of
both normal age-related and health condition specific
changes, as they may interfere with the older adult’s ability
to process information, participate in educational and skill
learning activities, demonstrate learning, or adopt a target be-
havior. For example, an older adult may be experiencing anx-
iety or depression, fatigue, or functional limitations, which may
lead to a lack of motivation. Similarly, musculoskeletal health
conditions may cause joint pain and stiffness, decreased range
of motion, and delayed response times, which may lead to
sedentary behavior in turn causing deconditioning. Standing
for long periods of time or participating in activities for ex-
tended periods may be difficult, thus frequent breaks may
need to be incorporated.
Impact of Cognitive Changes on Older
Adult Learning
In addition to sensory changes just discussed, learning can be
influenced by other cognitive changes associated with normal
aging (see Chapter 7). Slowed speed of mental processing has
particular implications for learning new information. If in-
formation is presented too fast for a person’s ability to men-
tally process this information, the information does not get a
chance to be adequately processed by the episodic memory
system. Slowed speed of mental processing is one of the core
cognitive changes associated with normal aging. Persons with
CHAPTER 25 ■ Learning in Later Life 385
slowed speed of mental processing will benefit from presen-
tation of information at a pace at which they can process this
information, for example, teaching one concept or task before
moving onto the next. Teaching new information in a step-
wise manner also helps mitigate difficulties in dividing atten-
tion, which is another common decline associated with
normal aging. Ability to divide attention (working memory)
and ability to generate strategies for organization and retrieval
of newly learned information (sometimes considered under
the rubric of executive functions) also affects learning
efficiency. Many day-to-day memory lapses occur because of
absentmindedness due to being distracted by external or in-
ternal factors. When absentminded, we may not process new
information at a sufficiently deep level, leading to difficulties
with encoding (Schacter, Chiao, & Mitchell, 2003).
Impact of Social-Cultural Elements on Older
Adult Learning
In many countries, ethnocultural diversity of the population
is increasing. For example, 27.7 percent (in 2013) of the
Australian population is foreign-born. Among G8 countries,
Canada’s proportion of foreign-born population is highest
(20.0 percent), followed by the United States (12.8% in
2013) and Germany (12.8 percent in 2013) (OECD, 2017).
With the increasing diversity of the population and the
increasing numbers of people over age 65, differences in cul-
ture, ethnicity, race, religion, values, socioeconomic status,
gender, lifestyle, and health status must also be considered
when engaging older adults in learning. These elements play
a role in older adults’ expectations of the teaching and learn-
ing process and how they may receive information being pro-
vided to them, in particular health-related information. How
a person adapts to aging varies across cultures, as well as indi-
viduals. Although there may be some commonalities among
ethnic, racial, cultural, and religious groups, it is important for
occupational and physical therapists not to stereotype or gen-
eralize common characteristics of a socio-ethno-cultural group
to all other members associated with that group.
Learning and Memory: Not Just
One Way to Learn
Learning is one of the more complicated cognitive processes.
Memory theory, which underlies our understanding of learn-
ing, separates many types of memory, each with evidence for
different underlying neural circuits. Most simply, however,
memory is separated into short-term memory and long-term
memory. Short-term memory is commonly referred to a mem-
ory system with very limited capacity, one in which memory
traces (physical or neural substrate of memory) decay rapidly—
within seconds—if they are not processed or rehearsed in some
manner (Cowan, 2008). We acknowledge that this definition
differs from the common colloquial use of short-term memory.
Colloquial definitions of short-term memory actually refer to
long-term memory, which has gradations of how “long-term”
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386 PART III ■ Active Aging: Supporting Client Activities and Participation
the memory trace actually is, for example, from minutes to
most of a lifetime. Long-term memory has an unknown ca-
pacity, likely unlimited, and memories stored in long-term
memory storage can be considered learning. Learning has been
defined or described differently depending on the discipline
undertaking the description. Learning refers to new neural
connections that are strengthened with repetition, rehearsal,
or with a one-time highly salient exposure, such as fear condi-
tioning. These new connections that constitute learning are as-
sociated with changes in the synaptic connections in the brain
(long-term potentiation; Lynch, 2004). All new learning in-
volves making a new neural connection—brains are constantly
evolving their connectivity (neuroplasticity). If not reinforced,
new learning stored in long-term memory becomes less acces-
sible over time (Schacter et al., 2003). In general, learning is a
multistep and complex process. Main processes involved in
learning include encoding of new information, which refers to
information entering the memory system. Sensory impair-
ments, superficial levels of processing (classic hypothesis
posited by Craik & Lockhart, 1972), and other cognitive im-
pairments that are discussed later can interfere with the ability
of new information to be admitted to the memory system. In
typical learning, however, once new information is entered into
the memory system, it needs to be consolidated, the process
of admission into long-term memory. Finally, new information
stored in long-term memory needs to be retrieved from long-
term memory. Difficulties with learning can occur at the level
of encoding, consolidation, or retrieval or through difficulties
with all of these memory processes.
There are two main broad categories of memory systems
within the brain, each with distinct neural circuitry. At the
broadest level of categorizations, learning is either declarative
or nondeclarative (Ashby & Crossley, 2010). Consciously re-
calling the information learned is considered declarative
learning. Nondeclarative learning, discussed in more detailed
later, involves priming, learning demonstrated without
awareness, and the procedural memory system that underlies
skill learning, which may be much more relevant to the phys-
ical and occupational therapist. Procedural memory is com-
monly spared even when declarative memory systems have
been disrupted by disease, a fact that can be capitalized on
during rehabilitation and intervention implementation.
Episodic and Semantic Memory
Declarative learning involves both episodic memory and
semantic memory. All new learning involves the episodic
memory system. Simply, episodic memory refers to memo-
ries with a personal connection, such as autobiographic
memory. Personal connections also include where new in-
formation was learned, and may include with whom, at what
time during one’s life, why the information was learned, how
the information was learned, and so forth. New learning
(non-autobiographical) includes a personal connection of
some sort and therefore involves the episodic memory sys-
tem, which is mediated by the hippocampus in the anterior
portion of the temporal lobes of the brain (Tulving, 2002).
With repetition and time, the personal trace associated with
new learning can decay and this new learning becomes merely
factual. The factual memory system is referred to as the se-
mantic memory system, which is likely distributed though
the temporal lobes and which is organized in networks based
on associations and the strengths of the associations. For ex-
ample, it is easier to think of cat when asked to think of dog
because of the multiple exposures one has likely had to cat-
dog as both are domesticated house animals (strong associa-
tions). All new learning is episodic, but the memory trace is
stored in the semantic memory network (non-autobiograph-
ical memory) and the hippocampus is involved in repetition
and retrieval of this new information. With repetition, the
personal trace associated with this new non-autobiographical
learning is no longer required, at least for non-spatial mem-
ory, and the hippocampus is no longer involved; at this time
new learning becomes facts accessible through the semantic
memory system (Moscovitch et al., 2005).
The episodic and semantic memory systems are clearly
linked, yet separable. Pathology involving only the semantic
memory system leads to a loss of understanding of the mean-
ings of words, which has implications for expressive and
receptive communication (semantic dementia). Episodic
memory impairments are most pronounced early in demen-
tia due to Alzheimer’s disease, but episodic memory loss is
also one of the prototypic features of normal aging. This has
implications for physical and occupational therapists work-
ing with older adults. Before discussing how to assess new
learning, it is important to discuss other cognitive changes
associated with normal aging that could underlie difficulties
with episodic memory.
Learning and Episodic Memory Impairments
Episodic memory has many facets relevant to how one
teaches an older adult, and thus, how one assesses whether
learning has taken place. Teaching new information can be
supported or unsupported, the latter requiring self-initiation
of strategies for organizing information (executive function-
ing). Older adults who have difficulties with self-initiation of
organizational strategies, which is highly effortful, will benefit
greatly from presentation of information in a manner that is
supportive. Supported learning of new information on stan-
dardized episodic memory tests, for example, includes pro-
viding a semantic category to aid in learning of a new word
on a word list. Day-to-day support could include taking time
to make links between new and existing learning—that is,
linking new information to something the older adult al-
ready knows. Another strategy of providing supported learn-
ing is teaching new information, along with a memory aid
strategy such as a verbal or visual mnemonic. Another key
strategy in teaching new information is making use of the
principles of errorless learning. Errorless learning is useful
for all, but for older adults with episodic memory impair-
ments allowing learning under conditions where errors are
avoided is very important (Kessels, Boekhorst, & Postma,
4605_Ch25_383-396 31/10/17 12:31 PM Page 387
2005). As discussed previously, most new learning is depend-
ent on repetition to create a stronger memory trace. When
episodic memory is impaired, the personal connection with
the memory trace that alerts the older adult that she or he
has made an error is weak, therefore the error is reinforced
in the memory system to a similar degree as the errorless
memory (Kessels et al., 2005). There are multiple methods of
reinforcing errorless learning that have been described in the
rehabilitation literature, including (1) providing cues initially
and gradually removing them when the older adult is able to
demonstrate repeated perfect recall and (2) asking the older
adult to recall new information and gradually increasing the
time span of recall, with the increases in time decided based
on repeatedly perfect recall.
Free Recall and Supported Recall
Although learning new information is important, it is equally
important for information to be able to be recalled when
needed. Memory retrieval can be problematic, even within an
intact memory system, which accounts for false memory or
incorrect memory recall (Meade & Roediger, 2009; Schacter
et al., 2003). New information can be recalled using two main
methods—free recall and supported recall (also known as
cued recall or recognition memory). Free recall is highly
effortful and dependent on spontaneous strategy use when
learning and retrieving new information (executive functions)
and is susceptible to blocking, resulting in the “tip of the
tongue” phenomenon—you know what you want to say, but
you cannot access it at that specific moment (Schacter et al.,
2003). This phenomenon is exacerbated under stress. Thus,
when working with older adults, occupational and physical
therapists need to be patient and provide older adults with
adequate time and support. Typically, blocking is resolved
quickly with the passage of extra time.
In contrast to free recall, supported recall is less effortful,
and performance demonstrating new learning tends to im-
prove under conditions of supported recall. In standardized
testing environments, such as a neuropsychological evalua-
tion, supported recall consists of provisions of multiple op-
tions (targets and foils), and the person states whether the
information was part of what he or she recently learned. Sup-
ported recall in a day-to-day context could include use of
smartphones for cueing, lists of reminders, memory books,
or formation of habits—essentially making links between a
new activity and an existing one that is always performed.
Formation of a habit also helps with the most common im-
pairment in memory—prospective memory—that has major
implications for day-to-day functioning and is most relevant
to occupational and physical therapists.
Prospective Memory
Prospective memory, although highly linked to episodic
memory, is distinct. Prospective memory refers to remember-
ing to do something in the future based on time—time-based
CHAPTER 25 ■ Learning in Later Life 387
prospective memory—or remembering to do something
in the future based on need or circumstance—event-based
prospective memory, which is hypothesized to be more re-
lated to executive functions. Learning and recalling new in-
formation is important, but applying that new learning when
it is needed is yet another aspect of memory that declines with
normal aging. Remembering to do something in the future is
complicated and includes the ability to form an intention, for
example: “I have a new exercise that I now need to do daily”;
retaining that intention over time, which requires consolida-
tion (e.g., remembering that after leaving a PT appointment,
there is an exercise that one needs to do daily); detection of
the time when the activity must be done—for time-based the
appropriate time, and for event-based when the moment the
activity needs to be done arrives), and then retrieving the
memory of what it is that needs to be completed (Hering,
Rendell, Rose, Schnitzpahn, & Kliegel, 2014). Rehabilitation
efforts aimed at ameliorating prospective memory impair-
ments have demonstrated some success when multifaceted ap-
proaches are used and are beyond the scope of this chapter
(for more information, refer to Hering et al., 2014). Briefly,
many approaches use external cueing devices or verbalization
of intentions, for example, “When I sit down to my nightly
game of Solitaire, I will perform my new arm exercise,” or not-
ing on a daily calendar “after taking morning pills, do stretch-
ing exercises.”
Procedural Memory and Motor Learning:
Skill Learning
Motor learning is defined as “a set of processes associated
with practice or experience learning to relatively permanent
changes in the capability for movement” (Schmidt & Lee,
2005, p. 302). Motor learning is not the same as motor per-
formance; motor performance involves the acquisition of a
skill, but not necessarily the retention of the skill. For motor
learning to have occurred, the skill has been retained such
that the learner can perform the skill at a later time and under
different conditions, such as different environments. Acqui-
sition or refinement of motor skills involves both motor and
cognitive processes. Although the initial learning of a new
skill may involve the episodic memory system to some degree
(e.g., the older adult can tell you that you taught her a specific
stretching exercise), motor learning is nondeclarative and in-
volves the procedural memory circuits, which are distributed
and linked with the neural circuits underlying motor planning
(premotor cortex), sensorimotor systems (primary somatosen-
sory cortex and motor cortex), and coordination (cerebellum).
In other words, procedural memory is performance based.
Fitts and Posner’s (1967) three-stage model of motor learning
provides a sequential framework for occupational and physical
therapists to adopt, as they consider, plan, and organize motor
learning strategies for older adults:
■ Cognitive—the beginning learning process phase, in
which the learner is working to develop an understanding
of the skill. The learner must focus and pay attention; thus
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388 PART III ■ Active Aging: Supporting Client Activities and Participation
this stage involves many cognitive components, including
executive functions, working and episodic memory, and in-
tellectual abilities.
■ Associative—the phase in which the skill improves with
practice; cognitive involvement decreases during this phase.
This phase is characterized by more consistent performance,
fewer errors, and slower gains (Schmidt & Lee, 2005).
■ Autonomous—the stage in which processes become auto-
matic; performance speed and efficiency improves, and cog-
nitive functions involved in the cognitive phase are not
required. As daily performance tasks are often “overlearned,”
they become automatic, and thus procedural memory is
often maintained with aging.
The cognitive stage is error-prone, with a high degree of
variability in performance—the learner receives instructions and
feedback from the “instructor” and needs to determine what to
do and how to do the task or activity. The associative stage is a
refinement stage, in which the learner makes fewer errors and
shows increased consistency of learning. The learner may asso-
ciate specific cues with the movements required to achieve the
goal or complete the task or skill. In the last stage, automaticity
is reached; learners no longer need to think about the specific
movement characteristics of the task or skill and may be able to
complete another task at the same time (Nieuwboer, Rochester,
Müncks, & Swinnen, 2009). Strategies to enhance learning in
each of the three stages of skill/motor learning and motor learn-
ing variables are summarized in Tables 25-1 and 25-2.
Older adults have decreased rates of skill learning; even
when provided with protracted rehearsal and practice, per-
formance levels equal to younger adults may not be achieved
TABLE 251 ■ Strategies to Enhance Learning in Each Stage
of Motor Learning
PHASE OF MOTOR
LEARNING STRATEGIES
Cognitive Stage ■ Minimize distractions
■ Emphasize purpose of the skill using a
meaningful and relevant context(s)
■ Use clear and concise instructions
■ Break down complex skills into parts, if
appropriate
■ Make connections to other/previously
learned skill(s)
■ Demonstrate ideal skill performance
■ Use guidance and feedback
Associative Stage ■ Focus on fine-tuning the skill
■ Increase the complexity of the skill
■ Increase the level of environmental
distractions
■ Emphasize problem-solving
■ Decrease feedback and guidance
Autonomous Stage ■ Focus on speed and efficiency
■ Set up progressive and more challenging skill
■ Practice the skill in a variety of environments
and in more challenging environments
From Schmidt & Lee (2005).
(e.g., Buch, Young, & Contreras-Vidal, 2003; Seidler, 2006).
However, evidence suggests that older adults can learn new
motor skills (Bock & Schneider 2002) despite age-related
decrements in sensorimotor function and adaptation (Buch
et al., 2003; Seidler, 2006). Because some older adults may
never reach the autonomous stage, in a rehabilitation context,
skill learning may include improvement of performance, de-
velopment of a new solution to perform a skill, retrieving a
solution from a set of previously learned options, or learning
compensatory strategies for the skill.
INTERPROFESSIONAL PRACTICE
Considerations for Occupational and Physical
Therapists When Teaching New Information
or Skills to Older Adults
■ Accommodate for slower speed of mental processing—do
not speak or present information too fast.
■ Ideally present one new item at a time, before moving onto
the next item. For example, if a multistep skill or task is to be
taught, consider teaching one step until it is perfected and
then teach the second step, and so on.
■ Encourage errorless learning. When teaching a skill or task,
do not encourage trial-and-error learning; rather, support
repeated performance by providing cues or having the older
adult verbalize in advance the steps.
■ Incorporate compensatory strategies as needed—for
example, technology (smartphones) or memory aides if
these are used already by clients, or as required.
■ Incorporate multimodal sensory inputs, for example, allow the
older adult to hear the information and read the information.
■ Encourage formation of a “habit”:
■ Link the new learning to a commonly engaged-in
activity—for example, stretching exercises to be
completed after playing nightly card game.
■ Work with older adult to determine what activities are
completed daily that could serve as reminders to
complete the new task.
■ Make the learning relevant; if the older adult perceives the
information to be important, the more likely a memory trace.
■ Have the older adult verbalize the new habit to encourage
formation of intentions to be completed in the future
(prospective memory).
■ Use repetition, and use it appropriately.
■ Have the older adult work with or manipulate the information.
■ Have the older adult paraphrase the information, demonstrate
a learned skill.
Formal, Nonformal, and Informal
Learning in Later Life
Since 1994, when both UNESCO and the Organization for
Economic Cooperation and Development (OECD) made ac-
cess to lifelong learning a priority, the role of learning in later
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CHAPTER 25 ■ Learning in Later Life 389

TABLE 252 ■ Motor Learning Variables

MOTOR LEARNING VARIABLE TYPE, DESCRIPTION, AND CONSIDERATIONS

Practice Massed practice—practice time greatly exceeds rest time
■ Can lead to fatigue

■ Decreases performance of continuous tasks (e.g., walking)

■ May be problematic for older adults with decreased endurance

Distributed practice—interspersed practice intervals in which rest time is equal to or exceeds practice time
Variable practice—task is practiced under a variety of conditions
■ Typically enhances learning; however, for some older adults with neurologic or cognitive health issues

variable practice may not enhance learning

Whole-task practice—the entire task is performed at once
■ More beneficial for continuous tasks (e.g., walking)

Part practice—the task is divided into its component parts and each part is practiced separately
Random practice—a variety of tasks are practiced randomly over different trials
■ Typically enhances learning; however, for some older adults with neurologic or cognitive health issues

variable practice may not enhance learning

Blocked practice—one task is practiced continuously
Guidance practice—verbal or physical guidance is provided during practice
■ Typically more beneficial in the early stages of learning

Discovery practice—the learner is encouraged to find a solution during the practice of a task
■ Typically enhances learning; however, for some older adults with neurologic or cognitive health issues

variable practice may not enhance learning

Mental practice—cognitively rehearsing a motor task, without performing the movement
Feedback Intrinsic feedback—sensory and perceptual information originates from the learner
Extrinsic feedback—information is provided by an outside resource, e.g., instructor, instrumentation
(e.g., biofeedback)
Knowledge of results—terminal feedback about the outcome of the movement relative to the goal
■ Typically enhances learning

Knowledge of performance—feedback about the movement itself

■ Typically more useful when learning a new skill

Continuous feedback—feedback provided ongoing during the movement performance

■ Typically more important during the early stages of motor learning

■ Can interfere with learning over time

■ Can create dependence on feedback

Intermittent feedback—feedback that occurs randomly and irregularly during the movement performance
■ Allows the learner to problem-solve and self-detect errors

■ Typically promotes learning more effectively than continuous feedback

■ Progressively decreasing the rate of feedback provided typically is more effective in facilitating learning

Concurrent feedback—feedback that occurs during the movement performance

Terminal feedback—feedback that occurs at the end of the movement; can be immediate, delayed, or
summary (describes average performance after several repetitions)
■ Summary feedback is not typically useful in the initial stages of learning, but improves performance retention

Adapted from Schmidt & Lee (2005).

life has become a topic of great interest as a pathway to posi-
tive aging in many countries (National Seniors Productive
Ageing Centre, 2010). According to Schuller (2010), learning
in later life is the “necessary lubricant” for the dynamics of op-
portunity and activity for older adults. If individuals are to re-
main engaged in meaningful and productive activities as they
grow older, there is a need for continuous training in the
workplace and lifelong learning opportunities in the commu-
nity (OECD, 2006). Later life learning may be undertaken
for a variety of purposes and can comprise the following:
■ formal learning—formal education or training for the pur-
poses of gaining a formal award, qualification, credential,
or other accredited outcome;
■ nonformal learning—structured education or training, but
does not lead to a recognized qualification or credential; and
■ informal learning—learning that takes place through un-
structured, noninstitutionalized learning activities that are
related to personal interests, work, family, community, or
leisure (National Seniors Productive Ageing Centre, 2010).
Interestingly, Jenkins and Mostafa (2015) found that infor-
mal and nonformal types of learning activities were associated
with higher well-being scores, whereas formal learning was not
associated with higher well-being. Although older adults tend
to engage more in nonformal and informal learning, the num-
ber of older learners enrolled in formal classroom learning and
higher education programs has been steadily increasing. For
example, in 2007, it was reported that about 2 percent of un-
dergraduate and postgraduate students were 60 years and older
in the United Kingdom and Australia and about 6 percent
of those students in the United States (National Center for
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390 PART III ■ Active Aging: Supporting Client Activities and Participation
Education Statistics [NCES], 2007; Phillipson & Ogg, 2010).
By 2011, enrollment statistics indicated a 70 percent increase
in learners over the age of 60 years (NCES, 2011). These data
suggest continued and growing interest in intellectual enrich-
ment in later life (NCES, 2011). Considering the economic,
social, and health benefits of learning (see Table 25-3), these
findings are not surprising.
Availability of learning opportunities for older adults
varies from country to country. Some provisions are within
or supported by the formal education system, others rely on
local initiatives, and in some cases, educational programs are
initiated by older adults themselves (Boulton-Lewis, 2012).
Policy (e.g., education, lifelong learning), at multiple levels,
has the potential to affect the lives of older adults in terms of
learning opportunities and constraints.
AROUND THE GLOBE: Program and Policy Initiatives
Related to Later Life Learning
Australia
Organizations that provide adult learning opportunities are
represented by Adult Learning Australia, a not-for-profit
organization funded by the Australian government. Adult and
community education, universities, Technical and Further
Education (TAFEs) vocational and educational training, and
informal learning, such as University of Third Age (U3A) and
study circles, are options for adult learners.
Finland
Because education is viewed as a key to Finland’s economic
sustainability, adult education policy is designed to provide a
variety of learning opportunities and flexible choices via the public
education system, universities, vocational institutes and centers,
adult education centers, folk high schools, “open universities,” study
circles (self-directed learning communities), and the workplace.
Hong Kong
The Labour and Welfare Bureau and the Elderly Commission
launched a school-based Elder Academy Scheme in 2007. The
primary objective of these Elder Academies is to offer older adults
opportunities to pursue studies and participate in activities that
foster their general well-being, both physically and mentally.
Norway
“Competence Reform” was introduced in 1999 to meet the
needs for new societal skills and competencies, and providing
TABLE 253 ■ Benefits of Learning
ECONOMIC BENEFITS SOCIAL BENEFITS
Improved employment opportunities Connecting with others who have similar interests
Higher average wages Creation of social networks
Increased financial literacy and knowledge
Summarized from National Seniors Productive Ageing Centre (2010).
educational opportunities for adults is a core aspect of the
Norwegian educational policy. Adult education in Norway
occurs through the public education system, adult education
associations, folk high schools, study circles, distance education
providers, and the workplace.
Sweden
The aim of Sweden’s education policy is to make the country a
leading knowledge-based nation characterized by high-quality
lifelong learning for both economic growth and justice; there
are a variety of flexible formal and informal opportunities for
learning, including formal education free of charge, language
and cultural education for recent immigrants, independent
supplementary education focused on specialized topics, advanced
vocational education and training, study circles (similar to Finland),
labor market training, and in-service training, which is undertaken
as part of a vocational role. In addition, both informal and formal
adult learning are recognized and validated, and all employees are
entitled by law to unpaid leave of absence for learning purposes.
United Kingdom
The United Kingdom has developed several initiatives designed to
increase the skill level of all adults to achieve its goal of becoming
a world leader in skills. These initiatives do not specifically target
older workers but do encompass older workers who are eligible.
From the National Seniors Productive Ageing Centre (2010).
Elderhostel, Inc. is a nonprofit organization that began in
1975 at five New Hampshire college campuses. Currently it
is regarded as the world’s largest educational travel organiza-
tion for persons aged 55 and over. Under Elderhostel, Inc. is
the Lifelong Learning Institute (LLI), which provides non-
credit college-level educational experiences to more than
100,000 students of retirement age at more than 400 colleges
or universities annually. Local LLIs represent membership
associations with fees typically $25 to $125 per individual per
year. Besides providing a variety of courses led by LLI mem-
bers, host college faculty, or outside experts, these associa-
tions offer such social activities as book discussion groups,
theater trips, and walking and hiking clubs. Annually,
170,000 older adults attend Road Scholar, a program of
Elderhostel, Inc. Road Scholar provides organized activities
that combine education, travel, and adventure in all 50 states,
150 countries, and aboard ships and sailing vessels worldwide.
HEALTH BENEFITS
Improvement in health knowledge
Changes in health behaviors
Improved physical health
Improved well-being and mental health
Improved cognitive performance
Reduced risk for dementia
4605_Ch25_383-396 31/10/17 12:31 PM Page 391
At a cost of several hundred to several thousand dollars per
participant, programs range from “Meetings With Gifted
Scholars” to “Southern Heritage on the Mississippi River” to
“The Seine: D-Day Beaches to Paris.” For both Road Scholar
and LLI courses, there are no prerequisite degrees and no
homework assignments, exams, or grades. Another interest-
ing educational opportunity for older learners is the Univer-
sity of the Third Age (U3A), which was founded by Professor
Pierre Vellas at the Faculty of Social Sciences in Toulouse,
France, in 1973. U3A includes university courses offered in
a local context. Since the early 1970s, U3As have appeared
in many countries worldwide. Although courses have tradi-
tionally been humanities and social sciences courses (e.g., art,
classical studies, computing, crafts, debating, drama, history,
languages, literature, music, natural sciences, social sciences,
and philosophy), course offerings have expanded to natural
sciences and technology areas (Formosa, 2010).
✺
PROMOTING BEST PRACTICE
University of the Third Age
The impact of U3A on a sample of individuals aged 55 to 70
who attended the University Program for Older Adults (PUMA)
at the Autónoma University of Madrid between 2007 and 2011
was examined. Pre–post analyses showed that even when
controlling for education and age, those who participated in the
PUMA demonstrated increased levels of activity, including social
activity, and improved memory, and they also performed better
on tests of information-seeking and general health awareness
compared with the control group who did enroll in educational
courses (Fernández-Ballesteros, Molina, Schettini, & del Rey,
2012). The study findings have important policy implications
for countries seeking to enhance active aging, in particular as
related to health, cognitive, and affective functioning.
Why Do Older Adults Engage in Learning?
Motivation plays an important role in later life learning
(Mulenga & Liang, 2008; Pintrich & Schunk, 2002). The
reasons why older adults engage in learning are complex and
multidimensional, and have been studied for decades. Cog-
nitive interest and a desire to learn are primary motivators,
whether in formal, nonformal, or informal contexts (Jones,
2000; Kim & Merriam, 2004; Mulenga & Liang, 2008).
Evidence suggests the following factors are also pertinent:
■ expressive goals, such as learning for its own sake (e.g.,
Sloane-Seale & Kop, 2010);
■ instrumental goals, such as manage basic survival needs,
maintain a sense of self-effectiveness (Brownie, 2014;
Villar & Celdran, 2014);
■ intellectual curiosity, personal fulfillment, or growth (e.g.,
Luppi, 2009; Villar, Triado, Pinazo, Celdran, & Sole,
2010; Villar & Celdran, 2014);
■ enrichment, enjoyment, self-satisfaction, and a sense of
accomplishment (e.g., Lin, 2011);
CHAPTER 25 ■ Learning in Later Life 391
■ social contact or enriched social contacts (e.g., Jamieson,
2007; Luppi, 2009; Cotten, Anderson, & McCullough,
2013);
■ to remain active, use time productively (e.g., Brownie,
2014; Kim & Merriam, 2004; Luppi, 2009; Villar et al.,
2010); and
■ to keep the mind active, stay mentally stimulated (e.g.,
Boulton-Lewis, Buys, & Lovie-Kitchin 2006; Brownie,
2014).
Although there has been much research over the years
related to why older adults engage in learning, little has focused
on what older adults want and need to learn (Boulton-Lewis,
2012). Boulton-Lewis (2012) suggested that often individu-
als or groups, other than the older adults themselves, make
statements about what they believe older adults should learn;
for example, health professionals indicate older adults should
learn about how to manage their health, and it is others,
rather than the older adult, who believe older adults should
learn about finance or information technology.
Learning and Older Adult Health
Large and persistent associations between education and
health have been observed in many countries, across many
time periods, and for a wide variety of health measures
(Cutler & Lleras-Muney, 2006). People with greater educa-
tion report lower acute and chronic conditions, better phys-
ical and mental functioning, fewer functional limitations, and
are less likely to report poor health and spending more days
in bed or not at work because of health conditions (Cutler &
Lleras-Muney, 2006). What might these findings mean for
older adults? Although Montross and colleagues (2006)
found education levels not to be related to self-rated “suc-
cessful aging,” as noted earlier, health benefits of learning
continue in later life. Improvements in health knowledge and
changes in health behaviors, such as smoking cessation, en-
gaging in exercise, improvements in physical health (Aldridge
& Lavender, 2000), improved well-being and mental health
(Feinstein, Hammond, Woods, Preston, & Bynner, 2003),
improved cognitive performance (Ordonez, Yassuda, &
Cachioni, 2011), and decreased risk for dementia (Wilson,
2002) have all been reported as benefits of participating in
learning for older adults.
Cognitive Reserve
How does education and learning reduce risk for health con-
ditions, such as dementia? The predominant hypothesis is
called cognitive reserve (see Chapter 7), which has support
from epidemiological, imaging, and clinical studies (Stern,
2012). The more cognitive reserve, the more the brain can ac-
commodate disease and resulting pathological changes before
having an impact on daily life. This has been demonstrated
time and time again, and accounts for what can appear to be
a paradoxically rapid decline after a diagnosis of dementia for
4605_Ch25_383-396 31/10/17 12:31 PM Page 392
392 PART III ■ Active Aging: Supporting Client Activities and Participation
persons with high cognitive reserve (Stern, 2012). The so-
called rapid decline seen in persons with high cognitive reserve
occurs because by the time they are diagnosed with a demen-
tia, they have a large amount of neuropathology—in other
words, those with high cognitive reserve enjoy a longer time
functioning well cognitively and independently, despite hav-
ing increasing amounts of neuropathology. For most types of
dementias, the neuropathology increases over time and kills
more and more brain cells; at some point a threshold is passed,
and the person is no longer able to function independently.
Cognitive reserve is multifaceted and includes issues related
to brain structure, brain networks, brain compensatory mech-
anisms, and day-to-day compensatory strategies. Cognitive
reserve is positively affected by formal education, life-long
learning, cognitively challenging occupations, socializing,
physical health and cerebrovascular health, physical activity
and exercise. Merely reading this chapter and, importantly,
actually learning this information is contributing to the
reader’s cognitive reserve. As noted earlier, all new learning
changes the structure of the brain.
Health Literacy
Most older adults have at least one chronic condition, and
many have multiple chronic conditions. Learning needs re-
lated to health are typically more complex and greater for
older adults compared to any other age groups. Evidence
suggests that older adults can benefit from health-related
learning and do adhere with specific directions. Although
literacy and health literacy are closely related, they are dif-
ferent concepts. No standard international definition of lit-
eracy exists nor captures all of its facets. There are various
and different understandings of literacy, some of which are
contradictory; and, globally, literacy is defined somewhat
differently by different countries. Literacy is considered a
fundamental human right and the foundation for lifelong
learning (UNESCO, 2004) and has been defined as the
ability to identify, understand, interpret, create, communi-
cate, compute, and use printed and written materials asso-
ciated with varying contexts. Literacy involves a continuum
of learning to enable an individual to achieve his or her
goals, to develop his or her knowledge and potential, and
to participate fully in the wider society (p. 13).
Health literacy refers to the ability of individuals to gain
access to, understand, and use information in ways that pro-
mote and maintain good health (World Health Organization,
2009). Health literacy is influenced by several factors, includ-
ing an individual’s cognitive and social skills, basic literacy
skills, communication skills of health professionals, and the
situations one encounters in the health-care system (U.S.
Department of Health and Human Services, 2007). Although
anyone can have low health literacy, including people with
good literacy skills, inadequate health literacy disproportion-
ately affects older adults. The 2003 National Assessment of
Adult Literacy found that only 3 percent of adults aged 65 years
and older were proficient in health literacy skills (Kutner,
Greenberg, Jin, & Paulsen, 2006). Low health literacy among
older adults is associated with higher hospitalization rates, dif-
ficulty managing chronic diseases, unnecessary health-care
costs, and increased mortality (Baker, Wolf, Feinglass,
Thompson, Gazmararian, & Huang, 2007; Center for Health
Care Strategies, 2000; Gazmarian, Williams, Peel, & Baker,
2003; Sudore et al., 2006).
✺ PROMOTING BEST PRACTICE
Health Literacy and Mortality
A population-based longitudinal cohort study investigating the
association between low functional health literacy and mortality
in older adults living in England reported that one third of older
adults had difficulties reading and understanding basic health-
related written information (low functional health literacy).
Low functional literacy was also associated with higher
mortality (Bostock & Steptoe, 2012). As rehabilitation
professionals play a vital role in the care and education of older
adults, an understanding of health literacy and how it influences
health-care and health outcomes is central to providing client-
centered care and effecting health outcomes.
Considering the prevalence of low health literacy in older
adults and the subsequent consequences, a component of the
occupational or physical therapy evaluation should include
assessment of health literacy. There are several instruments
available; see the Web resources in the online ancillaries.
E-Learning in Later Life
With the breadth of available information and resources, the
Internet provides an important tool for older adults to remain
independent, to socialize with family and friends, and to make
informed decisions about many topics including health infor-
mation and personal interests (Boulton-Lewis, 2012; White &
Weatherall, 2000). Older adults who have health problems and
are socially isolated are especially likely to benefit from using
Web-based technology because it allows them to carry out an
increasingly diverse array of tasks (N. G. Choi & DiNitto,
2013). According to White and Weatherall (2000), older adults
use technology because of their desire to be in touch with “mod-
ern life today” (Figure 25-1). Many benefits of computer and
Internet training and use, and e-learning have been reported,
including decreased social isolation and maintenance of geo-
graphically dispersed connections (Sum, Mathews, & Hughes
2009); ability to maintain social networks even when physical
mobility is affected (Chaffin & Harlow, 2005); decreased lone-
liness (M. Choi, Kong, & Jung, 2012; Cotten et al., 2013); in-
creased life satisfaction and mental function and decreased
depression (McConatha, 2002); ability to engage in contin-
uing education and maintain educational activities (Russell,
Campbell, & Hughes, 2008; Swindell, 2002); and increased
learning from health-related information and increased ability
to research non-health-related information (Crabb, Rafie &
Weingardt, 2012; Xie, 2011).
4605_Ch25_383-396 31/10/17 12:31 PM Page 393
FIGURE 251 Older adults receiving computer and Internet training.
Highwaystarz-Photography/iStock/Thinkstock
AROUND THE GLOBE: Older Adults’ Internet Use
Among Hong Kong Chinese adults between the ages of 55
and 91, males had higher frequency of Internet use than females.
Education was significantly correlated to perceived ease of use,
behavioral intention of Internet use, and frequency of Internet use;
physical health was positively related to frequency of Internet use.
In addition, perceived ease of use and attitudes, but not perceived
usefulness, were significantly predictive of behavioral intention to
use the Internet to search for health information (Wong, Young,
Ho, Tue, & Lam, 2014).
Frequency of computer and Internet use among Serbian older
adults was found to be 20.2 and 19 percent, respectively. Internet
use was lower compared with older adults in other countries,
including Korea (28.5 percent), the United Kingdom (29.8 percent),
and Australia (31.0 percent). In particular, being younger, having
fewer people living in the household (e.g., not having to care
for others), being more educated, having a higher income, and
having fewer comorbidities were correlated to Internet use
(Gazibara et al., 2016).
Almost half (45.3 percent) of Italian adults aged 50 years and
older have Web access. Of those older adults with a chronic
cardiovascular condition, 17.1 percent had Web access, with access
decreasing with increasing age; 57 percent of those with Web
access had basic information and communications technology
(ICT) skills, 40 percent asked family members for assistance for
ICT use, and the majority used the Internet to search for health
information (Romano et al., 2015).
These three studies suggest that ICT skills and use and nonuse
among older adults are variable and are dependent on demographic
and sociocultural characteristics. Older adults (in particular, younger
older adults) are learning to appreciate new technologies and are
using technology to search for health information. However, access
to technology remains an issue across the globe, and occupational
and physical therapists need to be aware of the demographic and
sociocultural elements that affect access and technology use.
Older adults’ overall health is positively associated with
computer and Internet use (N. Choi, 2011; N. G. Choi &
CHAPTER 25 ■ Learning in Later Life 393
DiNitto, 2013; Gracia & Herrero 2009; Werner, Carlson,
Jordan-Marsh, & Clark 2011). Although physical and func-
tional health problems may pose barriers to computer use,
having health problems may also motivate older adults to take
advantage of health information technology and seek health
information online (N. G. Choi & DiNitto, 2013; Flynn,
Smith, & Freese 2006). In addition, older adults with health
problems may use the Internet to address daily health and
disability-related care needs and to manage various aspects
of their health care (N. G. Choi & DiNitto, 2013). Despite
their rapidly increasing rate of Internet use, older adults do
still lag behind younger adults in everyday computer and In-
ternet use (N. Choi, 2011). Not surprising, older adults who
are non-Hispanic white, who are “younger,” and who have
a higher socioeconomic status (based on education, health
literacy, and income) are more likely to use the Internet
(N. Choi, 2011).
✺
PROMOTING BEST PRACTICE
Learning to Promote Healthy Behaviors
One hundred and forty-nine older adults (mean age = 65 years,
SD = 6), from a unique Belgian French-speaking municipality,
were randomized in one of four research groups for a
3-month intervention aimed at promoting physical activity
(PA) in older adults: (a) Web-based, (b) center-based,
(c) mixed (combination of Web- and center-based), and
(d) control (no intervention). The center-based intervention
was found more likely to produce significant improvements
in PA levels and the stage of change for PA change,
whereas the Web-based intervention was found to increase
awareness about PA. Only the mixed intervention condition,
comprising both online and offline components, resulted in
a significant increase of PA levels at 12 months. The study
findings underscore that older adults are accepting of a
Web-based intervention and that low computer knowledge
and skills should not be considered an automatic or
insurmountable barrier for behavioral change for older
adults (Mouton & Cloes, 2015).
SUMMARY
This chapter has provided an overview of learning in later life.
Older adults engage in a variety of formal, nonformal, and
informal learning activities, including e-learning, for various
reasons, leading to a multitude of social, economic, and
health benefits. Because of the strong links among education,
learning, and health in older adults, an older adult’s educa-
tion, literacy, and health literacy levels are important factors
to consider. Older adults can and do learn, and it is up to
occupational and physical therapists to recognize the age-
related factors that may affect learning (and hence “teaching”)
and respect older adult learners as individuals. Therapists
should use their knowledge and skills to maximize the learn-
ing environment for the older adult.
4605_Ch25_383-396 31/10/17 12:31 PM Page 394
394 PART III ■ Active Aging: Supporting Client Activities and Participation
CASE STUDY 1
Mrs. Papadopoulos
Mrs. Margeta Papadopoulos is a 95-year-old woman
who lives with her two daughters. She is completely in-
dependent in ADL and instrumental ADL and enjoys
gardening, spending time with her grandchildren, and
playing cards at her local Greek community center.
Mrs. Papadopoulos has hypertension, coronary artery
disease, and cataracts, and she has difficulty hearing in
crowded spaces. Mrs. Papdopoulos has been referred to
the therapist because of bilateral knee osteoarthritis
(OA), which is interfering with her ability to garden and
walk to the community center. The therapist wants to
plan an education session with Mrs. Papdopoulos to ed-
ucate her about exercise considerations, precautions, and
recommendations specific to OA.
Questions
1. What additional factors would be important to gather
and consider about Mrs. Papdopoulos as the “learner”?
2. How would the therapist go about determining
Mrs. Papdopoulos’s learning needs?
3. What strategies should be incorporated into your
education session?
4. How will learning be evaluated?
5. Develop an appropriate one-page handout for
Mrs. Papdopoulos about exercise considerations
and precautions, taking into account her possible
learning needs.
CASE STUDY 2
The Women’s Outreach Group of the Shiva
Vishnu Hindu Temple
The Women’s Outreach Group Executive of the Shiva
Vishnu Hindu Temple contact a therapist because they
are interested in having a health-care professional speak
to them about falls prevention. The women who will be
attending the 2-hour education session range in age from
50 to 103 years, not all are fluent in English, and educa-
tional levels vary.
Questions
1. What additional factors would be important to
gather and consider about the “learners”?
2. How should the therapist go about planning the
education session?
3. What strategies would be helpful to incorporate into
the education session?
4. How might learning be evaluated?
Critical Thinking Questions
1. What are the critical elements to consider when
developing written educational materials for older
adults?
2. Compare and contrast the following in terms of
description and implications for older adult learning:
short-term memory and long-term memory; episodic
memory and procedural memory; declarative learning
and nondeclarative learning; semantic memory and
prospective memory; free recall and supported recall;
memory trace and cognitive reserve.
3. Describe five strategies that occupational and
physical therapists can use to maximize learning
in older adults.
4. Compare and contrast the three stages of motor
learning in terms of description and implications
for older adult learning.
5. Describe how the following may influence the
teaching-learning process for older adults: sensory
changes, psychological and physical changes,
sociocultural factors, literacy, health literacy.
6. (a) Compare and contrast formal, nonformal, and
informal learning for older adults. (b) Provide an
example of each that can be found in your own
community
7. Describe relationship(s) between learning and older
adult health.
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“ There is a fountain of youth! It is in your mind, your talents, the creativity you bring to
your life and to the lives of others. When you tap this source, you will truly have defeated age.
LEARNING OUTCOMES
By the end of this chapter, readers will be able to:
1. Provide a working definition of spirituality.
2. Explain why occupational and physical therapists may be
interested in the spiritual aspect of elderly clients.
3. Identify several possibilities for engaging clients on a
spiritual level.
Clinical Vignette
Joan Wilson is an 80-year-old woman who was in excellent
health before a stroke that had only minor physical conse-
quences but left her speech unintelligible. Speech therapy
is involved to help with her speech, and some progress has
occurred in her ability to speak more clearly. As an occupational
or physical therapist, you are seeing Joan 2 months later; she is
living in the home of her daughter and family. You have been
asked to consult on a possible activation program because Joan
currently spends all her time sitting in a chair, often crying. She
often seems to be looking up at the ceiling, hands clasped
tightly in front of her in a posture reminiscent of prayer.
1. What kinds of cues might make you think that Joan
is thinking about spiritual issues, like how this could
happen to her, what it means about her relationship
with God, whether she is ready to die?
2. How might you be able to discover whether Joan is a
spiritual person or not?
3. As a therapist, are you guided by a personal spirituality
that shapes how you encounter spiritual issues in others?
If so, what effect might that have on your care of this
patient and her spiritual needs? How should providers
respond if they do not have a sense of spirituality?
T he final chapter in this section deals with spirituality
among older people. It addresses the question of why
occupational and physical therapists working with older
people need to understand the role of spirituality in their own
lives and in the lives of others. The chapter begins—as does
CHAPTER 26
Spirituality
Mary Ann McColl
—Sofia Loren
”
virtually every discussion of spirituality—by acknowledging
the difficulty of defining the construct. To define spirituality,
one has to accept the possibility of offending some and dis-
appointing others. That said, the following definition is a
starting point and a common reference for our discussions.
Defining Spirituality
The literature is clear that there are two features that appear
in almost every definition of spirituality: a relationship to a
higher power and a relationship with meaning or purpose in
life (Cunningham, 2002). Let us begin with a definition
derived in the simplest fashion, from etymology (McColl,
2000, 2003). It goes like this:
Spirituality is an abstract noun, made up of three parts:
SPIRIT (root) + UAL (suffix; of or related to) +
ITY (suffix; a state or quality)
Starting at the end and working backward, the suffix -ity
refers to “a state or condition”; therefore spirituality literally
means the state or condition of being spiritual.
But what does spiritual mean? The suffix -ual means “of
or related to”; therefore, spiritual means of or related to spirit.
The adjective spiritual might be used to describe a person, a
place, or an object. When applied to a person, spiritual refers
to someone’s relatedness to spirit. As Collins (2007) put it,
different people have different thresholds for experiencing
spirit.
So far, we have the state or condition of being related to spirit.
This brings us back to the root word: spirit. A standard dic-
tionary definition of spirit is a force or energy that animates living
things. According to Unruh (2002), there are three ways to
understand this force or energy: religious, sacred, or secular.
■ Religious: A religious understanding of spirit refers to a par-
ticular religious doctrine or faith. Members of that religious
group agree (to a greater or lesser extent) as to what spirit is
called and how it operates. For example, the three major
monotheistic religions call that force God, Yahweh, or Allah.
397
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398 PART III ■ Active Aging: Supporting Client Activities and Participation
■ Sacred: A sacred understanding of spirit sees it as beyond
human understanding, but not necessarily aligned with a
specific religion or faith tradition. The sacred perspective
acknowledges that spirit is eternal, divine, sacred, holy; that
it arouses fear, awe, mystery; that it has majesty, power. It
does not tend to use the language of any particular religious
tradition to describe or name it.
■ Secular: A secular understanding of spirit refers to some-
thing that can be understood by human beings, and can be
perceived with our senses. The secular perspective defers to
science and to the laws that govern the universe. A secular
definition of spirit describes it as a product of human will,
emotion, and intelligence.
If we are to have any sort of meaningful dialogue about
spirituality, it is important for us to be able to acknowledge
differences in conceptualizations and to listen to each other
and hear what the other means. We don’t necessarily have to
agree about the definition of spirituality, but we have to be
able to tell other people what we mean by spirituality and be
prepared to listen to what others mean. McGinn (2005) sug-
gested that any workable definition of spirituality must be:
■ hermeneutical—it must promote a dialogue;
■ ecumenical—it must apply across the boundaries of reli-
gious or faith traditions, including also those who adhere
to no particular tradition; and
■ liberating—it must promote equity and freedom from oppres-
sion, rather than being used as an instrument of oppression.
To that end, a smoothed-out version of the etymological
definition cited earlier is presented, acknowledging that the
root word spirit may be interpreted in different ways by differ-
ent individuals: Spirituality is sensitivity to and desire for the
presence of spirit (McColl, 2011).
Differentiating Religion from Spirituality
In some peoples’ minds, spirituality and religion become
inextricably entangled, and the characteristics of one, be they
desirable or undesirable, are attributed to the other. The
discussion begins by distinguishing between spirituality and
religion so that we can talk about both and be clear and
precise in our discussions.
It has already been noted that spirituality is a human char-
acteristic of being sensitive to or seeking the presence of spirit.
Religion, on the other hand, is an organized, institutionalized
expression of belief and system of worship. Ellwood (1993)
defined religion as a human-made organization that “actualizes
(or acts out) who one is deep inside” (p. 4). Most important
about this definition is that we understand that religion is en-
tirely a human-made enterprise. Although it exists to honor
and celebrate what people believe to be sacred or divine, reli-
gion is in itself a human undertaking and a human institution.
Some people would say that religion is a subset of spir-
ituality. Although all people possess the characteristic of
spirituality to a greater of lesser degree, a subset of those
people express their spirituality through organized religion.
Spirituality does not require any institutional structure;
however, for many people, religious traditions provide the
institutional structure and (it is hoped) supportive commu-
nity within which they seek to develop their spirituality.
Others would say that spirituality is a subset of religion—
that the quality of humans that allows them to experience
spirit is only one of the many facets of religion. Other facets
include the desire for community, an explicit morality, specific
beliefs and practices, and a shared form of worship. Either
way, what is important to clarify for our subsequent discus-
sions is that spirituality is an intrinsic characteristic of humans,
while religion is an institutional, organized way of viewing the
world and acting accordingly.
Spirituality as a Vital Dimension
of Rehabilitative Practice
Occupational and physical therapists working with older peo-
ple may be interested in spirituality for at least five reasons.
As Human Beings
From the beginnings of recorded history, human beings have
been fascinated by the prospect of a layer of existence and
meaning that is beyond our grasp. Humans have always
venerated invisible powers that they deemed responsible for
the ways of the world. Some authors and theologians suggest
that it is in the very nature of humans to be aware of spirit
and to seek to understand and approach it (Eliade, 1987).
As Health Professionals
In the course of their daily work lives, health professionals
have more direct experience with the challenges and finitude
of life than virtually any other occupational group. Day in
and day out, they are faced with the presence of illness, dis-
ability, suffering, and death. To be able to continue to relate
constructively in these situations, health professionals need a
way of making sense of all this suffering and loss. When faced
with questions of why people live or die, suffer or recover,
health professionals are often impelled to seek answers
through spiritual or religious beliefs. Kevin and Wildes
(1992) noted that the fundamental human experience of fini-
tude drives both medicine and religion. Where the former
seeks to conquer finitude, the latter seeks to understand it.
As Occupational Therapists in Particular
Occupational therapists have had the triad of mind-body-
spirit in their consciousness from the profession’s origins in the
early part of the 20th century. Although the rational-scientific
paradigm and the medical model began to dominate the health
sciences in the 1950s, occupational therapists have never
lost sight of the moral and religious origins of occupational
therapy (Friedland, 2009). The concept of spirituality was
explicitly reintroduced in the early 1980s, as part of an
4605_Ch26_397-404 31/10/17 12:30 PM Page 399
ideological renaissance in occupational therapy (OT). Specif-
ically, spirituality appeared at the core of the person in the
Canadian Model of Occupational Performance (Department
of National Health and Welfare & Canadian Association
of Occupational Therapists, 1983). Occupational therapists
believe that there is a special relationship among spirituality,
occupation, and health. Occupation has been described as a
doorway to spirit, a bridge to health, a source of meaning in
life, and a resource in stressful times (McColl, 2002, 2011;
Urbanowski & Vargo, 1994).
Note that although this section addresses OT specifically,
there has been growing awareness in a variety of health-care
professions over the past several decades about the value of
spiritual interventions in improving health and health care
(cf. Koenig, 2008). This is true in physical therapy (PT) as
well (Tapley, Fell, & Pitts, 2012). Physical therapists perceive
spiritual concerns as an important component of health,
although they are somewhat less likely than physicians
and occupational therapists to take a direct role in spiritual
interventions (Oakley, Katz, Sauer, Dent, & Millar, 2010).
Willingness to be open to discussion of spiritual concerns and
to acknowledge their importance to clients can be meaningful
in any therapeutic context.
As Witnesses and Advocates for People
With Chronic Illnesses and Disabilities
Whereas professionals encounter existential issues on a
general level, the people we work with encounter them on a
very personal level. The experience of illness or disability
raises questions of a profoundly spiritual nature, such as the
following: Why has this happened to me? Is there a force for
retribution or punishment at work in the world? Is the world
a fair and just place? Who is in control of my life? What is
the plan for my life? What does it mean to be human? Is my
humanity compromised by illness or disability? Am I still
acceptable to others, to my community, to the Divine (if
I have a relationship with a divine being)?
Our own research on spirituality and disability showed that
people with disabilities experience five common themes related
to spirituality and their relationship with a higher power:
awareness, intimacy, trust, vulnerability, and purpose (McColl
et al., 2000a, 2000b). Eiesland (1994) has suggested that the
search for meaning in disability ultimately leads people with
disabilities to conclude that they cannot be in a “normal” rela-
tionship with the world and with a supreme power. Typical
interpretations of the experience of illness or disability include
a punishment for sin, a test of strength or fitness, an opportu-
nity for virtue or redemption, a focus of mission and service, a
sacrifice to pay for transgressions, an expression of an omnipo-
tent deity, a cause for conversion, a reminder of embodiment,
or simply as a condition of life (Idler, 1994; McColl, 2011).
To be able to serve people facing these issues, regardless
of their age or stage of life, we need to understand how
chronic disease and disability affect our clients spiritually, as
well as physically, socially, and emotionally. Eiesland (1994)
CHAPTER 26 ■ Spirituality 399
acknowledges disability as a source of difficulty in the lives of
individuals, and as a source of oppression and alienation both
socially and historically. However, she also sees disability as a
source of creativity and resourcefulness, and she sees life with
a disability as an expression of faith and solidarity. She encour-
ages health professionals to seek a better understanding of the
spiritual lives of individuals living with disability. According
to Kleinman (1988), such an understanding may break the
“vicious cycle of distress,” contribute to better care by health
professionals, counteract the overly technical aspects of the
health-care experience, and offer possible coping strategies.
As Specialists in Elder Care
Finally, there is abundant evidence that spirituality takes on
special meaning in the later decades of life. Developmental
theorists, such as Erikson, Tornstam, Fowler, Moody, and
Carroll, have all characterized the later stages of life as in-
creasingly spiritual (Atchley, 2009; MacKinley, 2006). There
are two typical explanations for this. One is the cohort effect.
The cohort of older adults today grew up in a world where
religious participation was much more common and where
religious interpretations were more normative. Religious
organizations were at the center of many families and com-
munities and of many aspects of public life. This generation
grew up with religious habits, such as prayer, worship, and
participation in a faith community. They have more natural
access to language for describing spiritual experiences (albeit
religious language). They are more inclined to interpret events
large and small through a religious lens.
The second explanation relates to the increasing proximity
of death as one ages. Some theorists believe that a major stim-
ulus for spiritual or religious searching is the fear of death. As
a species, when humans became capable of contemplating
their own mortality, a need arose to alleviate the fear associ-
ated with death and nonbeing. The solution to this need was
to try to explain what lay beyond the limits of the material
world—what happens when we die, where we come from,
who controls what happens to us. As far as we know, no other
creature appears to be capable of appreciating that its own life
is finite, and that time exists before and after its lifetime.
Regardless which of these reasons one believes for the
emphasis on spirituality in later life, the evidence is clear that
spiritual factors can positively affect health, well-being, and
mental health among older adults (Hicks, 1999; Marcoen,
1994; Meisenhelder & Chandler, 2002). A systematic review
recently showed that the sense of connectedness to others, to
a faith community, to the world in general and to a higher
power was associated with increased hope and confidence in
old age (Joanna Briggs Institute, 2010).
Several themes consistently arise in discussions of later life
spirituality:
■ Emphasis on the spiritual rather than the material world,
on being rather than doing
■ Transcendence of the self and the ego in favor of a more
universal perspective
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400 PART III ■ Active Aging: Supporting Client Activities and Participation

■ Acceptance of paradox and ambiguity, and relinquishing

the ideal of coherence
■ Adoption of a cosmic perspective on issues of life and
death, space and time
■ A sense of belonging (vs. isolation) and a selectivity about
roles and relationships
The spiritual needs or tasks of elders have been character-
ized as follows (Koenig, 1994; MacKinley, 2008):
■ The search for life’s meaning, in day-to-day activities, in
the overall life trajectory, and in the world as a whole
■ The need to transcend specific personal circumstances, such
as ill health or other losses
■ The desire for continuity of one’s own identity, but also of
one’s beliefs, values, and hopes
■ The need to reconcile past hurts, angers, doubts, and
injustices
■ The need to reinforce connections and relationships,
including the relationship with the Divine
■ The need to forgive and be forgiven
■ The desire to express gratitude
■ The will to continue to be of service, to contribute, to give FIGURE 261 A Thai woman worships privately, with prayer beads in
■ The need to prepare for death and the desire for personal hand. Andy_Q/iStock/Thinkstock
dignity

Approaches to Spirituality in Therapists have four choices in terms of how to respond

Occupational and Physical Therapy
Occupational and physical therapists can engage with older
adult clients regarding their spiritual lives in many ways. This
section outlines four ways of thinking about the role of ther-
apists and six specific interventions that might be employed.
It is intended to provide some tools for those instances where
it is clear that a spiritual issue is present.
There are usually two ways that clients let us know that
they are amenable to spiritual discussions or that their func-
tional problems may have a spiritual component or a spiritual
origin: directly and indirectly. Some clients will be explicit
about their religious beliefs and convictions, their public or
private faith practices, and their relationship with a Higher
Power. Others will approach the issue more indirectly by
displaying symbols of their faith tradition or by asking ques-
tions about issues such as life after death, reasons for things
that happen, search for meaning, or loss of hope or faith.
AROUND THE GLOBE: Cultural Competence and Spirituality
It is important to keep in mind cultural differences in spiritual
expression (Figure 26-1). Spirituality is significantly related to
culture and requires highly developed cultural competence to
be able to address in practice. One need not know about every
religion to be able to talk to someone about his or her spirituality.
Discussions of spirituality may deal with generic concepts, like the
relationship with a higher power, hope for the future, meaning in
life, or belonging in a faith community.
to either a direct or an indirect overture about spirituality.
Each is briefly outlined here.
Acknowledge the Issue
The first thing that a therapist can do, and something that
perhaps every therapist should be prepared to do (regardless
of his or her own faith experience or preparation), is to listen
for and recognize the words, symbols, ideas, and themes that
clients may use to alert the therapist to the potential for a
spiritual issue. Spiritual issues are sufficiently sensitive in our
culture that clients may be insecure about raising them. It
would be a shame indeed if a therapist was unable to appre-
ciate the depth and importance of a spiritual issue that a client
was trying to raise and therefore left it unattended.
There are two difficulties that therapists typically en-
counter when clients raise spiritual issues. Either they do
not have language or concepts to respond confidently and
professionally to such an overture by a patient, or they are
worried about imposing their own beliefs and values on the
client. Both are legitimate issues, but both can be dealt with
by simply acknowledging the depth and importance of the
issue the person is raising and asking if he or she would like
to discuss it further.
Refer to a Spiritual-Care Professional
Another legitimate option for therapists encountering
spiritual issues in their older clients is to offer to help them
find someone who is qualified to have in-depth spiritual
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CHAPTER 26 ■ Spirituality 401

conversations with them. This may be an officiant of the

person’s own faith tradition, or it may be a multifaith chap-
lain, such as work in many hospitals and long-term care
facilities. Referral to a spiritual counselor can be a very
effective therapeutic contribution for a client who is strug-
gling with a spiritual issue.

INTERPROFESSIONAL PRACTICE
The Chaplain as Part of the Health-Care Team
Physical and occupational therapists may work closely with
chaplains, ministers, rabbis, imams, and other spiritual leaders
in addressing their clients’ spiritual and religious needs. These
religious leaders have specific training and expertise to equip
them to help clients address important existential questions.

Intervene Directly Using Spiritual

Interventions
Direct spiritual intervention refers to specific faith practices,
such as prayer, meditation, worship, or spiritual counseling. FIGURE 262 Meditation is a form of direct spiritual intervention.
These interventions usually require additional training and moodboard/moodboard/Thinkstock
qualifications to be able to administer with integrity and
expertise.

✺
PROMOTING BEST PRACTICE
Guidelines for Direct Spiritual Interventions
Most therapists will not feel that these practices are within their
professional scope of practice, unless they have obtained some
specialty certification. McColl & Farah (2011) offer guidelines for
the use of direct spiritual interventions (Figure 26-2). They
suggest that if the therapist can answer positively to the
following four questions, then it may be appropriate to
undertake a direct spiritual intervention:
■ Is the client’s problem inherently spiritual in nature?
■ Is the client receptive to spiritual intervention?
■ Is the therapist qualified to offer the spiritual intervention?
■ Would the therapist’s employer support him or her in
offering this type of intervention?
If the answer to all four questions is yes, then a therapist
may consider offering to pray, meditate, worship, or engage
in other spiritual practice with a patient.
McColl and Farah (2011) outlined several cautions, such
as the need for a secure therapeutic relationship, the necessity
for the practice to be genuine, the assurance that it is in no
way forced or imposed.
Intervene Indirectly Using Familiar
Therapeutic Interventions
Indirect spiritual interventions refer to a set of therapeutic
practices that offer the opportunity of a spiritual experience
or discussion but that are not inherently spiritual or religious
in character. A review of the rehabilitation literature revealed
six modalities that may be used in dealing with spiritual issues
among older adults. These modalities, detailed subsequently,
can be used by therapists even if they are not spiritual or
religious themselves.
Narrative
The process of creating and relating narratives has received
considerable attention in the gerontology literature. Accord-
ing to Kirsch (2011), narratives are vehicles for spiritual
exploration and growth. They enable the narrator to create
meaning, to connect to spiritual themes (e.g., hope, healing,
and redemption), and to make connections across past, pres-
ent, and future. The power of narrative lies in its potential to
relate an individual’s story to the story of the whole cosmos—
in relation to other people, to the natural world, and to one’s
own belief in a supreme power. Particularly in older people,
the process of life reminiscence may be a powerful tool for
spiritual expression and exploration.
Ritual
Rituals refer to ordinary activities that are invested with sym-
bolic meaning when performed to celebrate, commemorate,
or sanctify important events or ideas (MacKinley, 2006;
Niven, 2008; Thibeault, 2011). They have the power to mark
passages, transitions, and milestones. They allow individuals
to transcend the ordinariness of the activity and to reach a
new level of understanding of their place in their own lives,
their relationships, and the world.
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402 PART III ■ Active Aging: Supporting Client Activities and Participation
Appreciation of Nature
Appreciation of nature as a therapeutic activity has the
potential to promote spiritual growth and discovery (Unruh,
2011). Experiences in the natural world, such as walking
through the woods or sitting by a stream, can dissolve the
boundaries between the self and the world and make one
more aware of the mystery and connectedness of all things.
The sense of awe and wonder that often accompanies experi-
ences in nature can evoke thoughts and feelings about beauty,
creation, and the divine.
Creativity
A fourth type of indirect spiritual intervention is creative
activity, or what Peloquin (1997) referred to as “making
rather than doing” (p. 168). Creative activity affords an
opportunity for unconstrained expression of spirit and com-
munication of universal truths. Often spiritual concepts defy
expression through language, and instead are more effec-
tively communicated through the universally accessible
media of imagery music, or visual arts (Toomey, 2011;
Woodbridge, 2011).
Work
Work is an occupational medium that offers individuals an
opportunity for service and contribution, participation in a
shared mission, the dignity associated with a job well done,
and the rhythm of work and the orderliness of time struc-
tured by work routines. The workplace, whether it be at
home, school, community service, voluntary work, or remu-
nerative work, affords a sense of belonging and achievement
and reinforces the individual’s place in the world (Baptiste,
2011).
Movement
Movement therapy can evoke spiritual remembrance of our
physical connection to the earth, to our bodies, and to each
other. Embodiment is a fundamental aspect of what it means
to be human, even when the body is physically limited or
constrained. The fragility of the body, particularly among
older people, emphasizes the transition from material to spir-
itual and reminds us of the finite nature of our lives.
✺
PROMOTING BEST PRACTICE
Movement as Spiritual Expression
In a study in 2000, Bonder and Martin interviewed two women
who were self-described as highly spiritual and devoted to
their churches. One woman participated in traditional church
activities: attending services, participating in community
service, and doing good works. The other participated largely
through dance-related activities. She rarely attended services
but felt close to her congregation through movement-oriented
spiritual expression.
SUMMARY
This chapter has explored spirituality in physical and occu-
pational therapy with older adults. It began with a definition
of spirituality and a discussion of some of the difficulties in
talking about spirituality. We differentiated spirituality from
religion, while recognizing that for many people in the older
generations, religious participation and private religious
practices are an essential part of spiritual expression. We
looked at the importance of understanding spirituality in the
therapeutic relationship, both on the therapist’s side and on
the client’s side. Finally we explored what therapists can do
to acknowledge and support the spiritual aspects of our
clients. Four possible courses of action were offered, two of
which involve professionals with specific spiritual care train-
ing, and two of which could fall into the realm of occupa-
tional and physical therapists. These include (1) recognizing
spiritual themes when clients express them and finding ways
of responding to those overtures that do not foreclose the
conversation and (2) using indirect spiritual interventions to
afford clients an opportunity for spiritual exploration and
growth.
CASE STUDY
Martha Anderson is a 92-year-old widow who lives in
a low-income area of a large city. She has four grown
children and had another daughter who died at age 30
of a drug overdose. Two young-adult grandchildren live
with Mrs. Anderson. She worked at the post office until
her retirement 30 years ago. Since then, she has helped
her children with child care, spent time in her garden,
and participated actively in her church. She worshipped
every Sunday, attended Bible classes during the week,
and participated in the Church Women’s Group chari-
table and social activities. She describes herself as a devout
Baptist.
Mrs. Anderson has type II diabetes, arthritis, and
macular degeneration. In the past 3 years, these physical
ailments have made it increasingly difficult for her to
participate in church activities. Friends from the Women’s
Group visit her frequently, but she reports feeling cut off
and lonely.
Questions
1. To what extent do you think Mrs. Anderson’s
church-related activities reflect a sense of
spirituality?
2. What are potential consequences of her difficulty
addressing her current spiritual needs?
3. What other needs might be met by her church
participation?
4. What strategies might you suggest to help her feel
more connected?
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Critical Thinking Questions
1. Do you acknowledge that spirituality has spirit as its
root, and therefore to discuss spirituality, we need to
be explicit about what we mean by spirit? Or do you
have a more vague and generic definition of spiritual-
ity that is not necessarily based on the root-word
spirit?
2. Do you believe that spirit is located within human
beings, perhaps at the very core of human beings? Or
do you believe that spirit is shared among humans,
and binds humans to one another in some mysterious
cosmic way?
3. Does your definition allow for the possibility of
things that humans cannot understand, measure,
or situate in time and space? Or do you believe that
humans are ultimately capable of understanding all
that there is?
4. In seeking to develop your own personal spirituality,
or to assist clients to invoke their own spirituality, do
you imagine pursuing that individually, privately, or
in community, in relationships, through sharing time
and space?
More important than the answers is the discipline of mak-
ing the questions explicit. This permits us each to confront
what we believe about spirit.
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Krisch, B. (2011). Narrative: What makes narratives spiritual and how can
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PA RT IV
Service Delivery for the Aging Client
A winding road has brought readers to this section of
the text, which, at long last, addresses the specifics of
intervention. Although there has been discussion throughout
the book of therapeutic factors, this section places them in
the contexts in which they occur.
One important consideration here is that this section is
structured on the basis of health-care systems (a word that
doesn’t quite capture the realities of health care in the United
States) as they exist in the United States. A substantial chal-
lenge for individuals needing care and the institutions that
provide that care is the unfortunate lack of coordination
among those systems. Although Medicare, the dominant
third-party payer for health care for older adults in the
United States, attempts to coordinate benefits (Centers for
Medicare and Medicaid, 2014), the reality is that regulations
for care and for payment remain convoluted. Gaps remain
and can cause significant hardship to individuals and their
families.
Furthermore, because these systems operate on different
sets of regulations, with different requirements for intervention
and payment, transitions can be difficult and dysfunctional.
One 83-year-old man was discharged home from an acute care
hospital because he no longer needed hospitalization. He did
not qualify for rehabilitation, so Medicare would not cover a
nursing home stay, and he had too many assets to qualify for
Medicaid coverage of long-term care, even though his income
was only slightly above the U.S.-defined poverty level. His
adult children lived at a distance, his home did not have a first-
floor bathroom (and he could not climb stairs), leaving him in
a dire situation. Such stories are all too common.
Even when the transition is a smoother one, movement
from one system to another requires transfer of information
that may or may not happen effectively, separate evaluation
to conform to system regulations, expensive transport that
may not be covered by any source of funding, and adjustment
by the individual—often in a weakened and confused state—
to a new environment and new carers. Such transitions can,
in and of themselves, result in complications and excessive
stress for the individual.
Emerging trends may improve the situation somewhat.
The Affordable Care Act (ACA; hhs.gov, 2015) encourages
use of electronic medical records that can enhance access to
information as individuals are transferred among institutions.
But even with the implementation of the ACA, gaps and
overlaps remain—and remain problematic.
Readers will note that there is a good bit of overlap among
the following chapters; for example, occupational therapy and
physical therapy in primary care may seem quite similar to
their counterparts in community settings. This is not coinci-
dental. The main difference from the perspective of the
therapies is the setting, not the probable issues requiring at-
tention. A well older adult may see a physical therapist in a
primary care setting for advice and guidance about a fitness
routine to maintain cardiovascular capacity. A similar indi-
vidual may receive such interventions as part of a program in
a community center that would be considered part of the
community-care system.
Other countries have been somewhat more successful
in integrating the various elements of health care (Bloom,
Canning, & Lubet, 2015). Single-payer systems, such as
those in Canada and the United Kingdom, can provide more
predictable and sustained care based on guaranteed payment
for specific kinds of intervention. Sweden offers a model of
home health services to support older adults (Global Health
Aging, 2014). There is no question that the rapid aging of
the population is a global concern; learning from each other
405
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406 PART IV ■ Service Delivery for the Aging Client
about what works has the potential to improve care (Bloom
et al., 2015). It is unlikely that even with research that makes
progress in slowing the aging process and that establishes
effective personal medicine approaches to disease and disabil-
ity, these concerns will disappear.
For now, challenges remain. Therapists must work within
existing structures but must also address their responsibility
to their clients. While reading the chapters that follow, think
back to the discussion of advocacy as an important role for
occupational and physical therapists. Identify issues that
might require attention through changes in public policy and
other strategies. And think about what therapists might do
to help ensure improved care for older adults. After all, the
vast majority of people are all headed in that direction. With
luck, strategies can be designed to help individuals remain
functional and retain good quality of life. But it is inevitable
that those who live long enough will need help. Everyone
benefits from thoughtful attention to ensuring that care is the
best it can possibly be.
Bloom, D. E., Canning, D., & Lubet, A. (2015). Global population
aging: Facts, challenges, solutions & perspectives. Daedelus, 144, 80–92.
doi:10.1162/DAED_a_00332
Centers for Medicare and Medicaid. (2014). Coordination of benefits.
Retrieved from http://cms.gov/Medicare/Coordination-of-Benefits-and-
Recovery/Coordination-of-Benefits-and-Recovery-Overview/Coordination-
of-Benefits/Coordination-of-Benefits.html
hhs.gov. (2015). About the law. Retrieved from http://www.hhs.gov/healthcare/
rights/index.html
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Evaluation of Functional Performance
“I alwaysduethought my increased difficulty in walking and doing my daily activities was just
to aging but after my assessments and discussion from my physiotherapists and
occupational therapists, I came to realize there are issues I can seek help for and changes I
—Comment from a client involved in a study titled “Detecting and Addressing Pre-Clinical
LEARNING OUTCOMES
By the end of this chapter, readers will be able to:
1. Define functional performance.
2. Differentiate among the various purposes and types of
assessments and evaluations.
3. Describe the need for a conceptual framework to guide the
assessment of functional performance.
4. Compare and contrast among the International Classifica-
tion of Functioning, Disability and Health, the Glass Model,
and the Person–Environment–Occupation Model.
5. Identify important areas of functional performance that
should be assessed in older adults.
6. Describe factors, specifically related to older adults, that
affect functional performance and need to be considered
in assessment.
Clinical Vignette
Ms. Annette Altman is a 68-year-old woman with a med-
ical history of hypertension, obesity, and osteoarthritis in
her cervical spine, hands, and left knee. She has had a cor-
tisone injection in her left knee that provided temporary
relief of her symptoms. Ms. Altman has four children and
lives alone in a townhouse. She is recently retired, having
worked as a personal support worker for 25 years and, more
recently, as an educational assistant in an elementary school.
When asked about her current level of physical function,
she reports she is having difficulty going up and down the
stairs and has trouble crouching and kneeling due to her
knee pain. She is experiencing shortness of breath with ex-
ertion, which makes walking distances difficult for her. She
also describes pain in her hands that affects her ability to
do many of her daily chores and activities. Ms. Altman was
asked by the therapist working with her to identify important
CHAPTER 27
Lori Letts ■ Julie Richardson
can make to improve my performance!
”
Disability”
activities that she is unable to do or is having difficulty with
due to her health. She listed five activities: (1) walking
in the park or on local trails with her family, (2) using
her hands to perform fine motor activities for dressing her-
self or for hobbies (knitting and crocheting), (3) bowling,
(4) water exercise, and (5) gardening.
1. When you have been confronted with short- or long-
term health concerns, which activities in your daily life
do you give up first?
2. Why was it important for the therapist working with
Ms. Altman to ask about activities that were challeng-
ing for her?
3. How would you proceed to conduct a functional
assessment with Ms. Altman based on the information
you have so far?
I n this chapter, issues related to the meaning of functional
performance and why it needs to be assessed, conceptual
frameworks to guide assessment of functional performance,
and priority areas of functional performance that often
require evaluation by occupational therapists and physical
therapists are discussed.
Functional Performance
Functional performance refers to the capacity or perform-
ance of an individual to carry out activities required for daily
living. These activities can be broadly defined, but typically
in the context of physical and occupational therapy, they in-
clude mobility, self-care, leisure, and activities associated
with contributions to society through work or volunteering.
Within areas of functional performance, therapists also fre-
quently consider the underlying components that contribute
407
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408 PART IV ■ Service Delivery for the Aging Client
to functional performance, including physical and cognitive
abilities of the person, but also contextual and environmental
factors that affect performance.
In many clinical situations, the functional performance
that is the focus of evaluation is negotiated between the client
and the therapists. Assessments such as the Patient-Specific
Function Scale (Stratford, Gill, Westaway, & Binkley 1995)
and the Canadian Occupational Performance Measure (Law,
Baptiste, Carswell, McColl, Polatajko, & Pollock, 2014) are
frequently used so that clients identify the activities or areas
of function that are of importance to them and with which
they are having difficulty. These patient-identified items then
become the focus of more intense evaluation.
Evaluating Functional Performance
An evaluation process involves gathering information using
quantitative or qualitative methods and occurs at various
points in the rehabilitation process. For example, at the be-
ginning of services, evaluation may help the client and ther-
apist better understand the issues or challenges that can be
addressed during intervention. At the end of service delivery,
evaluation may be conducted to document change or to en-
sure intervention goals have been achieved. During rehabili-
tation services, evaluation may be required to justify ongoing
services, provide required documentation, or to monitor
change or goal achievement. There are several purposes for
evaluation with older adults, including screening to detect
initial changes or need for further assessment, description of
client status, prediction of functional outcomes, and outcome
evaluation to detect change.
Functional performance is often assessed in older adults
because changes in functioning are common. As people grow
older, changes in health status and an increasing prevalence
of chronic diseases, such as cardiovascular disease, arthritis,
stroke, dementia, and Parkinson’s disease, may lead to increas-
ing difficulties in performing the daily activities of self-care,
household maintenance, shopping and other community
activities, voluntary or work pursuits, and recreation and leisure
activities. The Federal Interagency Forum on Aging Related
Statistics (2012), designed to identify key elements of well-
being in older adults found that 30 percent of women and
19 percent of men over age 65 reported difficulty with at
least one of five self-care activities. The proportion of older
adults with difficulties in self-care increased with age, with
53 percent of women and 40 percent of men over age 85
reporting difficulties. Disabled older adults living in Canada
have difficulty with the following tasks: preparing meals
(49 percent), housework (55 percent), heavy chores (59 percent),
personal finances (35 percent), and personal care (53 percent)
(Statistics Canada, 2002).
Aging produces changes in physical functioning and tran-
sitions through disabled states. The process of disablement is
dynamic and involves varying functional states, such as
changes in mobility, activities of daily living (ADL), and
instrumental ADL (IADL). The onset of disability can be
slow and progressive, which often occurs with chronic dis-
ease, or sudden and acute as occurs following a catastrophic
medical event (Guralnik, Ferrucci, Balfour, Volpato, &
Di Iorio, 2001).
The period between the onset of impairment and the
onset of disability has been termed a stage of preclinical dis-
ability (Fried, Herdman, Kuhn, Rubin, & Turano, 1991).
Preclinical disability is a transitional state between impair-
ment and disability which is characterized by a general
decline in activity level or by limitation of ability to perform a
task using the normal method), although the individual can
still accomplish the task under certain circumstances with-
out perceived difficulty (Fried et al., 1991; Guralnik, 1996).
Specifically, preclinical disability in mobility predicts the
onset of future disability (Fried, Ettinger, Lind, Newman,
& Gardin, 1994). It is important for therapists to be in-
volved in evaluation and intervention of older adults to prevent
preclinical disability that may be the result of deconditioning
and increase functional performance affected by chronic
conditions.
Because of increasing rates of difficulties with functional
performance, a critical component of evaluation of older
adults is to screen for problems in functional performance to
develop strategies to improve performance or prevent further
deterioration in the ability to perform the activities that a per-
son needs or wants to do. Screening can identify older adults
who may need further evaluation, intervention, or both. It is
important that screening evaluations be easy to do, take little
time, and accurately identify those who require further eval-
uation for intervention. Examples of screening assessments
include the Montreal Cognitive Assessment (MoCA;
Nasreddine et al., 2005), IADL Screener (Fillenbaum, 1985),
Functional Activities Questionnaire (Fillenbaum, 1985),
the Frail Elderly Functional Assessment (Gloth, Watson,
Meyer, & Pearson, 1995), and the Geriatric Depression
Scale (Yesavage et al., 1983). Some of these measures are
discussed in other chapters in this book. There are also
various measures of performance, such as the Timed Up
and Go Test (TUG; Podsiadlo & Richardson, 1991), the
Functional Reach Test (Duncan, Weiner, Chandler, &
Studenski, 1990), and the Berg Balance Scale (Berg, Wood-
Dauphinee, Williams, & Maki, 1992), that are used to
screen for particular impairments associated with older adult
mobility. Information about a wide range of assessments can
be found in the online ancillary materials.
Evaluations that are used for descriptive purposes focus
on gathering information to describe characteristics of indi-
viduals and enable differentiation between persons on the
specific characteristic that is being measured (Law, 1987).
This type of assessment is important to identify issues that
merit intervention; to determine specific problems in the
areas of impairment, activity limitation, and participation re-
striction; and to help determine the need for therapeutic serv-
ices. For example, a descriptive cognitive assessment provides
information about the cognitive status of an individual and
4605_Ch27_405-420 31/10/17 12:29 PM Page 409
helps the person, his or her family, and the service provider
decide whether there are difficulties related to cognitive status
and whether intervention is warranted. Assessments used for
descriptive purposes, such as the Functional Behavior Profile
(Baum, Edwards, & Morrow-Howell, 1993) or the Assess-
ment of Motor and Process Skills (Fisher, 1995), include
items that have been shown to discriminate among individ-
uals based on the characteristic being assessed. The Modified
Falls Efficacy Scale is an activity questionnaire that can be
used to identify older adults with balance and mobility prob-
lems and reflects confidence levels and fear of falling (Hill,
Schwarz, Kalogeropoulos, & Gibson, 1996). In many in-
stances, assessments that work well for descriptive purposes
do not perform adequately in evaluating change over time
after therapeutic intervention.
Assessments used for prediction include items related to
a specific characteristic to forecast another trait. Items on a
predictive measure are included if they describe the charac-
teristic of interest and predict the trait or criterion of interest
now or in the future. Examples include the Cognitive
Performance Test (Allen, Earheart, & Blue, 1992) and the
Tinetti Performance-Oriented Mobility Evaluation (Tinetti,
1986). The Cognitive Performance Test has been used to pre-
dict functional capacity in a range of daily activities of older
adults with cognitive impairment, and to predict harm out-
comes after discharge from hospital in older adults (Douglas,
Letts, Richardson & Eva, 2013). The TUG (Podsiadlo &
Richardson, 1991) is frequently used to determine older
adults’ risk for falls.
A common use for assessments is to evaluate outcomes or
change in persons after they have received rehabilitation serv-
ices. Items included on this type of evaluative measure are
those that can be demonstrated to be responsive to change in
individuals when change actually occurs. Examples include
the Functional Independence Measure (FIM; State University
of New York at Buffalo [SUNY], 1990) and the Canadian
Occupational Performance Measure (COPM; Law et al.,
2014). The FIM is widely used to measure the overall per-
formance in daily living skills through the need for assistance,
providing an indicator of functional ability, and is used to eval-
uate the effectiveness of rehabilitation services. The COPM
was designed specifically as an evaluative tool to measure
clients’ self-perception of change in occupational performance
and satisfaction with performance after occupational therapy
intervention.
Therapists need to have a thorough understanding of the
purposes for which an assessment or evaluation tool has been
developed and validated (this information is typically included
in the assessment manual, if available) and to match that pur-
pose to the given situation. For example, if an assessment that
is primarily designed to describe differences between persons
is used to evaluate change or outcomes after a therapeutic pro-
gram, it may lead to a situation in which a clinically important
change has occurred, but the evaluation is not able to measure
that change. Other psychometric characteristics that therapists
need to review before using an assessment include issues
CHAPTER 27 ■ Evaluation of Functional Performance 409
of reliability, validity, and clinical utility (Van Dusen &
Brunt, 1997).
Conceptual Frameworks for Evaluation
of Functional Performance
A conceptual framework has been defined as a conceptual
structure that explains the relationship among key factors,
concepts, and variables (Miles & Huberman, 1994). A widely
recognized framework is the World Health Organization’s
(WHO; 2001) framework, the International Classification of
Functioning, Disability and Health (ICF), in which out-
comes of functional performance might occur at the activity
or participation level. Wade and Halligan (2003) have pro-
vided an excellent critique of the ICF and of concepts that
need to be included in the assessment of a person’s function-
ing that are currently omitted from the ICF. Context is an
important consideration for the assessment of functional per-
formance and can be simplified into environmental (physical
and social environment) and personal (the person’s cognitive
and emotional state) at the time of the evaluation. The envi-
ronment and personal contexts can act as resources that
enhance or deplete the outcome of the functional performance
evaluation and as such need to be assessed separately using
standardized assessments (e.g., motivation and fatigue) so
they can be incorporated into an overall analysis of a client’s
functional performance. Conceptual frameworks can provide
guidance to help a therapist integrate findings across several
functional areas into one overall picture of the client’s abili-
ties. Another conceptual framework is found in the Occupa-
tional Therapy Practice Framework: Domain and Process
(3rd ed.; American Occupational Therapy Association
[AOTA], 2014). Both the ICF and the Practice Framework
are described in more detail in Chapter 2.
Within the context of clinical practice, occupational and
physical therapists enter into partnerships with our clients.
Client-centered practice has been defined as follows:
a partnership between the client and the therapist that
empowers the client to engage in functional perform-
ance and fulfil his or her … roles in a variety of envi-
ronments. The client participates actively in negotiating
goals, which are given priority and are at the centre of
assessment, intervention and evaluation. (Sumsion,
2000, p. 308)
One way to ensure that therapists are addressing the as-
pects of older adults’ lives that the older adults consider to be
important is to use a model of practice or conceptual frame-
work that considers the person performing activities of his or
her choice within a supportive environment. Examples of
such tools are the ICF (WHO, 2001) and Glass’s (1998)
Conceptual Scheme for Conjugating the Tenses of Function.
Other models that have been developed are profession spe-
cific, such as Person–Environment–Occupation Model of
Occupational Performance (Law et al., 1996). As had been
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410 PART IV ■ Service Delivery for the Aging Client
described in previous chapters, the American Occupational
Therapy Practice Framework (3rd ed.; AOTA, 2014) incor-
porates many of these constructs in its guidelines for evalua-
tion and intervention.
International Classification of Functioning,
Disability, and Health
The goal of evaluation is to ensure that the activities that older
adults value, need to perform, and with which they may be
experiencing changes are identified and that the reasons for
the difficulties in performance are established. The use of a
conceptual framework can help therapists and older adults
work together to identify the focus of evaluation and the
measures to use. Various conceptual frameworks have influ-
enced the understanding of disability over the years, for ex-
ample, the Nagi Model (Nagi, 1976); and the International
Classification of Impairments, Disabilities and Handicaps
(ICIDH; WHO, 1980). The latter was the basis for the ICF
(WHO, 2001), described in Chapter 2, which provides stan-
dard language and a conceptual framework that can underpin
the evaluation process. Consideration is given to the health
condition of the individual within the body functions and
structures, the activities in which a person engages, as well as
participation within the various contexts that make up the
environment.
The use of a conceptual framework depicting the interac-
tions between the components of the ICF (WHO, 2001) en-
ables therapists to identify attributes for evaluation and
ensures that the evaluation process develops logically and fo-
cuses only on areas of evaluation that are important and
meaningful to older adults and their families. Table 27-1 pro-
vides examples of how this framework can be used to specify
attributes for evaluation along with appropriate evaluation
tools. This conceptual framework is an excellent guide to
therapists and rehabilitation teams in making decisions about
the specific attributes to be assessed in each clinical situation.
Glass Model
Glass (1998) argued that the Nagi Model (Nagi, 1976) and
the ICIDH (WHO, 1980) did not go far enough to allow
those working with older adults to understand disability and
its complexity in later life functioning. Traditionally in aging
TABLE 271 ■ Using the International Classification of Function, Disability, and Health (ICF) to Organize Evaluation
BODY FUNCTIONS AND
ICF DOMAIN STRUCTURES ACTIVITIES
Evaluation attribute Body movement Functional mobility
Evaluation Chedoke-McMaster Late Life Function and Disability
Stroke Assessment Instrument— Function Index
(Gowland et al., 1995) (Haley et al., 2002)
research, measures of disability have focused on hypothetical
reported functional capacity (what the older adult says he or
she can do) rather than on actual performance in everyday
life (what the older adult does do). Glass (1998) maintained
that measures of capacity provide limited information and
often produce disability rates that underestimate actual levels
of disability among older adults. He suggested that more
focus should be given to performance rather than capacity.
This resulted in the development of a “conceptual scheme for
conjugating the tenses of function” (Glass, 1998, p. 103)
among older adults (Figure 27-1). His conceptual scheme has
three levels. The first level, the hypothetical level, measures a
person’s capacity by assessing what she says she can do. Ac-
tivities are not placed within a context, and self-report or
proxy responses are sought in relation to the degree of diffi-
culty or the degree of assistance required. At the second level,
the experimental level, the person’s capabilities are measured
by assessing timed performance and standardized task com-
pletion in a laboratory or clinic setting or by assessing what
the person could do when asked to simulate activities. The
third level, enacted level, reflects what the person actually does
in his or her home or community environment, based on self-
report, proxy, or direct observations that provide measures of
the frequency and duration of activities, tasks, and roles.
Glass (1998) demonstrated the discrepancy between self-
report and actual everyday performance through qualitative
interviews with members of three sites of the EPESE survey
and the MacArthur Research Network on Successful Aging.
For one third of the sample, there was congruency between
what they reported they did and what they actually did, one
third reported poorer functioning, and one third reported
higher functioning than their actual functioning. The impli-
cations of Glass’s (1998) research for therapists suggest that
given the complexity of aging, it is important to consider
what older adults can do and what they actually do. In evalu-
ating occupational and physical therapy interventions to
determine whether older adult clients are improving or main-
taining functional performance, it is critical to measure func-
tional outcomes that include performance rather than only
ask about hypothetical functional capacity. Glass’s (1998)
work also reminds therapists of the importance of considering
the context within which older adults participate, as well
as the importance of compensatory strategies already used
to maintain activity and participation. For example, when
ENVIRONMENTAL
PARTICIPATION FACTORS
Participation in leisure activities Accessibility
London Handicap Scale The Housing Enabler
(Harwood, Rogers, Dickinson, (Iwarsson & Slaug,
& Ebrahim, 1994) 2001)
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CHAPTER 27 ■ Evaluation of Functional Performance 411

Hypothetical Experimental occupational performance can be considered equivalent terms

(Law & Baum, 2005). Occupational performance is the
transactional outcome of the overlap of a person engaging in
a specific occupation within an environment, with person,
Can Could do… occupation, and environment representing the three spheres
of the model that overlap to result in occupational perform-
ance. The three spheres of person, occupation, and environ-
Definition: capacity Definition: capability ment, as well as the occupational performance that result
Context: none Context: laboratory
from the overlap of the three, need to be considered in a tem-
poral context as well. Variations in functional performance
Measures: Measures: over time can occur because of changes in the person (e.g.,
Self-report Performance the changes that are associated with aging) or because of dif-
“are you able to” (observation/timed) ferences in the environmental setting (e.g., it is easier to walk
QOL items Qualitative terms the distance of a city block in Prairie city than in a moun-
tainous region).
Enacted When considering the use of the PEO model for assess-
ment of functional performance, the assessment could focus
on the area of overlap and can assess a person’s abilities to en-
gage in the actual functional activity. This could involve basic
Does do… self-care activities, such as dressing or bathing; instrumental
activities, such as driving or banking; or functional mobility
activities. In addition, or as an alternative, assessment of func-
Definition: performance tional performance could focus on the components of per-
Context: home
formance, with an emphasis on the person (e.g., assessing joint
range of motion or muscle strength, cognitive abilities), the
Measures:
environment (e.g., an assessment of the home environment),
or the occupation itself (e.g., through task analysis). The as-
Self-report or
observation sessment of all components would provide a therapist with a
Frequency/duration comprehensive understanding of the person’s performance,
of activity calories and the factors that are contributing to that performance. In-
expended
terventions designed to improve functional performance could
FIGURE 271 Conceptual scheme for conjugating the tenses of then be developed to target the specific areas identified
function. (From Glass, T. (1998). Conjugating the tenses of function: through assessment as leading to performance challenges.
Discordance among hypothetical, experimental, and enacted function

✺
in older adults. The Gerontologist, 38, 101–112.)
evaluation takes place within the client’s own home or com-
munity, it is possible to observe how he would ordinarily
manage an activity rather than how he performs an activity
in a hospital.
PROMOTING BEST PRACTICE
Environment and Compensation in Physical Function
A conceptual model for assessment of relevant physical
functioning that takes into account habitual environmental
factors and compensation strategies has been described
(Tomey & Sowers, 2009).

Person–Environment–Occupation Model
The Person–Environment–Occupation (PEO) model (Law
et al., 1996) is a commonly used model in occupational ther-
apy practice. It is one of several models in occupational ther-
apy that incorporates the multiple factors that influence
people’s abilities to engage in meaningful functional activities.
The model places occupational performance at its center, with
occupational performance defined as the “dynamic experi-
ence of a person engaged in purposeful activities and tasks
within an environment” (Law et al., 1996, p. 16). Essentially,
occupational performance is the act of engaging in activities,
typically functional activities to fulfill life demands or
roles within varying contexts. Functional performance and
What to Assess When Focusing
on Function in Older Adults
As people age, their life roles and the kinds of activities in
which they participate tend to change. People may not engage
in paid work as they get older; in many countries and in cer-
tain vocations, mandatory retirement policies prevent them
from doing so. Nonetheless, many older adults engage in pro-
ductive roles through volunteering. Due to retirement or re-
ductions in time spent in paid roles, the amount of available
leisure time usually increases with age. Therefore, physical and
occupational therapists need to consider leisure activities as
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412 PART IV ■ Service Delivery for the Aging Client
being potentially significant to the client. ADL are often a
focus of functional performance evaluation in older adults.
Self-care, although an essential component of evaluation of
function, should not be used to the exclusion of evaluation in
other areas of function, including IADL, functional and com-
munity mobility, productivity, and leisure. Functional mobility
underlies many areas of performance and may be key to plan-
ning interventions to help clients meet their goals. All of these
functional performance areas can be important, and together
they form the balance of activities in which people participate.
For an in-depth discussion of self-care, work and retirement,
and leisure, refer to Chapters 18, 19, and 20.
Several functional performance evaluations can be used
with older adults to address a broad range of functional areas
of performance, such as the following examples.
■ Lower extremity performance: The Short Physical Per-
formance Battery (Guralnik, Ferrucci, Simonsick, Salive,
& Wallace, 1995), which includes balance tests, repeated
chair stands, and an 8-meter walk.
■ Exercise capacity and tolerance: The Two-Minute and Six-
Minute Walk (Butland, Pang, Gross, Woodcock, & Geddes,
1982); the Long-Distance Corridor Walk (Simonsick,
Montgomery, Newman, Bauer, & Harris, 2003).
■ Functional mobility: The Environmental Analysis of
Mobility Questionnaire (EAMQ; Shumway-Cooke, Patla,
et al., 2002, 2005) evaluates the frequency of encounter and
avoidance of 24 features of the physical environment,
grouped into eight dimensions.
■ A person’s usual or actual performance of mobility: The
Life Space Diary (May, Nayak, & Issacs, 1985)—the en-
vironment in which a person expects to move within a day,
for example, is divided into concentric zones and the per-
son records over 24-hour periods the areas in which they
have moved during the day. Stavley, Owsley, Sloane, and
Ball (1999) developed a questionnaire version of this ap-
proach, the Life-Space Questionnaire (LSQ), which com-
prises nine questions that ask whether the respondent has
been to each of the regions of his or her environment
within the past 3 days.
■ Overall functioning and disability: Late Life Function and
Disability Index (LLFDI; Haley et al., 2002).
■ Performance difficulties in self-care, productivity, and leisure
areas: the Canadian Occupational Performance Measure
(Law et al., 2014).
■ Roles that are important sources of activity for older adults:
The Role Checklist (Oakley, Keilhofner, Barris, & Reichler,
1986); the Activity Card Sort (Baum & Edwards, 1995);
leisure and social activities are incorporated into these
instruments.
■ ADL and IADL: The Kitchen Task Assessment (Baum &
Edwards, 1993); Arnadottir OT-ADL Neurobehavioral
Evaluation (A-ONE) (Arnadottir, 1990); the Physical Self-
Maintenance Scale; the Instrumental ADL Scale (Lawton
& Brody, 1969); the Functional Autonomy Measurement
System (Hebert, Carrier, & Bilodeau, 1988); the Assess-
ment of Living Skills and Resources (Williams et al., 1991)
■ Multiple domains of physical function using observed per-
formance of tasks: The Physical Performance Test (Reuben
& Siu, 1990)
■ Home safety: The Safety Evaluation of Function and the
Environment for Rehabilitation—Health Outcome Meas-
urement and Evaluation (SAFER-HOME v3; Chiu &
Oliver, 2006; Chiu et al., 2006) focuses on the person’s
ability to manage functional activities safely within the
home environment.
INTERPROFESSIONAL PRACTICE
Administering Standardized Tests
A qualitative paper described the experiences of occupational
therapists and physiotherapists acting as standardized test
administrators. The authors found the test situation generates
a tension between what standardization demands and
what individualization requires and that physiotherapists
and occupational therapists navigate between adherence to
the test standard and meeting what they consider to be the
individual patient’s needs in the test situation (Krohne, Torres,
Slettebø, & Bergland, 2013).
Although this is not a comprehensive listing of functional
assessments available for use with older adults, it provides
evidence of the vast array of available instruments that address
functional mobility, self-care, productivity, and leisure.
✺
PROMOTING BEST PRACTICE
Use of Functional Assessments in OT Interventions
Wales, Clemson, Lannin, and Cameron (2012) describe a
systematic review protocol related to the identification of
functional assessments used in randomized trials of occupational
therapy interventions for older adults (70 years of age or older).
Interventions will focus on enhancing functional independence
for either older adults transitioning from hospital to home, or
community dwelling older adults (Wales et al., 2012).
Priority Areas of Functional Performance
With Older Adults
Functional performance is a broad term, and therapists must
decide on how to focus an overall assessment of functional per-
formance. Based on what is known about changes that occur
with aging and considering the importance of identifying pre-
clinical or actual disability, several areas may be considered pri-
orities for assessment by physical therapists and occupational
therapists. These include mobility, lower extremity functioning,
upper extremity functioning, and activities of daily living.
Mobility
Walking speed (gait speed) or mobility is necessary for most
tasks that humans undertake. Slowing of walking speed is
associated with aging in all persons (Hardy, Roumani,
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CHAPTER 27 ■ Evaluation of Functional Performance 413

Chandler, & Studenski, 2007). Walking speed has also been gait symmetry, gait endurance, adaptability of gait, and dual-
associated both with survival (Studenski et al., 2011) and task performance during gait to quantify gait performance.
with changes that occur when older persons are having diffi- Both fast-paced and normal-paced walking were found to
culty or become unable to do tasks (Abellan van Kan et al., predict functional decline (Middleton & Fritz, 2013).
2009; Bohannon, 1997).
Mobility, the ability to move independently within one’s
environment, is essential to maintaining independence in Lower Extremity Function
personal and instrumental ADL (Patla, Adkin, Martin,
There is strong evidence that changes in lower extremity
Holden, & Prentice, 1996). Changes in mobility are fre-
function are the hallmark for the onset of disability with
quently the first indication of functional decline (Gill,
aging. However, assessment using performance measures as
Williams, Richardson, & Tinetti, 1996). Mobility disability,
part of routine functional assessment of lower extremity func-
a highly dynamic process, is often indicative of health status
tion is more likely to include walking speed assessment as an
(Cesari et al., 2005). Mobility disability is characterized by
indicator of mobility rather than functional limitations such
frequent transitions between states of mobility independence
as stooping, kneeling, crouching, pushing objects, climbing
and mobility limitation (disability) (Gill, Allore, Hardy, &
stairs, and transferring. These latter items are from the Nagi
Guo, 2006).
(1976) assessment and the Rosow–Breslau Scale (Rosow &
Mänty et al. (2007) hypothesized that major mobility dis-
Breslau, 1966). This level of functioning is sometimes deter-
ability develops through stages of preclinical mobility limi-
mined via surveys or self-report but is rarely assessed through
tation and more minor mobility limitation. Preclinical
performance. Performance of these activities would indicate
mobility limitation is a stage in the natural history of func-
changes in functioning. By identifying persons who are ex-
tional change when there is the opportunity for primary pre-
periencing changes in lower extremity functioning, the ther-
vention interventions. Preclinical mobility difficulties can be
apist could intervene to prevent the older adult from making
reliably identified when adults modify the frequency, method,
the transition from preclinical disability to disability. The re-
and time taken to complete walking tasks and report in-
lationship between impairments such as muscle strength,
creased fatigue and tiredness associated with task (Fried,
range of motion, pain, and flexibility and functional limita-
Bandeen-Roche, Chaves, Johnson, 2000; Fried, Young,
tion items and lower extremity functioning needs to be con-
Rubin, Bandeen-Roche, & WHAS II Collaborative Re-
sidered. The final issue that needs to be addressed in lower
search Group, 2001). The prevalence of preclinical limitations
extremity performance is what is usual performance and how
with mobility tasks in community-dwelling samples has been
does the older adult perform within his or her environment
reported as ranging from 20 to 40 percent (Shumway-Cook,
(Glass, 1998)? This provides important information about
Ciol, Yorkston, Hoffman, & Chan, 2005) and from 31 to
possible areas of intervention by identifying gaps between
55 percent in adults older than 75 years (Mänty et al., 2007).
what is actually done and what an older adult may be capable
Persons in the preclinical mobility limitation stage are at in-
of doing.
creased risk for the onset of disability and for the onset of
Interventions targeted at prevention of functional limita-
early disease (Fried et al., 2000, 2001). Persistent deteriora-
tions should focus on screening for changes in lower extremity
tion in mobility is a predictor of mortality and has been re-
functioning. For therapists, then, this implies that although
ported in the absence of changes in ADL over a 2-year period
it may be important to evaluate both upper and lower body
(Khokhar et al., 2001). Mänty et al. (2007) have established
disability, lower body functioning may be more predictive of
the predictive validity of the following three tasks to deter-
future activity and participation limitations. One study (Bean
mine preclinical disability: walking 2.0 km, walking 0.5 km,
et al., 2004) compared the Short Performance Battery, with
and climbing one flight of stairs where respondents are given
the function component of the Late Life Disability Instru-
the following options: (1) Able to manage without difficulty,
ment (LLFDI), a self-report measure. The authors concluded
(2) able to manage with some difficulty, (3) able to manage
that the two measures assess different aspects of an older
with a great deal of difficulty, (4) able to manage with the help
person’s lower extremity function. The SPPB was associated
of another person, or (5) unable to manage even with help.
with age and physiologic factors such as muscle strength, leg
Persons who reported preclinical changes at baseline had 3 to
velocity and exercise tolerance, while the LLDFI was associ-
6 times higher age and sex adjusted risk of experiencing major
ated with these same factors as well as psychosocial (sex) and
mobility limitations during the 2-year follow-up compared
health factors (number of chronic conditions and falls) (Bean
with persons who reported no limitation at baseline.
et al., 2004).

✺
PROMOTING BEST PRACTICE
Assessing Gait, Balance, and Mobility
A review paper discussed the issues with assessing gait,
balance, and mobility in older adults and the psychometric
properties of associated assessments for each area of physical
functioning; it also outlined how clinicians can use gait speed,
It is well documented that poor lower extremity function
predicts subsequent disability. There is also evidence that gait
speed alone accurately predicts onset of incident disability
almost as well as a battery of lower extremity performance
tests (Guralnik et al., 2000). Therefore, it is worth consider-
ing using walking speed and gait assessments as an evaluation
of current abilities and to predict future physical functioning.
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414 PART IV ■ Service Delivery for the Aging Client
An index of ambulatory mobility-related physiological
limitations (MOBLI), which includes self-reported walking
difficulty, walking speed, time to complete five chair stands,
and peak expiratory flow, has established evidence of respon-
siveness and predictive validity over a 4-year period with
evidence of a dose response relationship. The predictive validity
of this index was similar to self-reported mobility (Melzer,
Lan, & Guralnik, 2003). If emphasis is on prevention of
functional decline, therapists may want to consider adopting
this index as one of the assessments to screen for potential
decline.
Upper Extremity Function
As people age, upper extremity function also declines. How-
ever, systematic studies of upper extremity function associated
with aging are quite limited. In one study, Bravo, Desrosiers,
Dutil, and Hébert (1995) collected normative data on upper
extremity motor coordination and demonstrated that coordi-
nation declined with age in both men and women. However,
Bailey and Lang (2013) found that there were no differences
in the amount of time spent in upper extremity activities across
age-groups in a sample of individuals aged 30 to 83 years. The
authors hypothesized that vigorous activity may have been re-
placed with less vigorous activities in older adults, resulting
in similar hours of upper extremity activity regardless of age.
Several studies have demonstrated that declines can be ob-
served in grip strength as people age, with hand-grip strength
being predictive of disability in ADL, IADL, and mobility
(Giampaoli et al., 1999).
Although changes in upper extremity function may not be
as predictive of functional decline as lower extremity function
and mobility, there is a need to ensure that older adults have
the capacity to continue with their usual functional activities,
including those that involve upper extremity performance.
Thus, assessment of upper extremity function can contribute
needed information to a rehabilitation assessment designed
to assess and address functional performance.
There are limited assessments of upper extremity function
that have demonstrated measurement properties for use with
older adults. Grip strength, measured with a dynamometer,
is a common assessment and is often used as a proxy for over-
all muscle strength. Norms for community-dwelling older
adults have been published based on a sample of 360 older
adults in Quebec (Desrosiers et al. 1995), and a sample of
224 older adults in Texas (Jansen, 2008). However, the link
between grip strength and successful completion of daily
functional activities is not always clear, and interpretation of
grip strength assessment can be challenging for therapists in
clinical contexts. McGee and Mathiawetz (2003) suggested
that upper extremity assessment results below normative val-
ues may be predictive of IADL limitations in elderly women
and that assessment findings of impaired muscle strength, in
particular shoulder strength, can be used to indicate a need
for a detailed assessment of IADL. In turn, significant IADL
impairments may be indicative of a need for thorough upper
extremity strength assessment.
Besides upper extremity strength, other assessments of
upper extremity function include tests of motor coordination,
such as the Finger–Nose Test (Bravo et al., 1995); finger dex-
terity with pegboard tests, such as the nine-hole pegboard
(Son et al., 2012) or the Purdue pegboard (Bravo et al., 1995);
or assessments of manual dexterity through tests such as the
Box and Block test (Bravo et al., 1995).
Some assessments are designed to assess upper extremity
function for people with particular conditions or diseases. For
example, some upper extremity functional assessments have
been used primarily for people poststroke or with other neu-
rological conditions, for example, the Wolf Motor Function
Test (Wolf et al., 2001) and the Chedoke Arm and Hand
Activity Inventory (Barecca et al., 2004). These may be more
clinically useful to therapists in practice, particularly if the
population served has a high proportion with a particular
condition, such as stroke or Parkinson’s disease.
Upper extremity function is needed for various daily func-
tional activities, in particular personal care and instrumental
activities. Although people may be able to sustain their in-
dependence in these activities if upper extremity function de-
teriorates, it is important for therapists to maintain awareness
of upper extremity function as a prerequisite for performance
of daily activities and to be prepared to assess upper extremity
function to understand the extent to which such factors as
strength, motor coordination, and dexterity may be con-
tributing to functional impairments.
Activities of Daily Living
As people age, changes in independence in basic and instru-
mental ADL may occur. Typically, IADL present challenges
before personal care activities. Thus, some assessments are
designed to demonstrate the progression of change within
various instrumental and personal activities of daily living.
The ADL Staircase, for example, includes both IADL and
ADL items; IADL items were added to personal ADL
items in the assessment originally formulated by Katz
(Jakobsson, 2008). The internal consistency and validity of
hierarchical arrangement of items was confirmed for people
older than 75 years; however, data for people 60 to 74 years
was less clearly clustered into categories of personal ADL
and IADL, perhaps because of greater functional variations
in that age-group.
Much research has focused on the incidence of mobility
and ADL disabilities with increasing age (Ayis, Bowling,
Gooberman-Hill, & Ebrahim, 2007; Dunlop, Hughes,
& Manheim, 1997); however, IADL have also been researched,
exploring typical patterns of functional impairment with
aging.
Another important consideration in the assessment of
ADLs and IADLs is performance versus capacity. In one
study, the prevalence of disability in IADLs was much higher
based on what participants reported they did, relative to what
they were capable of doing (Bootsma-van der Wiel, et al.,
2001). It is important for therapists to consider whether they
want to evaluate the ability or capacity of the older adult, or
4605_Ch27_405-420 31/10/17 12:29 PM Page 415
whether they want to evaluate the actual usual tasks under-
taken. It may be possible to use the differences between ca-
pacity and performance to guide interventions.
Therapists have many assessments of ADLs and IADLs
from which to choose. There are numerous measures that are
designed for descriptive purposes. For example, the Kohlman
Evaluation of Living Skills has been proposed as a measure
of IADL that may help identify older adults’ abilities to man-
age independently and safely in the community (Burnett,
Dyer, & Naik, 2009). The Functional Autonomy Measure-
ment Scale (SMAF; Hebert, Carrier, & Bilodeau, 1988)
includes items addressing ADL, mobility, and IADL, as well
as communication and mental functions. Lawton and Brody’s
(1969) original measures of Physical Self-Maintenance
(ADL) and IADL are still frequently cited and used in both
research and practice. There are also numerous assessments
that focus exclusively on personal ADL, such as the Barthel
Index (Mahoney & Barthel, 1965) and the Melville Nelson
Self-Care Assessment (Nelson et al., 2002).
As with the selection of any assessment, choosing an ap-
propriate measure of ADL or IADL function in clinical prac-
tice relies on the purpose of the assessment and review of
available instruments, while taking into consideration evidence
of measurement properties. Evaluation of ADL can provide
useful clinical information about an older adult’s current status
and the impact that a condition or set of conditions is having
on his or her ability to manage day-to-day activities.
Specific Issues Related to Evaluation
of Functional Performance
Regardless of the area of focus for any assessment of func-
tional performance, therapists must always consider how the
assessment findings might be influenced by circumstances be-
yond the specific area of assessment. For example, if an older
adult is experiencing depression, it may be difficult for the
person to participate actively in any physical performance
testing. Other factors to consider include the older adult’s
education, literacy, and health literacy levels (see Chapter 25),
especially if pen-and-paper assessments are being adminis-
tered, as well as sensory changes, fatigue, and other concerns.
Many of the factors that have potential impact on functional
assessment results are highlighted next and discussed in
greater detail in other chapters in this book.
Sensory Changes With Aging
Sensory loss occurs as a part of usual aging and includes
changes in vision (e.g., presbyopia), hearing, and touch, all
of which can influence functional performance. When eval-
uating functional performance, however, it is important to
consider that changes in the sensory systems may, in fact,
contribute to difficulties with performance, particularly when
standardized tests are being used. For tests that have norms
for comparison, the normative sample should include a group
of older adults, so that the usual aging changes present in the
normative sample are similar to the older adult client group.
CHAPTER 27 ■ Evaluation of Functional Performance 415
Without age-related norms, interpretation would need to be
completed with caution.
It is also useful to set up the evaluation environment in
such a way as to limit the extent to which sensory changes
cause difficulties in the performance of the evaluative items,
within the constraints of standardized administration. When
evaluating older adults, it is useful to ensure the following:
■ There is adequate lighting in the environment.
■ All materials presented to the person, especially written
materials, are in print that is large and in a contrasting color
with the background, so that they can easily be read.
■ The environment should have minimal background noise
to enable the client to focus on the evaluation and any
interaction with the assessor.
■ The assessor should face the client. Verbal communication
should be clear, allowing the older adult to hear what is
said optimally, and at the same time see the assessor’s face
to pick up any nonverbal communication as well.
■ The older adult is using any prescribed aids (e.g., glasses,
hearing aid).
For additional information, refer to Chapters 9 and 14.
Fatigue
Older adults who experience fatigue associated with mobility
or ADL often report a lack of energy, changes in cognitive
processing, a need for increased sleep, depression, and de-
creased physical activity (Alexander et al., 2010). Fatigue is a
self-perceived concept, but manifests as an older person’s lack
of participation in physical functioning activities such as
walking or activities of daily living. As a result, a client expe-
riencing fatigue may struggle to participate in functional as-
sessments of mobility, activities of daily living, and lower or
upper extremity function.
Fatigue occurs when metabolic demands exceed energy re-
sources, and increases with aging and in the presence of chronic
conditions especially those associated with inflammation
(Alexander et al., 2010). Older adults with greater disability
likely expend greater energy on tasks than those without or
with lesser disability (Knaggs, Larkin, & Manini, 2011). There
are disease specific scales for measuring fatigue as well as
generic scales. An example of a unidimensional scale is the
Mobility-Tiredness Scale (Avlund, Kreiner, & Schultz-Larsen,
1996; Fieo, Mortensen, Rantanen, & Avlund, 2013); examples
of multidimensional instruments are the Fatigue Scale
(Chalder et al., 1993) and the Multidimensional Fatigue In-
ventory (MFI-20; Smets, Garssen, Bonke, & De Haes, 1995).
In clinical practice, if an older adult reports fatigue that is in-
terfering with functional performance, therapists may want to
explore more in-depth assessments of fatigue to better under-
stand and develop interventions to address this issue.
Cognition
Similar to fatigue, the assessment of an older adult’s func-
tional status may need to take into consideration the person’s
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416 PART IV ■ Service Delivery for the Aging Client
cognitive status. The risk of cognitive impairment increases
with age. For older adults diagnosed with cognitive impair-
ments such as dementia, the impairment may affect the abil-
ity to manage functional activities. Assessments such as the
Cognitive Performance Test (Burns, Mortimer, & Merchak,
1994) are designed to assess cognitive status in people with
dementias or other diagnoses linked to cognitive impairment.
People with mild cognitive impairment may also have dif-
ficulties completing activities such as IADLs that have
higher cognitive demands, such as banking or managing
medications (Mariani et al., 2008). For example, Artero,
Touchon, and Ritchie (2001) noted higher rates of difficulty
with mobility, personal ADL and IADL in older adults with
mild cognitive impairment compared with those with no
cognitive impairment.
Regardless of a person’s age, limitations in functional
abilities do not necessarily mean that the older adult has con-
comitant cognitive impairment. In situations where an older
adult does not have a diagnosis known to cause cognitive im-
pairment but is demonstrating difficulties with cognition, it
may be useful for a therapist or member of the interdiscipli-
nary team to administer a cognitive screening assessment
such as the MoCA (Nasreddine et al., 2005). In situations
in which cognitive performance is significantly affecting
functional performance, a more comprehensive cognitive as-
sessment may be warranted, and the evaluation setting may
need to be modified. Refer to Chapters 7 and 12 for more
information.
Education
In clinical practice, it is important for therapists to take into
consideration the educational and literacy (including health
literacy) levels of the older adult being assessed. If the evalu-
ation requires any kind of written language or numeric work,
it is important to ensure that the older adult can read and un-
derstand the materials. Although some assessments take into
account the education level in scoring (e.g., the Montreal
Cognitive Assessment), others may require consideration by
the clinician in interpreting scores. Refer to Chapter 25 for
more information about the importance of education, liter-
acy, and health literacy for older adults.
✺ PROMOTING BEST PRACTICE
Relationship Between Educational Level and Physical
Vulnerability
A 2007 paper presented data from a national study of
community-based adults (65 years and older; Clark, Stump,
Miller, & Long, 2007). The authors found that people with lower
educational levels (e.g., less than 12 years of education) had
higher prevalence of physical vulnerability compared with
people with 16 or more years of education. However, there was
not strong evidence to suggest that people in a high physical
vulnerability category were at higher risk of death if they had
less education. This suggests that social determinants of health
are complex and affect disability prevalence. Future research
could explore the value of monitoring physical vulnerability
through regular functional assessments, and developing
preventative interventions to address prevalence in older adults
with lower education or other socioeconomic factors associated
with disability and functional impairment (Clark et al., 2007).
Caregiver Support
Family members often take on roles as informal caregivers to
ensure that older adults living in community settings are
monitored and supported in activities with which they may
have difficulty. Commonly, family caregivers provide assis-
tance with transportation and community-based instrumental
activities such as shopping and managing finances. For some
older adults, family caregivers also provide personal care and
assistance with mobility.
In most clinical situations, an assessment of an older
adult’s functional performance would typically be completed
with a focus on determining the client’s current abilities and
deficits. The extent of caregiver support being provided is not
often incorporated into the scoring of performance (e.g., as-
sessment of walking speed or lower extremity function).
However, for some instruments, particularly those describing
ADL, the amount of assistance or supervision required may
be part of the scoring. For example, in the Functional
Autonomy Measurement System (SMAF; Hebert et al.,
1988), consideration is given to whether a client has supports
and resources available to compensate for any functional
impairments. Other measures, such as the Functional Inde-
pendence Measure (SUNY, 1990), are scored based on the
type and amount of support required to complete the task.
However, whether the support is provided by paid or unpaid
caregivers is not considered in the scoring.
Regardless of the considerations of caregiver or family
supports in the administration or scoring of functional as-
sessments, therapists will frequently consider caregiver sup-
ports in planning interventions. Refer to Chapter 24 for more
information on caregiver support and caregiving.
SUMMARY
Functional performance is an important area of assessment for
occupational therapists and physiotherapists when working
with older adults. Any assessment can be guided by client-
identified areas of either functional difficulty or priority. Func-
tional assessment can be completed for multiple purposes:
screening, description, prediction, and/or outcome evaluation;
selection of the best measure is determined by the purpose of
the assessment as well as the measurement properties of the in-
strument. Ideally, assessment of functional performance should
be conducted within a conceptual framework that can help a
therapist select measures and interpret findings. Although there
are many areas of functional performance that can be assessed,
mobility, lower extremity function, upper extremity function,
and ADL are often priority areas. In any assessment of function,
4605_Ch27_405-420 31/10/17 12:29 PM Page 417
the therapist needs to consider factors that may affect results,
such as sensory changes, cognition, education, fatigue, and care-
giver supports. In turn, interpretation of findings and recom-
mendations for interventions emerge from well-considered
assessments of functional performance.
CASE STUDY
Mr. Patrick is an 80-year-old man who lives alone in a
single-story home. He was divorced about 35 years ago;
he has two adult children whom he seldom sees.
Mr. Patrick has a history of addiction to alcohol; he re-
ports that he is not drinking more than one beer per day
now. He smokes cigarettes frequently. He was fired from
his job in his early 60s and did not find work after that.
He is a patient of a local primary care community health
center. The primary care team is concerned that he may
be experiencing some early cognitive changes. He has
missed three previous appointments at the clinic with his
physician, the dietician, and for the foot care clinic, stating
that he had no record of them. Mr. Patrick’s medical his-
tory includes osteoarthritis, hypertension, type II diabetes,
and depression.
The physician has referred Mr. Patrick to see both
the physical and the occupational therapist that provide
services through the community health center. The
therapists conduct a battery of functional performance
assessments, beginning with the Patient-Specific Func-
tion Scale (PSFS; Stratford et al., 1995). Mr. Patrick
identifies the following activities as being affected by his
health condition:
1. Walking outside the house for adequate distance:
Mr. Patrick has had a recent bout of pneumonia
and fell the first time he walked outside after recovery
from the pneumonia. He can walk independently
about three houses down from his own to get to the
community mailbox. He wants to be able to walk to
the corner store for provisions.
2. Bowling: Mr. Patrick states that he was in a bowling
league at one time and believes that there is a weekly
seniors’ league that he would like to join.
3. Bathing: Mr. Patrick reports that he showers about
twice weekly. He has no safety devices in his bath-
room at this time. He states that he is independent
but a bit shaky getting in and out of the tub when he
showers. He sits down on the side of the tub to dry
his lower extremities but reports difficulty ensuring
his feet are dry. He knows he should inspect his feet
regularly because of his diabetes, but he is not able to
do this easily.
4. Dressing: Mr. Patrick reports difficulty donning his
socks; he therefore wears shoes or slippers without
socks on most days.
CHAPTER 27 ■ Evaluation of Functional Performance 417
Questions
1. What framework would you use to conceptualize the
evaluation of Mr. Patrick’s functional performance
issue?
2. How would you use the information provided by the
framework?
3. Which areas of functional performance would you
want to assess? Which assessment would you select?
Justify your response.
4. A good starting point might be the Canadian Occu-
pational Performance Measure, which would help
identify Mr. Patrick’s specific concerns and goals. He
seems primarily focused on self-care and leisure, so
additional follow-up using the Melville Nelson Self-
Care Assessment and the Activity Card Sort would
be helpful.
5. How would you evaluate lower extremity perform-
ance? Given Mr. Patrick’s profile and his current
status of lower extremity performance, what do you
expect his future trajectory to be if he didn’t have any
rehabilitation intervention?
6. You have been asked to consult on whether
Mr. Patrick is safe to remain at home. Given
Mr. Patrick’s ADL challenges, how will you
assess his performance to make a determination?
7. What other issues should be assessed that might
affect the evaluation of Mr. Patrick’s functional
performance?
Critical Thinking Questions
1. How might the ICF (WHO, 2001) be used by ther-
apists in practice to guide their clinical assessments?
Would this influence how assessment findings are
documented?
2. Consider Glass’s (1998) model. Would you always
want or need to assess an older adult at the hypotheti-
cal, experimental, and enacted levels? Why or why not?
3. How would you go about selecting an outcome
measure to evaluate the effectiveness of a falls
prevention program, for example?
4. In assessing a client with cognitive impairment,
how would you determine the extent to which
the person’s cognition is affecting the results on an
assessment of lower extremity function?
5. In-patient rehabilitation requires comprehensive yet
efficient assessments of function to be completed. On
a geriatric rehabilitation unit, which areas of assess-
ment would be most important for an occupational
therapist and a physiotherapist to complete?
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418 PART IV ■ Service Delivery for the Aging Client
6. How might the physical therapist and occupational
therapist best convey important results to the re-
mainder of the treatment team? What issues might
arise regarding efficiency and effectiveness of assess-
ment and planning?
7. What might be some strategies for evaluating social
and environmental supports, and how might findings
from these evaluations affect treatment planning?
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“To keep the body in good health is a duty, otherwise we shall notmindbe strong
LEARNING OUTCOMES
By the end of this chapter, readers will be able to:
1. Define concepts associated with health and wellness for
older adults.
2. Describe specific factors that have been associated with
health and wellness in older adults.
3. Summarize the characteristics of evidence-based programs
that support health and wellness for older adults.
4. Discuss roles and emerging opportunities for physical and
occupational therapy practitioners on interprofessional and
interdisciplinary teams in health and wellness programs.
5. Discuss environmental influences on health and wellness,
including cultural, political, and global characteristics.
Clinical Vignette
Gloria O’Leary is a 75-year-old manicurist who lives in an
older suburb of a major city. She states that she is fortunate
to have few physical health problems that affect her work
performance. Occasionally she has eye strain because of the
nature of her work, but she recently purchased a magnifying
light that makes it easier to see details. Gloria currently works
20 to 30 hours a week but reports her time in the salon always
goes fast because she greatly enjoys spending time with her
“regulars”; they are an important part of her social network.
Gloria works so she can supplement her social security
income and do the necessary maintenance on her older
two-story home. She lives in a single-family dwelling with
her 93-year-old father who recently has had some health
and memory problems. At times, she worries about him,
especially when he is home alone. Gloria and her nearby
siblings make an annual trip to visit with their extended
family who live about 300 miles away. This yearly celebra-
tion is important because it keeps her connected with
friends from her hometown and the family members who
don’t live near to her.
1. Would you describe Gloria as having health and
wellness given the information provided? Why or
why not?
CHAPTER 28
Health and Wellness
Julie D. Bass
able to keep our
and clear.
—Buddha
”
2. What personal and environmental factors are supports
and barriers for Gloria’s occupational performance and
participation?
W hat does it mean to have health and wellness as
an older adult? Perhaps you have an older adult in
your life who serves as your role model of what it means to
age gracefully and retain a sense of well-being. What is it
about this person that you admire? How has this person
stayed engaged in life? How would you describe her or his
everyday activities? What are some of the contributing factors
that enabled this person to maintain health and wellness in
the later years of life? Has this person had any ailments or
signs of aging that posed challenges? How was she or he able
to retain a sense of health and wellness despite these chal-
lenges? What advice has this person shared on strategies for
living a long and happy life?
Globally, there is increasing interest in health and wellness
for older adults. This chapter defines health and wellness;
relevant factors that support this outcome, including envi-
ronmental influences; evidence-based programs that support
health and wellness; and roles and emerging opportunities
for occupational and physical therapy practitioners on inter-
professional and interdisciplinary teams. For therapists who
wish to serve the healthy older adult population, it is essential
that they have familiarity with both disciplinary and inter-
disciplinary concepts and research.
Concepts Related to Health
and Wellness
Defining health and wellness for any population is challeng-
ing. Many terms describe health and wellness. In 1946, the
World Health Organization (WHO) defined health as “a
state of complete physical, mental and social well-being and
not merely the absence of disease or infirmity” (2007, p. 100).
This early definition recognized that there is more to health
than just the medical conditions we may or may not have.
421
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422 PART IV ■ Service Delivery for the Aging Client
Health and wellness are frequently used in the same sentence
to describe the status of a person.
Definitions of the term wellness emphasize the holistic,
multidimensional, and positive aspects of health. In the
United States, the President’s Council on Physical Fitness
and Sports proposed a definition of wellness as “a multidi-
mensional state of being, describing the existence of positive
health in an individual as exemplified by quality of life and a
sense of well-being” (Corbin & Pangrazi, 2001, p. 3). The
primary dimensions of wellness include physical, emotional,
social, intellectual, and spiritual aspects; these aspects of well-
ness contribute to positive health and well-being for individ-
uals (Corbin & Pangrazi, 2001). Secondary dimensions of
environmental and vocational factors may also be important.
Corbin and Pangrazi added that “wellness results from
healthy behaviors, rather than the healthy behaviors consti-
tuting wellness” (p. 2). Finally, other terms such as quality of
life (QOL) and well-being are needed to measure individuals’
sense of wellness in their lives.
Health and wellness are often thought of as contributing
to QOL and well-being. As you saw in Chapters 1, 2, and 5,
positive or healthy aging is a goal increasingly recognized as
important in later life, regardless of the kinds of changes that
aging brings. Healthy aging is another term used to describe
a positive trajectory late in life. “Healthy aging is the process
of slowing down, physically and cognitively, while resiliently
adapting and compensating in order to optimally function
and participate in all areas of one’s life (physical, cognitive,
social, and spiritual)” (Hansen-Kyle, 2005, p. 52). Adapta-
tion, compensation, and resilience were identified as the an-
tecedents of healthy aging, and the consequences were
successful aging, independence, and autonomy. Some states
have emphasized the role of the community in a definition
of healthy aging as “the development and maintenance of
optimal mental, social and physical well-being and function
in older adults. This is most likely to be achieved when com-
munities are safe, promote health and well-being, and use
health services and community programs to prevent or mini-
mize disease” (Minnesota Department of Health, 2006, p. 2).
The American Occupational Therapy Association (AOTA)
currently uses productive aging as the name of the practice
area focused on older adults. Like the other concepts associ-
ated with health and wellness, there are several definitions.
Butler and Schechter provided one of the earlier definitions
of productive aging as “the capacity of an individual or
population to serve in the paid workforce, to serve in volun-
teer activities, to assist in the family, and to maintain himself
or herself as independently as possible” (cited in Hinterlong,
Morrow-Howell, & Sherraden, 2001, p. 7). Most definitions
of productive aging emphasize the role of activity in the
everyday lives of older adults.
This section of the chapter provided several formal defi-
nitions of concepts related to health and wellness. These
concepts are used by interprofessional and interdisciplinary
teams as they develop knowledge, measures, and interven-
tions for health and wellness in the older adult population.
To be recognized and respected in these professional settings,
occupational and physical therapy practitioners must be
skilled in the language and concepts that guide practice and
programs.
Factors Associated With Health
and Wellness in Older Adults
Several factors have been identified as central to health and
wellness in older adults. There are many models that propose
factors associated with aging, but Rowe and Kahn’s (1997)
model of successful aging remains the most commonly used
as the basis for research, education, and practice.
Rowe and Kahn Model of Successful Aging
The Rowe and Kahn (1997) Model of Successful Aging has
been used in numerous studies of aging to examine charac-
teristics that support health and wellness. The concepts that
have been discussed in previous chapters are reviewed here
in the context of health and wellness in later life. Rowe and
Kahn identified three components that are reviewed in fur-
ther detail in this section: disease and disability, cognitive and
physical function, and engagement with life.
Disease and Disability
Increased risk for disease and disability is associated with ad-
vancing age and may be explained by genetic predisposition
and lifestyle factors (Rowe & Kahn, 1997). Genetic influ-
ences are evident in many medical conditions, including
cardiovascular and cerebrovascular disease, diabetes, and
some cancers. Studies of risk factors associated with genetics
have found that environmental and lifestyle factors play an
equally important role in determining disease and disability;
genetic factors have less of an influence in advanced age-
groups; and modification of the environment and behaviors
change the aging process.
Cognitive and Physical Function
Cognitive factors of language, memory, conceptualization,
and visual spatial function are believed to support functional
levels and participation in everyday activities (Rowe & Kahn,
1997). Physical factors of upper and lower extremity move-
ment, trunk control, balance, and gait also promote successful
aging and performance of activities.
Engagement with Life
Social networks of various kinds serve to provide socio-
emotional support and instrumental or physical assistance
that may be necessary for performing activities (Rowe &
Kahn, 1997). Involvement in meaningful, productive activities
(paid or unpaid) also supports successful aging. Productive
activities help older people remain active in their families
and communities.
4605_Ch28_421-436 31/10/17 12:29 PM Page 423
Other Factors Associated With Health
and Wellness for Older Adults
Given concerns about what the Rowe and Kahn (1997)
model does not address, other studies have examined addi-
tional and related factors associated with health and wellness
for older adults. The International Classification of Function
(ICF; WHO, 2008) has been discussed in previous chapters
and provides a model frequently incorporated into physical
therapy assessment and intervention emphasizing wellness.
Person–environment–occupation models in occupational
therapy (e.g., Baum, Christiansen, & Bass, 2014) may be
helpful in organizing these contributing factors to health and
wellness. Person factors may include genetics, mental health,
and spirituality. Occupation and performance factors include
physical activity, active living, and nutritional habits. Envi-
ronmental factors include social support and the natural and
built environment in the home and community. These factors
operate in concert to impact health positively or negatively.
Several of these contributing factors are reviewed here.
Person Factors
Genetics
Genetics is known to influence the aging process. One
impact of genetic factors on later life has to do with predis-
position to potentially disabling or fatal diseases. For example,
type II diabetes, Alzheimer’s disease (AD), heart disease, and
various cancers have a genetic component. In some diseases,
like Huntington’s disease, the genetic component is clear and
compelling. For other conditions, however, the influence of
genetics is less clear. Genetics has been found to account for
only 20 to 30 percent of the variability in human life span
(Hjelmborg et al., 2006). Thus, except for diseases that will
be expressed regardless of health behaviors, genetics is not
destiny but only a form of predisposition that can, in many
instances, be moderated.
Spirituality
Many individuals seem to become more focused on
spiritual concerns in later life. Spirituality involves the devel-
opment of an “internalized personal relation with the sacred
or transcendent that is not bound by race, ethnicity, econom-
ics, or class and promotes wellness and welfare of self and
TABLE 281 ■ Recommendations for Physical Activity in Older Adults
AREA RECOMMENDATIONS
Aerobic Health benefits options (10+ minutes per session spread
throughout week)
1. Moderate intensity: 150 minutes per week for substantial
benefits; 300 minutes per week for greater benefits
2. Vigorous intensity: 75 minutes per week for substantial
benefits; 150 minutes for greater benefits
3. Mix of moderate and vigorous intensity
CHAPTER 28 ■ Health and Wellness 423
others” (Crowther, Parker, Larimore, Achenbaum, & Koenig,
2002, p. 614). Chapter 26 elaborates on considerations
regarding spirituality in providing physical and occupational
therapy interventions.
Psychological Characteristics
Among the factors associated with good health are per-
ceived control and a sense of self-efficacy. Individuals who
have perceived control over their circumstances report their
health as better and their lives as more satisfying. Perceived
control is associated with lower rates of hospitalization
and reduced mortality (Menec & Chipperfield, 1997). Self-
efficacy, the belief that one can organize and execute courses
of action needed to achieve a desired goal or succeed at
desired undertakings, also influences health status. Self-
efficacy is enhanced through experiences of success, partic-
ularly success in overcoming difficulties. This factor, in turn,
has a positive impact on mental health and improves quality
of life (Blazer, 2002).
Occupation Factors
Physical Activity
Physical activities have been shown to help older adults
maintain function and lower risk for cardiovascular diseases,
diabetes mellitus, some cancers, weight gain, falls, depression,
and cognitive decline (Elsawy & Higgins, 2010). Older
adults who engage in a variety of physical activities are more
likely to achieve recommended levels for aerobic, strength-
ening, flexibility, and endurance exercise. Supporting older
adults’ physical activity and assisting them to identify helpful
and safe opportunities to engage in such activities are impor-
tant considerations for physical therapists. Physical activity
guidelines (Centers for Disease Control [CDC], 2015) are
summarized in Table 28-1.
Staying Active
Staying active by engaging in a variety of occupations
supports cognition, social connectedness, and productivity as
well as physical health. Occupations that are intellectually,
physically, and socially enriching may prevent cognitive
decline for older adults. Health benefits of staying active
include engagement in cognitive (Verghese et al., 2003),
productive (Glass, de Leon, Marottoli, & Berkman, 1999),
EXAMPLES
Moderate intensity: heart is beating faster, breathing is harder,
can talk but not sing
Vigorous intensity: heart is beating much faster, breathing is
harder than normal, can only say a few words before
breathing
Activities: walking/jogging, dancing, swimming/water
aerobics, exercise classes, bicycling, active gardening)
Continued
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424 PART IV ■ Service Delivery for the Aging Client

TABLE 281 ■ Recommendations for Physical Activity in Older Adults—cont’d

AREA RECOMMENDATIONS EXAMPLES

Strengthening ■ All major muscle groups: legs, hips, back, abdomen, chest, Activities: resistance exercise (e.g., weights, machines, bands),
shoulders, arms callisthenic exercises, activities requiring lifting/carrying
■ 2+ days per week
■ Set: 8–12 repetitions with resistance at level that it is
difficult to do another repetition
Balance ■ 3+ days per week Variations in walking (backward, sideways, heel, toe),
■ Balance exercises stand-to-sit, tai chi

Note. Recommendations are from the Centers for Disease Control, 2015.

physical (Elsawy & Higgins, 2010), and social activities

(Glass, de Leon, Marottoli, & Berkman, 1999; James, Wilson,
Barnes, & Bennett, 2011). There is some evidence that
cognitive activities (learning a language, reading complex
material) may protect cognition in later life (Valenzuela
et al., 2003). Staying active by engaging in leisure-time
physical activity and daily commuting have also been shown
to reduce the risk for stroke (Hu et al., 2005).

Nutrition
Nutrition has an impact on normal growth and devel-
opment, preservation of health, healing, and recovery
from illness. According to Chernoff (2001), “Building
muscle strength, developing antibodies to potential invading
microorganisms, maintaining immune function, preserving
cellular integrity, healing wounds, and experiencing a
general sense of wellbeing and an active lifestyle are all
dependent on maintaining nutritional health” (p. 43). The
Academy of Nutrition and Dietetics (www.eatright.org)
has nutrition and health eating recommendations for a
variety of populations, including older adults. It may well
be possible to promote nutrition through such pleasurable
activities as gardening, which also provides for physical FIGURE 281 Many older adults enjoy gardening, an occupation
engagement (Figure 28-1). that involves physical activity and can encourage good nutrition.
Casanowe/iStock/Thinkstock
Environment Factors
Home
The home environment may include a variety of assets Community
or barriers to health and wellness for older adults. Older Environmental characteristics of the broader community
adults’ perceptions of their home environment as well as also support or limit participation and health. A study of
objective characteristics related to accessibility and safety 1,970 older adults found that individuals who lived in neigh-
may influence healthy aging. In a study of more than 1,900 borhoods that had high walkability were more likely to have
older adults from five European countries, elders who lived increased walking time, decreased time spent in cars, and
in accessible homes and perceived their homes as being decreased body mass index (Frank, Kerr, Rosenberg, & King,
in good condition, having meaning, and supporting their 2010). The natural and built community environment is
activities were more likely to have better performance of especially important for older adults who may have activity
daily activities and better mental health and well-being limitations even if they have overall good health. In a cross-
(Oswald et al., 2007). Smart-home technology or informa- sectional study of 156 older adults, individuals who had more
tion communications technology have been developed to sup- activity limitations were more likely to report physical and
port aging in place and safety in the home. See Chapter 21 social environmental barriers to participation (Levasseur,
for discussion of assistive devices. Desrosiers, & St-Cyr Tribble, 2008).
4605_Ch28_421-436 31/10/17 12:29 PM Page 425
Studies of neighborhoods and communities have exam-
ined the relationships between design characteristics (e.g.,
walkability, proximity to healthy services), physical activity
levels, and active aging. Older adults report that neighbor-
hood features of shopping and services, traffic, pedestrian
walkways, aesthetics, and public transportation are important
for active aging (Michael, Green, & Farquhar, 2006). The
WHO commissioned a study of 33 urban settings to identify
the themes and variations in communities that were associated
with active aging and age-friendly cities (Plouffe & Kalache,
2010). Eight domains were determined to be associated
with age-friendly cities: outdoor spaces and buildings,
transportation, housing, social participation, respect and
social inclusion, civic participation and employment, com-
munication and information, and community support and
services.
Social Determinants of Health
Social determinants of health are “the conditions in which
people are born, grow, live, work and age, including the
health system. These circumstances are shaped by the distri-
bution of money, power and resources at global, national and
local levels, which are themselves influenced by policy
choices. The social determinants of health are mostly respon-
sible for health inequities—the unfair and avoidable differ-
ences in health status seen within and between countries”
(WHO, 2014, n.p.). Environmental influences on health
and wellness for older adults are being examined in research
and social policy. Population-based initiatives are designed
to address the inequities that are due to social determinants
of health. Refer to Chapter 1 for a further discussion of social
determinants of health.
AROUND THE GLOBE: Social Determinants of Health
Research in Canada
Health Canada proposes four foci for research on social determinants
of health: community health (e.g., community capacity, resilience,
efficiency), social capital, socioeconomic inequality (e.g., income,
social status), and social cohesion (e.g., shared community values,
challenges, opportunities) (Health Canada, 2003).
Therapy for Health and Wellness
Occupational Therapy
Occupational therapy has had longstanding involvement in
promoting health and wellness for older adults. Practice,
education, policy and research initiatives provide support for
occupational therapy’s contributions to positive aging. In this
section, a few highlights are summarized.
The Health and Wellness and Productive Aging practice
areas on the American Occupational Therapy Association
(AOTA) website (www.aota.org) provide a variety of resources
CHAPTER 28 ■ Health and Wellness 425
for practitioners who promote healthy aging. The AOTA
also has a statement describing Occupational Therapy in the
Promotion of Health and Well-being (AOTA, 2013). Although
this statement is targeted to the entire life span, it includes
valuable resources and references to support practice, in-
cluding summaries of health promotion, health disparities,
prevention strategies, population health approach, health
promotion and occupation, and role of occupational therapy
in health promotion. AOTA Societal Statements on Health
Disparities (2013), Health Literacy (2011), and Livable Com-
munities (2008) also relate to health and wellness for older
adults (http://www.aota.org/Practice/Manage/Official.aspx).
Occupational Therapy Health and Wellness
Interventions
A special issue of the American Journal of Occupational Therapy
(AJOT) (May 2012) on the relationship between occupation
and productive aging was commissioned as part of the AOTA
Evidence-Based Practice Project. Four systematic reviews
were conducted to examine the evidence on community-
dwelling older adults regarding how participation in occupation
and activities support health, the effect of occupation-based and
activity-based interventions on performance of instrumental
activities of daily living (IADL), the effective of occupation-
based and activity-based health management and mainte-
nance interventions on performance, and the effect of home
modification and fall prevention interventions (Arbesman &
Lieberman, 2012).
There is strong evidence to support the relationship
between participation in occupation and activities and health.
In this systematic review, a total of 98 peer-reviewed journal
articles, including 59 longitudinal studies, 95 Level II and
3 Level I studies on occupation and health were found (Stav,
Hallenen, Lane, & Arbesman, 2012). Engagement in phys-
ical activity was associated with maintenance of an active
lifestyle, lower mortality and morbidity, improved ability to
perform activities of daily living (ADL) and IADL, and fewer
limitations in functional performance. Having social activities
and social networks was also linked to slower rates of cogni-
tive and physical decline. There was moderate evidence for
the health benefits of leisure activities, religious activities,
sleep, and instrumental ADL. On the basis of the strength
of the evidence, occupational performance and participation
were recommended as integral to health and wellness pro-
grams for older adults living in the community.
There is moderate to strong evidence for the effect of
occupation and activity-based interventions on performance
of instrumental activities of daily living. A systematic review
found 38 studies, including 31 Level I articles on programs
that emphasize occupation based and client-centered, func-
tional activities, performance skills, home modifications and
assistive technology (Orellano, Colón, & Arbesman, 2012).
Multicomponent interventions provided by occupational
therapy and other disciplines were particularly effective in
improving performance in instrumental activities of daily
living. Occupation-based programs and functional task
4605_Ch28_421-436 31/10/17 12:29 PM Page 426
426 PART IV ■ Service Delivery for the Aging Client
exercises have moderate evidence for improving IADL per-
formance, but there is limited evidence for simulated IADL
programs.
Another systematic review found moderate to strong evi-
dence for health management and maintenance interventions
for older adults that restore, modify, and maintain IADL per-
formance. For this review, 28 articles, including 24 Level I
studies were identified (Arbesman & Mosley, 2012). Health
management and maintenance interventions were classified
as occupational therapy programs, health education, self-
management, and specific skill programs. For many of these
programs, there is at least moderate evidence that the inter-
ventions improve performance and participation and decrease
the impact of various conditions.
The final systematic review in this special issue of the AJOT
examined the impact of fall prevention and home modification
programs on performance. In this review, 33 studies including
31 Level I studies were found on multifactorial interventions,
physical activity interventions, home assessments and home
modifications (Chase, Mann, Wasek, & Arbesman, 2012).
The strongest evidence was for multifactorial interventions
that included exercise, education, and recommendations for
assistive technology and home modifications. Evidence for
programs with a singular focus (e.g., exercise) were moderate.
Client-centered programs that include multiple interventions
may support health and wellness for older adults by prevent-
ing falls.
Physical Therapy
If there is a fountain of youth, it includes a prescription for
participating in regular exercise. Exercise can have substantial
benefits for physical status, emotional status, and maintaining
cognition. A glance at the MedlinePlus information page on
exercise for seniors (2014), lists among the health benefits:
■ Exercise may prevent or delay onset of many diseases and
conditions.
■ Physical fitness is associated with lower likelihood of
developing dementia.
■ Exercise helps ease arthritis pain and stiffness.
■ Exercise helps to manage stress and improve mood.
✺ PROMOTING BEST PRACTICE
The Evidence for Exercise
According to the CDC (2015), 150 minutes per week of
moderate-intensity exercise (walking briskly is an example)
is sufficient in terms of physical and mental health and well-
being. That exercise can be done in small increments. Even
10 minutes at a time has shown to reduce risk of disease
and cognitive decline.
The physical therapist has a critical role to play in assessing
older adults’ levels of fitness, helping them design safe and
enjoyable exercise routines, and monitoring participation over
time. Motivation to exercise can be a particular challenge, so
identifying activities that the older adult will enjoy and can
participate in easily are critical to success. For example, walk-
ing is inexpensive, requires only a good pair of walking shoes,
and does not involve complicated learning. However, in some
inner-city neighborhoods, older adults have no safe place to
walk. Helping the individual solve such a dilemma can make
a significant difference in encouraging the behavior. Exercise
can also provide opportunities for social engagement, which
may, in turn, encourage continued participation in exercise
(Figure 28-2).
In addition, physical therapy can provide essential assistance
in ensuring that elders retain or gain the physical mobility and
endurance to participate in the occupations that are most
meaningful to them. As one example, elders often struggle
with self-care activities such as dressing because their balance
and range of motion become impaired. Gentle exercise pro-
grams that address these components may extend self-care
independence while also helping to minimize the risk of falls.
There is strong evidence that even moderate engagement
in physical activity promotes health for older adults (Hogan,
Mata, & Carstensen, 2013). Such activity helps to maintain
bone health, balance, and functional capacity as well as cog-
nition and positive affect.
Occupational Therapy and Physical Therapy
Interventions and Programs
Many intervention plans that are based on a rehabilitation
framework begin by identifying the occupational performance
problems that need to be addressed through occupational
therapy, and strength, mobility, and physical capacity issues
that may benefit from physical therapy intervention. Efforts
may focus on restoration, remediation, compensation, or
adaptation as means to achieve goals and overcome problems.
The intervention goals to support health and wellness for older
adults will typically emphasize health promotion, mainte-
nance, and prevention. Some interventions fall outside the
FIGURE 282 Exercise is vital to good health and to wellness. Plush
Studios/Blend Images/Thinkstock
4605_Ch28_421-436 31/10/17 12:29 PM Page 427
medical or public health model but have been proposed as
wellness programs that support QOL for older adults. Keep
in mind that while many of the specific programs described
here are found in the United States, similar kinds of wellness
programs have been implemented around the world.
Health Education, Health Coaching, and Health
Promotion
Health education, health coaching, and health promotion
are related programs that are designed to develop the health
behaviors that support health and wellness for older adults.
They are the predominant intervention approaches for healthy
aging. A brief summary of their similarities and differences
are included here.
Health education uses a variety of approaches to improve
health outcomes and maintain health and wellness. The Joint
Committee on Health Education and Promotion Terminology
has adopted the definition of health education as “any combi-
nation of planned learning experiences using evidence-based
practices and/or sound theories that provide the opportunity to
acquire knowledge, attitudes, and skills needed to adopt and
maintain health behaviors” (2011, p. 12). Health education is
used by health professionals to give evidence-based information
and advice on disease management (Butterworth, Linden, &
McClay, 2007).
Health coaching may have similar goals to health educa-
tion, but the process is quite different. Many health-coaching
programs have their basis in cognitive-behavioral therapy
(Neenan, 2008). Health coaching has been defined as “a
behavioral health intervention that facilitates participants in
establishing and attaining health-promoting goals in order
to change lifestyle-related behaviors, with the intent of re-
ducing health risks, improving self-management of chronic
conditions, and increasing health-related quality of life”
(Butterworth et al., 2007, p. 300). Health coaching is a
client-centered approach that is based on behavior change
models and uses motivational interviewing to help individuals
develop and implement a plan of action to achieve goals
(Butterworth et al., 2007). Although there is promise in
health coaching programs, more research is needed to develop
systematic coaching strategies and evidence that demon-
strates its efficacy and cost-effectiveness.
Health promotion is a central intervention strategy in
public health. It is defined as “the art and science of helping
people discover the synergies between their core passions
and optimal health, enhancing their motivation to strive
for optimal health, and supporting them in changing their
lifestyle to move toward a state of optimal health. Optimal
health is a dynamic balance of physical, emotional, social,
spiritual, and intellectual health. Lifestyle change can be
facilitated through a combination of learning experiences that
enhance awareness, increase motivation, and build skills and,
most important, through the creation of opportunities that
open access to environments that make positive health
practices the easiest choice” (O’Donnell, 2009, p. iv–v). This
definition of health promotion emphasizes the importance of
CHAPTER 28 ■ Health and Wellness 427
motivating people to establish health and wellness goals as a
means to engage in their life passions.
Lifestyle Redesign
The Lifestyle Redesign intervention emerged from the
landmark study by Clark et al. (1997) that compared the
outcomes of an occupational therapy preventive intervention
for elders living in the community to a social activities pro-
gram led by nonprofessionals with a group that received no
intervention. The elders receiving the occupational therapy
program demonstrated greater gains in physical and social
functioning, mental health, and life satisfaction, and those
gains were maintained at 6-month follow-up. The out-
comes for the social activities group were similar to those
who received no treatment at all (Clark et al., 1997, 2001).
Lifestyle Redesign focuses on educating older adults about
the importance of occupation to enhance physical, mental,
emotional, social, and spiritual health and on preparing
them to be reflective about their occupational choices. The
combination of knowledge of the health benefits of occupa-
tion and the skills to be reflective enables the person to “con-
struct daily routines in a manner that would optimize their
health and psychosocial wellbeing” and to participate in a
process of lifestyle redesign (Jackson, Carlson, Mandel,
Zemke, & Clark, 1998, p. 329).
Life Review
Life review has been proposed as a meaningful wellness ac-
tivity for both older adults and the important people in their
lives. Life review is structured around selected themes (e.g.,
life roles, turning points, major events, experiences, values)
and tends to be “an evaluative process, in that participants
examine how their memories contribute to the meaning of
their life, and they may work at coming to terms with more
difficult memories” (Haber, 2006, p. 154). The processes that
are part of life review are “extremely complex, nuanced, emo-
tional, often inchoate and contradictory, and are frequently
filled with irony, comedy and tragedy” (Butler, 2002, p. 7).
One elder who participated in the life review and memoir
process stated, “Because you’re asking me all these questions,
it’s like a dam breaking open. I now realize (that) I’ve had a
very wonderful life!” (Tyrrell, 2012, p. 3).
Life review may be conducted in individual or small group
formats with the process usually led by a personal historian
who is skilled in working with elders. Personal historians (or
memoirists) are skilled in the art of the interview and crafting
narratives that may become family heirlooms (Tyrrell, 2012).
The profession of personal historian is relatively new and usu-
ally operates from small microbusinesses; personal historians
need knowledge and skills related to business management,
health risk assessment, interviewing, writing, aging processes,
and ethics (Tyrrell, 2012, 2013). Because personal historians
may uncover mental health issues in the life review process,
knowledge of posttraumatic stress, trauma, stress, family
dynamics, boundary issues, and mental illness is essential in
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428 PART IV ■ Service Delivery for the Aging Client

this work (Birren & Svensson, 2013; Haber, 2006; Tyrrell,
2012, 2013). Additional information on life review programs
may be found using several similar key terms, including rem-
iniscence, oral history, guided autobiography, personal narrative
or memoir, and narrative gerontology (Birren & Svensson,
2013; Haber, 2006).
Physical Activity to Support Health and Wellness
Governmental, nonprofit, and health organizations promote
physical activity as an important strategy for maintaining
health and wellness in the older adult years. Exercise and
occupations that require moderate to high intensity may be
used as part of an active lifestyle to achieve the recommended
physical activity levels and physical health that support cardio-
vascular health (Haskell et al., 2003) and a reduced risk of
cognitive decline (Buchman et al., 2012). Physical activity
programs are generally community-based and are offered
through small groups, media campaigns, and online resources.
A variety of physical activity options are generally available
for older adults to support the different needs and perspec-
tives regarding physical activity. Individual fitness routines,
fitness programs at community organizations, online fitness
programs, and/or rehabilitation fitness programs provide
older adults with the necessary supports to follow national
guidelines. Options are important because individuals and
communities may have different preferences regarding phys-
ical activities. In focus groups with seven ethnic groups
(American Indian/Alaska Native, African American, Filipino,
Chinese, Latino, Korean, and Vietnamese), recommenda-
tions regarding physical activity programs emphasized the
importance of culture-specific exercises, programs in close
proximity to living environments or social services, family-
based health education, low-cost programs, and involvement
of older adults in planning programs (Belza et al., 2004).
INTERPROFESSIONAL PRACTICE
Fitness Programs
Occupational and physical therapy practitioners have had
a long-standing involvement in fitness programs for special
populations. Tai chi (Mihay, Boggs, Breck, Dokken, & NaThalang,
2006) and yoga (Schmid, Van Puymbroeck, & Koceja, 2010)
are examples of fitness programs that may be extended
to meet the needs of older adults with goals of positive
aging.
Active Living and Staying Active Programs to Support
Health and Wellness
Active living and staying active programs have been shown
to be effective for promoting physical, psychological, and
cognitive health. These programs emphasize engagement in
a variety of activities beyond physical exercise, including work
and volunteering, social interaction, creative activities, and
many more to maintain involvement in daily life. The WHO
proposed a policy framework for active aging that includes
key proposals for health, participation, and security. Many
policy areas are aligned with occupational and physical ther-
apy domains of concern. For example, active aging requires
barrier free environments, options for activities, training for
informal caregivers, and community mobility systems that
meet the needs of an older adult population Primary policy
areas related to physical and occupational therapy are sum-
marized in Table 28-2.
Evidence-based active aging and staying active programs
are readily available through various governmental agencies
and organizations. These programs introduce a variety of in-
dividual and group strategies for engaging in activities that
promote health. Recruitment of individuals into any active
aging program requires consideration of their readiness

TABLE 282 ■ World Health Organization Policy Framework for Active Aging

WHO KEY POLICY PROPOSALS
FOR ACTIVE AGING
Health
Prevent and reduce the burden of
excess disabilities, chronic disease,
and premature mortality.
Reduce risk factors associated with
major diseases and increase factors
that protect health throughout the
life course.
Develop a continuum of affordable,
accessible, high-quality and
age-friendly health and social
services that address the needs
and rights of women and men
as they age.
Provide training and education
to caregivers.
PRIMARY POLICY AREAS RELATED
TO THERAPY
Prevention and effective treatments, age-friendly,
safe environments, barrier-free living, quality of
life, social support, mental health
Physical activity, healthy eating, psychological
factors, adherence
Informal caregivers, mental health services, aging
at home and in the community, partnerships
and quality care
Informal caregivers
SECONDARY POLICY AREAS RELATED
TO THERAPY
Goals and targets, economic influences on health,
hearing and vision, HIV and AIDS, clean
environment
Tobacco, nutrition, oral health, alcohol and drugs,
medications
A continuum of care throughout the life course,
affordable, equitable access, formal caregivers,
coordinated ethical systems of care, iatrogenesis
Formal caregivers
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CHAPTER 28 ■ Health and Wellness 429

TABLE 282 ■ World Health Organization Policy Framework for Active Aging—cont’d

WHO KEY POLICY PROPOSALS PRIMARY POLICY AREAS RELATED SECONDARY POLICY AREAS RELATED
FOR ACTIVE AGING TO THERAPY TO THERAPY
Participation
Provide education and learning Basic education and health literacy, lifelong
opportunities throughout the learning
life course.
Recognize and enable the active Formal work, informal work, voluntary activities Poverty reduction and income generation
participation of people in economic
development activities, formal and
informal work and voluntary activities
as they age, according to their
individual needs, preferences, and
capacities.
Encourage people to participate fully Transportation, a society for all ages, positive Leadership, support organizations representing
in family community life as they image of aging, reduce inequities in older people
grow older. participation
Security
Ensure the protection, safety, and Social justice, shelter, crises, elder abuse Social security, HIV/AIDS, consumer protection
dignity of older people by
addressing the social, financial,
and physical security rights and
needs of people as they age.
Reduce inequities in the security Legislation and laws, social security
rights and needs of older women.

Note. Adapted from the World Health Organization (2002).

to change past patterns of behaviors and adopt new daily
activities (Hildebrand & Neufeld, 2009). An occupational
therapy perspective may enhance interest in these programs
by helping individuals explore the full array of occupations
for older adults who have different personal capabilities and
environmental settings. An occupational profile may be used
as part of this process to explore a person’s interests and past
experiences that support active aging.
Self-Management Programs
Self-management programs are relatively new strategies to
promote health and wellness for older adults who have
chronic conditions. Self-management has been defined as a
“dynamic and continuous process of self-regulation” to “man-
age the symptoms, treatment, physical and psychosocial con-
sequences and life style changes inherent in living with a
chronic condition” and to “monitor one’s condition and to
effect the cognitive, behavioral and emotional responses nec-
essary to maintain a satisfactory quality of life” (Barlow,
Wright, Sheasby, Turner, & Hainsworth, 2002, p. 178).
Most self-management programs include both coaching and
education, require core competencies of staff, and use out-
come measures to evaluate the program (Pearson, Mattke,
Shaw, Ridgely, & Wiseman, 2007).
Stanford University’s Chronic Disease Self-Management
Program (CDSMP) is an evidence-based model for user-led
self-management programs in which health professionals
train volunteers to lead self-management groups for their
peers (Department of Health, 2001). The programs are typ-
ically offered in 6-week sessions for about 2.5 hours per week
and emphasize five core skills: “problem solving, decision-
making, resource utilization, formation of a patient-professional
partnership, taking action” (Department of Health, p. 25)
to decrease symptoms and pain associated with various
conditions and improve performance, participation, and life
satisfaction. The five core skills are based on social cognitive
theory and the role of self-efficacy in influencing action; self-
efficacy is emphasized to promote confidence and provide
opportunities to achieve mastery, share experiences, commu-
nicate positivism, receive feedback, and obtain support
(Joice, 2012).
Programs may be provided online or in the home, clinic,
or community and structured for use by individuals or small
groups. Many programs incorporate two or more of these for-
mats and include general health information, medication and
symptom management, behavioral conditioning, psychosocial
adjustment, lifestyle issues, social support, communication,
and goal setting. The desired outcomes of self-management
programs include improved health and health practices of
the participant (physical, psychological, and social health;
knowledge; medication use; self-efficacy and self-management
behaviors) and decreased demands on the health system (use
of health resources, health costs) (Barlow et al., 2002).
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430 PART IV ■ Service Delivery for the Aging Client
User-led self-management programs are cost-effective
and designed to give people with chronic conditions more
control over their health management (Department of Health,
2001). The goals, models, outcomes, content, and interven-
tions of self-management programs were summarized in
a special report prepared for the Agency for Healthcare
Research and Quality (Pearson et al., 2007). The Affordable
Care Act emphasizes preventive and wellness services,
including self-management programs, as an essential health
benefit and an important part of patient- and family-
centered care (Ulmer, Ball, McGlynn, & Bel Hamdounia,
2012; U.S. Department of Health and Human Services,
2011).
Cognitive and Social Activities
Active lifestyles that are intellectually stimulating and enrich-
ing appear to support cognitive and psychological health.
The benefits of an enriching lifestyle program are based on
evidence from several areas of cognitive research: cognitive-
training studies, multimodal lifestyle interventions, and aerobic
exercise or physical activity (Hertzog, Kramer, Wilson, &
Lindenberger, 2009; Lustig, Shah, Seidler, & Reuter-Lorenz,
2009).
Experience Corps (EC) is an example of a lifestyle inter-
vention that is targeted to older adults. Several studies have
been conducted on EC with positive results for overall health
and wellness of older adults (Carlson et al., 2008; Fried et al.,
2004; Tan et al., 2009). In EC, community-dwelling elders
are invited to serve as volunteers in elementary schools to
provide enrichment programs for students. The volunteers
are provided with training and experiences that support
physical activity, social engagement, and cognitive stimu-
lation. Outcomes of randomized clinical trials of the EC
programs have shown improved executive function and
memory (Carlson et al., 2008; Fried et al., 2004), physical
activity levels (Fried et al., 2004; Tan et al., 2009), and
social connections (Fried et al., 2004). The initial EC
program was based in Baltimore, MD, and most of the
participants were African American. The randomized trials
of EC showed that recruiting senior volunteers was a
feasible intervention that benefitted both the students
and the older adults in a diverse community.
Environmental Interventions
Many older adults prefer to stay in their own home and
age in place, as described in Chapters 1 and 21. Home
modifications and assistive technology are often recom-
mended as important interventions that enable older adults
to live in their preferred home settings. Several studies have
found that these interventions help older adults maintain
functional status (Mann, Ottenbacher, Fraas, & Tomita,
1999) and are cost-effective when considering the ex-
penses associated with long-term care settings (Lansley,
McCreadie, & Tinker, 2004). Newer home technologies are
helping to monitor health, manage care, and motivate older
adults to assume primary responsibility for their health
(Marchibroda, 2015).
The environmental characteristics of the broader com-
munity are just as important as the home, especially to support
social participation. With the aging population, many commu-
nities are rethinking their health-care settings, transportation,
shopping and service areas, workplaces, and centers for
recreation and lifelong learning; changes are needed to
respond to increased demand for environments that are use-
able, accessible, convenient, health promoting, and responsive
to personal needs and choices (Coughlin, 2007). The WHO
(2007) completed a major study that identified the issues and
needs for age-friendly communities from the perspective of
older adults in 33 major cities. A planning guide summarizes
specific needs related to outdoor spaces and buildings, trans-
portation, housing, social participation, respect and social
inclusion, civic participation and employment, communica-
tion and information, and community support and health
services. Table 28-3 summarizes issues and needs related to
age-friendly cities.
Physical and occupational therapists have opportunities to
make significant contributions to the development of age-
friendly cities to support health and wellness for older adults.
Occupational therapy researchers have added to our under-
standing of environmental supports and barriers for people
with disabilities and this knowledge in turn has guided de-
velopment of interventions (e.g., Hammel, Jones, Smith,
Sanford, Bodine, & Johnson, 2008). Physical therapists un-
derstand the ways in which physical barriers may impede
movement through the environment and can guide planners
in avoiding or minimizing those barriers. Therapists who
enjoy working on interdisciplinary and interprofessional
teams and with members from the older adult community
may provide added value to community initiatives and help
to shape practice, policy, education, and research.
Professional Development for Practice
Health and wellness for older adults may be considered an
area of specialization for therapists. There are growing op-
portunities related to health and wellness. Most professional
development programs on health and wellness are offered by
interdisciplinary academic institutions, organizations, and
programs. Therapists who work on interdisciplinary practice,
research, education, or policy teams to promote health and
wellness for older adults know that interdisciplinary organi-
zations, conferences, journals, and professional networks are
essential to build their knowledge and skills
Addressing Health and Wellness in the
Current Health-Care Environment
Although there are still limitations on reimbursement for
health and wellness programs in the current health-care
environment, there is growing recognition of the importance
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CHAPTER 28 ■ Health and Wellness 431

TABLE 283 ■ Age-Friendly Cities: Issues and Needs

ISSUES NEEDS
Outdoor spaces and Environment Cycle paths
buildings Green spaces and walkways Safety
Outdoor seating Services
Pavements Buildings
Roads Public toilets
Traffic

Transportation Affordability Information

Reliability and frequency Community transport
Travel destinations Taxis
Age-friendly vehicles Roads
Specialized services Driving competence
Priority seating Parking
Transport drivers

Housing Affordability Aging in place

Essential services Community integration
Design Housing options
Modifications Living environment
Maintenance

Social participation Accessibility of events and activities Promotion and awareness

Affordability of activities
Range of events and activities Addressing isolation
Facilities and settings Fostering community integration

Respect and social Respectful and inclusive services Public education

inclusion Public images of aging Community inclusion
Intergenerational and family Economic inclusions
interactions

Continued
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432 PART IV ■ Service Delivery for the Aging Client

TABLE 283 ■ Age-Friendly Cities: Issues and Needs—cont’d

ISSUES NEEDS
Civic participation Volunteering options Civic participation
and employment Employment options Valued contributions
Training Entrepreneurship
Accessibility Pay

Communication Information offered Automated communication and

and information Oral communication equipment
Printed information Computers and internet
Plain language

Community support Service accessibility Voluntary support

and health services Offer of services Emergency planning and care

HOSPITAL

of evidence-based health promotion programs in improving
health outcome and controlling health-care costs. Many
health-care systems are offering an assortment of health and
wellness programs to improve the overall health of the people
they serve. Some of these programs are specifically targeted
for the older adult populations, and others may focus on the
needs of people with specific risk factors across the life span.
These organizations and agencies have their own source of
funding that supports health and wellness initiatives.
Occupational and physical therapists in the United States
who are interested in health and wellness initiatives for older
adults are encouraged to explore opportunities outside the
current health-care system. Public health systems, govern-
mental agencies, community education, non-profit organiza-
tions, residential living environments, and employers regularly
develop and implement health initiatives that may be
improved by incorporating occupational therapy knowledge
and expertise. However, job descriptions will generally be
framed around interdisciplinary health professional skills
rather a specific profession like occupational therapy. Models
from well-developed and well-designed programs in other
countries, including Canada, the United Kingdom, and the
Scandinavian countries, can help identify strategies that
might be effective in the United States (cf. Joanette, 2013).
Many of these countries have a longer history of providing
wellness interventions, often in the context of universal health
care systems.
Businesses have also started to target programs and
services for older adults. New products, technology, support
services, one-stop shopping, living environments, and online
resources are developed to meet the needs of healthy older
adults and enable them to engage in meaningful occupations
and participate in their communities. Entrepreneurial occu-
pational and physical therapists may tap into this growing
market and provide valuable services for older adults who are
looking for trustworthy providers.
4605_Ch28_421-436 31/10/17 12:29 PM Page 433
SUMMARY
Health and wellness is the hope that all of us have in our
older adult years. This chapter introduced concepts related to
health and wellness; factors associated with positive, success-
ful, or productive aging; and evidence-based interventions
that support occupational performance and participation for
older adults.
In many communities, the fastest growing demographic
is the older adult population. There are many opportunities
for therapists to serve on interdisciplinary practice, research,
education, and policy teams that address the needs of older
individuals and communities as they age. Evidence-based pro-
grams that are focused on prevention, health promotion, health
education, and self-management will support older adults’ goals
for performance, participation, and engagement in everyday life.
CASE STUDY
A nonprofit organization that serves older adults has
recently acquired 100 acres in a new mixed-use development
area (residential and commercial). They are in the early
planning stages to develop an evidence-based, flourishing
community that serves and supports the needs of its future
residents. An occupational and a physical therapist have
been invited to be members of the design team, which
includes an architect, gerontologist, nurse practitioner,
interior designer, and three leaders from a nearby senior
citizen center.
The goal of the design team is to develop a vision for
the environment and programs in this new development
that would advance the organization’s mission to promote
health and wellness for older adults. The occupational
therapist and physical therapist will each serve as a con-
sultant to the organization for approximately one year
and are contracted to provide 10 hours of services per
month. The design team has been asked to conduct a needs
assessment and summarize the evidence on programs
and living environments that promote positive aging.
They will meet for 1 or 2 hours twice a month during
the year and complete an executive summary of their
recommendations.
Questions
1. What additional information would the occupational
therapist want about the proposed project to be an
effective team member?
2. What additional information would be helpful in
framing the physical therapist’s involvement.
3. What occupational and physical therapy knowledge
and skills would be particularly valuable on this
design team?
4. What do you believe is important to consider and
determine in a needs assessment?
CHAPTER 28 ■ Health and Wellness 433
Critical Thinking Questions
1. How are the definitions of successful aging, healthy
aging, positive aging, and productive aging similar
and different?
2. What additional knowledge, skills, and attitudes
would you need to develop to be effective in interdis-
ciplinary initiatives related to health and wellness for
older adults?
3. Discuss the similarities and differences between the
health and wellness interventions discussed in this
chapter and interventions summarized in the Occu-
pational Therapy Practice Framework.
4. Why have health and wellness programs for older
adults gained in popularity? What benefits do they
offer the client? The community? The health care
system?
5. Of the various health education roles (health educa-
tor, health coach, etc.), which seems most consistent
with the roles of OT and PT?
6. What information would be helpful in convincing a
community to expand its wellness programming for
older adults?
7. What ethical dilemmas does a practitioner face when
some older adults or communities do not have the
financial means to engage in healthy behaviors that
support health and wellness?
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Acknowledgements
With special thanks to Marjorie E. Scaffa and Bette R. Bonder
for sharing the chapter on health promotion and wellness from
the previous edition of this text.
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CHAPTER 29
Community-Based Services
Georgia J. Anetzberger

“I findprocess:
that the ‘winding down’ process of life isn’t much different than the ‘growing up’
New experiences everyday and problems to be solved. We had lots of help
in growing up and we have lots of help in winding down.
—Richard Kauffman, retired musician and settlement house worker, at age 88
”
LEARNING OUTCOMES 2014). It is not so much that medical and nursing facilities
are seen as uncaring or unsafe. Rather, community-dwelling
By the end of this chapter, readers will be able to:
carries with it a sense of familiarity, individual identity, per-
1. Discuss factors that influence the use of services. sonal control, and freedom. As adults age, remaining in the
2. Identify levels of service barriers. community becomes more challenging. Impairments and
3. Describe resources that link individuals with available com- social losses can serve to compromise well-being and inde-
munity services. pendence. Facing these challenges usually means confronting
4. List the various resources available for older adults to remain the need for services. Much help comes from family and
active through work, learning, volunteerism, or social and friends (Feinberg, Reinhard, Houser, & Choula, 2011;
recreational experiences. National Alliance for Caregiving & American Association of
5. Explain the nature of adult protective services. Retired People [AARP], 2009; O’Shaughnessy, 2013a;
6. Identify housing options that exist for older adults. Reinhard, Levin, & Samis, 2012). The rest is available from
7. Describe the roles of physical and occupational therapy in organizations or housing options in the community. Many
supporting older adults in the community. of these community-based services are described here; others
are considered in the remaining chapters.
Discussion in this chapter focuses on the importance
Clinical Vignette placed on community-based services. The chapter then iden-
Jean Clark is 70 years old and reasonably healthy, except for tifies various ways to classify them and select a functional
hypertension and some arthritis. Divorced with two adult chil- approach to care. Service utilization and barriers to service
dren living in other parts of the country, she just retired after use are explored. Identifying community-based services can
decades in the labor force, first as secretary and more recently be difficult without the help of linkage resources, which con-
as office manager of a small insurance firm. Jean did not make nect individuals with available services. This chapter describes
specific plans for her retirement and is now concerned about these and then discusses various community-based services
what she will do. Although her health is good at present, she in terms of their provision of something to do, someone to
worries about what would happen if she became ill or disabled. care, and someplace to live. Throughout, case examples act
1. How might Ms. Clark explore what she might do with to introduce these service classifications as well as to illustrate
her time? the use of select services.
2. What help is available, if she needs it? Note that this chapter deals primarily with the situation
3. What factors might she need to consider with regard as it exists in the United States. Community services are pro-
to whether to remain in her present home or move vided in most countries, although the governing policies,
elsewhere? structures, and expectations for such service vary considerably.
Refer back to the essays you read earlier in Chapter 4, and

N early all older adults want to remain in the commu-

nity and out of institutions (Keenan, 2010). Most
believe that they will be able to live in their current homes
until they die (Robison, Shugrue, Fortinsky, & Gruman,
compare and contrast what you learned about Mexico, South
Africa, and Israel as you read here about the United States.
The Scandinavian countries and the United Kingdom have
extensive and effective community-based services that you
may also wish to explore.

437
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438 PART IV ■ Service Delivery for the Aging Client
Service Imperative
The importance placed on community-based services has in-
creased significantly during the past few decades. This has
been fuelled by such factors as the growth of the older adult
population and decline of available informal caregivers, as
family size, structure, and mobility changed (see Chapter 24
for further discussion). In particular, because of insufficient
informal care, community-based services have become critical
for aging in place. In a survey of Older Americans Act Title III
service users, more than 85 percent reported that receiving
home-delivered meals, homemaking, case management, trans-
portation, and other such services has enabled them to remain
at home, and out of nursing homes (Altshuler & Schimmel,
2010).
Public policy propelled growth in community-based
services, bolstered by interest groups for older adults, is
considered to be among the nation’s most powerful lobbies
(Binstock, 2005). Federal legislation, like the Older Americans
Act, Title XX of the Social Security Act, and Medicaid
waivers, provided funding for community-based services and
encouraged more organizations to become service providers
for older adults. Many states also used general revenues for
community-based services, targeting older adults ineligible
for Medicaid-funded services (Kassner, 2011). In addition,
several states used property tax levies to generate funding for
further services. For example, 83 local senior service levies in
Ohio produce more than $166 million to serve about 200,000
older residents annually with the goal of helping them live in
their own homes and communities (Payne, Applebaum, &
Straker, 2012).
The 1999 U.S. Supreme Court decision on Olmstead v.
L.C. gave priority to community-based services by recogniz-
ing the general responsibility of states to serve people with
disabilities in the community, if they are eligible and do not
oppose receiving services there. The ruling is widely seen as a
stimulus for changing the long-term care balance from insti-
tutional to community-based services (Velgouse, 2000).
Moreover, in recent years the high cost of institutional
care and its effect on Medicaid budgets, the largest source of
funding for long-term care, has reinforced federal and state
government interest in rebalancing the use of Medicaid dol-
lars toward community-based services and away from nursing
home care. In fiscal year 1997, three-fourths of Medicaid
funding for long-term care went to institutional care and one-
fourth went to community-based services, but by 2014, the
distribution was nearly fifty–fifty (Henry J. Kaiser Founda-
tion, 2015). This shift occurred in part through efforts to help
more than 25,000 persons with disabilities transition from
living in institutions to living in the community through pro-
gramming authorized under the Deficit Reduction Act of
2005 and extended under the Patient Protection and Afford-
able Care Act of 2010’s Money Follows the Person Rebal-
ancing Program (O’Shaughnessy, 2013b). Other provisions
of the Act also emphasize community-based services, includ-
ing Community First Choice (covering personal care and
other services for eligible persons), Balancing Incentive Pro-
gram (providing incentives to eligible states to rebalance their
long-term care systems toward more community-based
services), and 1915(i) State Plan Option (covering a range of
community-based services for eligible persons) (U.S. Gov-
ernment Accountability Office, 2012). Indeed, 38 studies
published during the period 2005–2012 demonstrate the
cost effectiveness of community-based services in Medicaid
balancing efforts; as just one example, those in nursing homes
cost the state of California three times as much as those
receiving home and community-based services (Fox-Grage
& Walls, 2013).
Finally, the federal commitment to community-based
services perhaps is best illustrated in the creation in 2012 of
the new Administration for Community Living (ACL)
under the U.S. Department of Health and Human Services.
The ACL brought together the Administration on Aging,
Office on Disability, and Administration on Developmental
Disabilities for the purpose of “promoting community living
and finding new mechanisms to help ensure that the supports
people with disabilities and seniors need to live in the com-
munity are accessible” (HHS Press Office, 2012).
Service Classifications
Community-based services can be classified in numerous
ways. Three common classifications include the following:
■ Continuum of care
■ Location
■ Function
Continuum of Care
Continuum of care describes the system of services that
supports the well-being of older adults at every stage of func-
tioning. It is typically presented in linear fashion. Older
adults without service needs are at one end (independence),
and those requiring total care or assistance are at the other
end (dependence). Community-based services fall all along
the continuum of care. For example, transportation ranges
from driving a car oneself to being transported by ambulance.
In between these extremes are such options as community
response transport and escort services. Housing, too, ranges
from living in one’s own home or apartment to residing in
a nursing facility, with congregate care and assisted living
facilities found midway in this continuum. The extent and
type of services required by older people primarily reflect their
physical and mental health. Those who are well and able need
no or very few services. Those who are ill and disabled may
need many and varied services.
As individuals, families, and care providers examine the
continuum of care, three considerations must be kept in
mind. First, older adults usually require a comprehensive as-
sessment to determine specific service needs. Comprehensive
assessments explore an individual’s physical, intellectual,
4605_Ch29_437-452 31/10/17 12:28 PM Page 439
emotional, social, financial, and environmental status. They
evaluate level of functioning, particularly with respect to the
individual’s ability to perform tasks, like bathing, and fulfill
social roles, such as being a spouse (Miller, 2012). Compre-
hensive assessments often involve an interdisciplinary team
of professionals, minimally including a physician, nurse, and
social worker. Occupational and physical therapists can pro-
vide important information about specific aspects of function,
and about valued roles and activities. Second, it is essential
that older adults receive the level and type of services required
to address their needs. Too much help can foster dependency
or helplessness (Cimarolli, Reinhardt, & Horowitz, 2006;
Thompson & Sobolew-Shubin, 1993). Too little help can
risk health and safety (Dong et al., 2009; O’Brien, Thibault,
Turner, & Laird-Fick, 1999). Third, service needs may change
over time, making ongoing reassessment necessary. Older
adults do not necessarily follow the continuum of care
linearly. Most do not experience a consistent and gradual
decline in functional capacity over time from independence
to dependence. Rather, they move into and out of various
states of independence and dependence based on health,
performance skills, personal factors, and circumstances.
Walter Lehman, an 82-year-old retired carpenter, illus-
trates this dynamic quality of well-being and service need
after his recent discharge from a hospital following a stroke
that resulted in left hemiparalysis. At home alone, he was
assisted by his daughter who lived nearby as well as by
community-based agencies which provided home health care,
homemaking, chore, and home-delivered meal services. An
occupational therapist came to do a home safety evaluation,
and worked with Walter to develop energy conservation
strategies in the home. A physical therapist developed a home
exercise plan to help Walter regain strength and maintain
mobility. As his recovery and rehabilitation progressed, his
need for these services disappeared. Eventually Walter only
required transportation, so he contacted the local office on
aging to arrange a minivan to take him to doctor appointments.
Location
Community-based services can be classified by their location,
in which case three types are usually presented: in-home care,
outside-of-the-home assistance, and housing modifications
or options. In-home care represents services provided in the
homes of older adults. They include homemaking, chore
services, and home-delivered meals. They are appropriate
when older adults need help to maintain themselves at home
but do not require around-the-clock care or supervision. Out-
side-of-the-home assistance is available for those able to
travel to a service site where often group activities are high-
lighted. They include adult day care, congregate meals, and
senior centers. Finally, housing modifications or options
represent changes in residence or living arrangements that
address functional limitations on the part of older adults.
Modifications represent alterations to an existing home
so that it is more accessible to an individual with deficits.
CHAPTER 29 ■ Community-Based Services 439
Examples include ramps at entrances, grab bars for tubs, and
electric openers for garage doors. Housing options are the
range of residences available to older adults that offer services
or other accommodations to meet their specific
Function
The last classification presented here considers the general
function of community-based services and will be used to
describe available resources in the remainder of the chapter.
This approach focuses on ways in which services meet the
basic needs of older people. Accordingly, community-based
services offer
■ Something to do (performance areas)
■ Someone to care (social and interpersonal context)
■ Someplace to live (environmental context)
Service Utilization
The majority of older adults do not use community-based
services even when they are readily available and needed; only
5 percent rely exclusively on paid assistance (Hansen &
Scharlach, 2012). Older adults prefer help from family,
friends, and neighbors (Brossoie, Roberto, Willis-Walton, &
Reynolds, 2010; Eckert, Morgen, & Swamy, 2004). In a
report to Congress, Assistant Secretary of Aging Kathy
Greenlee (2013) revealed that just over 20 percent of older
Americans use community-based services. Assistance from
the informal care network, as it is called, usually reflects a
history of reciprocity and is easier to arrange, longer term,
free, and based on emotional bonds. In contrast, community-
based services from the formal care network tend to be
shorter term and may require payment. They can seem hard
to locate and overly structured and impersonal. There is evi-
dence that increasingly, older adults are receiving assistance
from the combination of formal and informal care networks
(Liu, Manton, & Aragon, 2000). More specifically, Liu and
colleagues, using data from the National Long Term Care
Survey, discovered that four million persons age 65 and older
received an average of 25.4 hours of paid assistance. Similarly,
LaPlante, Harrington, and Kang (2002), using data from the
National Health Interview Survey on Disability, found that
6.2 million older adults received an average of 39.9 hours of
help per week, including 1.9 hours of paid help. This rate of
service use may stem from growing awareness of community-
based services, particularly among family caregivers, who
often facilitate care arrangement and monitoring for elderly
relatives. Additionally, it may reflect better understanding of
the key role of community-based services in keeping older
adults with functional limitations and other needs out of
institutions (Chen & Berkowitz, 2012; Chen & Thompson,
2010).
Physical therapy interventions are helpful in supporting
older adults’ wish to age in place (Pande, Laditka, Laditka,
& Davis, 2007). The focus on enhanced physical capacity
4605_Ch29_437-452 31/10/17 12:28 PM Page 440
440 PART IV ■ Service Delivery for the Aging Client
and functional mobility can help delay the need for more
intensive care.
Occupational therapists in many developed countries pro-
vide community-based services (Hearle, Prince, & Rees, 2005).
In Canada, community-based therapy services are widespread,
although a shift to increased assessment and less intervention
has been described (Hollis, Madill, Darrah, Warren, &
Rivard, 2006). In the United Kingdom, and elsewhere in
Europe, the emphasis in community-based occupational therapy
intervention is on maintaining both independence and mean-
ingful occupations (Hearle et al., 2005). Community-based
occupational therapy can be challenging in unfamiliar envi-
ronments, particularly in developing countries (Bourke-Taylor
& Hudson, 2005). Because most therapists tend to be edu-
cated in Western countries, careful identification of local
values and beliefs is essential to effective intervention.
AROUND THE GLOBE: Service Utilization
Community-based service utilization is lower in the United States
than in Europe, Canada, or even some Asian countries (Applebaum,
Bardo, & Robbins, 2013; Eaton, 2005; Fransen, 2015). For example, in
comparing patterns of formal and informal help to older adults in
the United States and Sweden, Davey et al. (2005) found formal
service use was higher in Sweden and informal service use was lower.
Sweden provides health and long-term care to all citizens based on
need. Formal care for older adults is viewed as a public responsibility,
shared among multiple government levels (Collins, Wacker, &
Roberto, 2013). Core cultural values differentiate countries generous
in publicly supported services for older adults from countries that are
not. Sweden, like most other European countries, Canada, and Japan
emphasizes solidarity, community, equity, and dignity, values missing
or deemphasized in the United States (Brown, 2003).
Research on the use of services by older adults suggests the
importance played by three sets of characteristics (Anderson,
1995; Anderson & Aday, 1978): (1) need characteristics, like
self-rated health, number of illnesses, and disabling conditions;
(2) predisposing characteristics, such as age, gender, and race
or ethnicity; and (3) enabling characteristics, including educa-
tion, income, and residence with another person. Although
there is some variability among a large body of research find-
ings, in general they suggest that the following specific charac-
teristics result in greater use of community-based services by
older adults: having health conditions or physical disabilities,
perceiving a need for services, being female or of advanced
age, being a nonminority, having high or low educational or
income attainment, residing alone, and living in an urban area
(cf. Siegler, Lama, Knight, Laureano, & Reid, 2015).
Service Barriers
Barriers can inhibit use of specific services or community-
based services in general. Biegel and Farkas (1989) suggest
three levels of service barriers: system, agency, and individual.
Applied to programs for older adults (Biegel, Farkas, &
Wadsworth, 1992), they can be distinguished in the follow-
ing manner:
■ System-level barriers are political, economic, and social
forces that influence policy development, such as the cost
of transportation or lack of linkage between formal and
informal care.
■ Agency-level barriers are structures, staffing, funding, and
procedures within organizations that affect service delivery,
such as difficulty in recruiting and retaining paraprofes-
sional staff or the complications of having multiple funding
sources to support adult day care operations.
■ Individual-level barriers are personal attitudes or behaviors
toward services, such as the perception of formal assistance
as “welfare” and “charity” or discomfort with group recre-
ational activities because of shyness or fear of strangers.
These three levels of barriers provide understanding
about why some older adults refuse or fail to use existing
community-based services. However, to capture fully the
difficulties, a fourth conceptual barrier must be added: group-
level barriers. Group-level barriers are inhibitors to service use
that relate to membership in or identity with a larger social
entity. For example, Hispanic elders are more likely than Anglo
elders to turn to families, rather than community-based services,
for support. This reliance on family reflects a cultural tradition
that underscores respect for older adults and obligates family
members to collaborate for mutual support (Angel & Angel,
2015). Not surprisingly, Hispanic elders are almost twice as
likely to live with relatives as the general older adult popula-
tion in the United States (U.S. Administration on Aging,
2015a, 2015b, 2015c). Moreover, Native American elders
experience more victimization than other groups of older adults.
However, less than 1 percent uses elder abuse prevention
programs, in part because most such programs are not offered
by their respective tribes or considered culturally appropriate
(Davis, 2013). Asian American/Pacific Islander elders also
tend to underutilize community-based services. Reasons
given include preference for informal care, Asian values, and
culturally insensitive programs (Henderson, 2011; Young,
McCormick, & Vitaliano, 2002). Finally, lesbian, gay, bisex-
ual, and transgendered elders are underserved by traditional
community-based service providers, often because of their
concern about discrimination from these providers. Indeed,
their fear of stigmatization and hostility can be so great as to
render them at high risk of isolation and possible self-neglect
(Anetzberger, Ishler, Mostade, & Blair, 2004).
✺ PROMOTING BEST PRACTICES
Service Utilization
Services and Advocacy for Gay, Lesbian, Bisexual, & Transgender
Elders (SAGE) is the oldest and largest organization in the United
States dedicated to improving the lives of older adults who are
lesbian, gay, bisexual, and transgender (LGBT). This award-
winning agency was founded in 1978 in New York City, where it
4605_Ch29_437-452 31/10/17 12:28 PM Page 441

CHAPTER 29 ■ Community-Based Services 441

continues to be headquartered, having expanded to more

than two dozen affiliates in the United States. It provides a
wide variety of services and programs including social services,
employment assistance, caregiver support, health and wellness,
lifelong education, and arts and culture. Moreover, SAGE
facilitates the National Resource Center on LGBT Aging.
Information on SAGE can be accessed through www.sage.org.

Linkage
Most communities have a variety of services for older adults.
Moreover, many types of services have multiple providers in
any locale. The catch is to find those most appropriate based
on need, eligibility, and preference considerations. Several
resources exist which help to connect individuals with avail-
able services. Outreach by professionals can help elders learn
about their options (Figure 29-1). The most common linkage
forms are information and referral, case management, out-
reach, service guides, and educational programs. These link-
age forms are described in Table 29-1.
In addition to local linkages, national ones have evolved
to accommodate the needs of families living at a distance FIGURE 291 Outreach by professionals helps older adults learn
from elderly members and service providers advocating for about available community services. (Courtesy of The Benjamin Rose
older adults about to relocate. All of these national linkages Institute, Cleveland, Ohio.)
are accessible through the Internet.
Finally, in 2003 the U.S. Administration on Aging and
agencies on aging as the lead organization for local ADRC
the Centers for Medicare and Medicaid Services launched
development, partnering with other agencies to carry out
the Aging and Disability Resource Center (ADRC) initiative
ADRC functions; however, in some states, centers for inde-
to help states develop a system of “one-stop shop” programs
pendent living have been designated as the lead organizations
at the community level designed to offer people of all ages
(O’Shaughnessy, 2011).
and all disabilities information, assistance, and access, par-
ticularly around the maze of fragmented long-term care op-
tions, so that they could make informed service decisions. Something to Do
Older Americans Act legislation in 2006 required the estab-
lishment of ADRCs in all states, and the Patient Protection Martha O’Malley was sixty-eight years old and widowed
and Affordable Care Act in 2010 appropriated funding for three times. When her last husband died of cancer, she vowed
ADRCs through 2014. Most states have designated area never to marry again. Widowhood had not left Martha

TABLE 291 ■ Linkage Forms Connecting Individuals With Services

FORM DESCRIPTION ARRANGEMENT

Information and referral Resources that link older adults to services and services to each
other, usually through telephone contact or Internet access
Case management Use of human service professional to arrange and monitor a
comprehensive package of services
Outreach Actions taken by service providers to reach individual older
adults and encourage their use of available services
Service guides Lists of available services, often arranged by locale or function
Educational programs Lectures, workshops, demonstrations, and fairs highlighting
available services
Stand-alone service or as a component of other
services offered by an organization like a
community center
Health or social service agency function or
available from a professional social worker or
nurse in private practice
Community or senior center or office on aging
function
Provided by government agencies, planning
organizations, or private entrepreneurs
Offered by health and social service organizations,
colleges and universities, and the mass media
4605_Ch29_437-452 31/10/17 12:28 PM Page 442
442 PART IV ■ Service Delivery for the Aging Client
without financial resources. It did, however, leave her lonely
and unoccupied. She had no close friends with whom to talk,
eat meals, shop, or take trips. Having reasonably good health
and adult children busy with their careers and families,
Martha felt anxious to find meaningful activity and human
connections at this stage of life.
An array of community-based services has evolved since
the mid-1960s providing Martha with numerous opportuni-
ties to remain active and to stay connected. Categorically they
can be divided by primary function or performance area:
■ Working
■ Learning
■ Giving
■ Experiencing
Each area will be examined briefly with respect to use by
older adults, available options, and public policy connections.
See Chapters 18, 19, 20, and 25 for more information on
these topics.
Working
Under the federal Age Discrimination in Employment Act
(ADEA), persons become “older workers” beginning at age 40.
Most adults remain active in the labor force until their
early to mid-60s, with more and more electing to stay into
advanced old age or perhaps never retire. Employment of
persons age 55 and older is at a record high of more than
40 percent. Approximately 27 million Americans age 55 and
older are employed, and nearly two million are actively seek-
ing work (Tishman, Van Looy, & Bruyere, 2012). In 2002,
workers age 50 and older made up nearly a quarter of the
workforce and almost one-third by 2012. It is projected that
they will constitute 35.4 percent of the total workforce by
2022 (Hewitt, 2015).
As an important element of community-based services,
the federal government supports several programs for older
adults. The two most important are the following:
■ Senior Community Services Employment Program
(SCSEP): SCSEP is authorized under Title V of the Older
Americans Act and administered by the U.S. Department
of Labor. It is the first nationwide program designed to
help older workers find jobs, matching their abilities with
their work preferences.
■ Age Discrimination in Employment Act (ADEA): ADEA
promotes employment based on ability rather than age and
protects workers age 40 and above from arbitrary age dis-
crimination in employment.
Delegates at the 2005 White House Conference on Aging
gave priority to public and private initiatives for enhancing
employment opportunities in later life. Of 15 top-ranked
resolutions, two dealt with efforts to strengthen labor force
conditions for older workers by (1) promoting incentives
to continue working and improving employment training
and retraining programs, and (2) removing barriers to the
retention and hiring of older workers, including age discrim-
ination. Finally, Grantsmakers in Aging has recognized older
workers as an issue deserving of philanthropic response, noting
that foundations have awarded few grants in recent years that
address the challenges and needs of older adults who want to
remain part of the labor force. Notable exceptions identified
were the MacArthur Foundation’s funding of the Research
Network on an Aging Society, W.K. Kellogg Foundation’s
support to expand the Experience Corps Literacy Program
in Michigan, and Alfred P. Sloan Foundation’s award to the
National Opinion Research Center to increase coverage on
aging workforce economics (Snyder, 2014). Chapter 20 dis-
cusses older adults and work in greater detail.
Learning
A second option for Martha is to return to school. The intent
may not be to train for reentry into the labor force. Rather,
Martha can pursue adult education for personal growth, to
advance a hobby, for socialization, or to learn a skill. Many
older adults want to participate in a learning process and
become actively engaged in that process when it is interesting,
relevant, and recognizes the experience they bring to the
education context.
The concept of lifelong education originated in England
during the 1920s and has evolved over the years. By defini-
tion, lifelong education implies a cradle-to-grave approach
to education and recognizes that adults of any age can be
learners (MacArthur Foundation Network on an Aging
Society, 2012; Manheimer, Snodgrass, & Moskow-McKenzie,
1995). Federal programs such as the National Endowment
for the Arts funded demonstration projects at institutions of
higher learning as a national goal, but without public funding,
in 1976. Subsequently, the U.S. Office of Vocational and
Adult Education has helped adults acquire basic literacy
skills, and the U.S. Administration on Aging has encouraged
area agencies on aging to collect and disseminate information
on local colleges and universities that offer tuition-free edu-
cation to older adults. Area agencies on aging also sponsor
various educational programs for older adults on topics
ranging from Medicare prescription drug coverage to advance
directives and other legal concerns.
One way to classify the various educational opportunities
that exist for older adults is where they are located (e.g.,
institutions, communities, and home; see Chapter 25 for
further discussion).
Giving
Volunteerism, an important aspect of civic engagement
(Kaskie, Imhof, Cavanaugh, & Culp, 2008), would provide
Martha with constructive use of her time and the opportunity
to contribute her talents in a meaningful way to the commu-
nity. Twenty-four percent of those age 65 years and older
spend an average of 86 hours per year helping others formally
through public or nonprofit organizations (U.S. Bureau of
4605_Ch29_437-452 31/10/17 12:28 PM Page 443
Labor Statistics, 2014). Although the proportion of older
adults among American volunteers has increased in recent
decades, it has fallen each year since 2011. Currently 23.6
percent of those aged 65 and over volunteer, most typically
for religious organizations followed by education or youth
services organizations (U.S. Bureau of Labor Statistics,
2015). On the other hand, older adults volunteer their time
for more hours per year, about 90 hours, than any other age-
group. In 2014, this meant 10.6 million older volunteers per-
forming 187.2 million hours of service (Aging Today, 2015).
✺ PROMOTING BEST PRACTICE
The Value of Volunteering
Volunteering in later life has been shown to provide role
identity, give purpose to life, and increase life satisfaction
(Greenfield & Marks, 2004; Morrow-Howell, Hinterlong, Rozario,
& Tang, 2003; Piliavin, 2010).
A wide range of services are available to help match older
adults with volunteer experiences that may be of interest to
them and of service to others. Some of these can be found in
the online ancillaries for this text.
Experiencing
Each community offers an array of social and recreational
options intended to provide older adults like Martha with
interpersonal contact, stimulation, and activity. They include
the following:
■ Senior centers
■ Congregate meal programs
■ Adult day services
Community-based services that offer older adults experi-
ences exist for varied reasons. Senior centers serve as com-
munity focal points, providing opportunities for older adults
to come together for services and programs “which enhance
their dignity, support their independence and encourage their
involvement in and with the community” (National Institute
of Senior Centers, 1978, p. 18). Congregate meal programs
offer lunches in group settings to improve the nutrition of
older adults. At the same time, these programs typically pro-
vide nutrition education and information on benefits or other
services available locally. Finally, adult day services offer so-
cialization to reduce the isolation of older adults with disabil-
ities along with a variety of services that have health
maintenance or restoration as their goal. Moreover, adult day
services evolved to address the respite needs of caregivers as
much as the dependency of older adults with impairments
that limit their ability to self-care.
Senior Centers
More than 10,000 centers across the country (U.S. Admin-
istration on Aging, 2012) serve over one million older adults
CHAPTER 29 ■ Community-Based Services 443
daily (National Council on Aging, 2012) The typical partic-
ipant is a 75-year-old woman who lives alone. Compared
with her peers, she is likely to be poorer but enjoys better
health, greater life satisfaction, and more social contacts. She
usually visits the center one to three times weekly for about
three hours per visit (National Council on Aging, 2012).
Participation at senior centers has been declining for many
years, although, due to access barriers, such as transportation
and disability, as well as the image of senior centers and the
changing interests of older people (Gitelson, Ho, Fitzpatrick,
Case, & McCabe, 2008). A qualitative study on shaping
senior centers for 2030 concluded with four recommenda-
tions: balancing aesthetics and practicality in the environ-
mental landscape of public space, providing opportunities
for high-quality social engagement and activity, integrating
health promotion into all aspects of the physical and social
environment, and expanding the scope of programs to
include activity across the life span (Marken, 2005).
Trends identified in senior-center program development
suggest that more centers are offering intergenerational
programming (Kronkosky Charitable Foundation, 2009;
Markwood, 2013–2014; Ohio Department of Aging, 2002);
however, most programming is still of two types: recreation/
education or services. Recreation and education may include
arts, crafts, dance, movies, fitness activities, music, and trips.
Services may include counseling, information and referral,
employment services, meals, legal assistance, friendly visiting,
telephone reassurance, transportation, health screening, and
outreach.
Today more than 200 centers have been credentialed as
meeting the highest standards, following evaluation by their
peers (National Council on Aging, 2014). In addition, more
centers have established partnerships with local hospitals, parks
and recreation departments, neighborhood associations, and
businesses (Dichele, 2013) to continue or expand programming.
Congregate Meals Programs
Thousands of congregate meal programs operate nationwide,
supported through Older Americans Act funding (U.S.
Administration on Aging, 2003).
By law, Older Americans Act congregate meals programs
must provide at least one hot meal 5 days each week in a
group setting (Figure 29-2). For fiscal year 2014, 438 million
federal dollars were appropriated for congregate meals, more
than for any other program area under the U.S. Administra-
tion on Aging. Congregate and home-delivered meals to-
gether represented 43.4 percent of total Older Americans Act
funding in 2014 and 70.7 percent of Title III funding (Napili
& Colello, 2015). An estimated one in six older Americans
is threatened by hunger, an increase of 88 percent from 2001
to 2011, with an increase of 42 percent alone in the aftermath
of the Great Recession (Gundersen & Ziliak, 2013; Ziliak &
Gundersen, 2011)
Nonetheless, many older people in need of nutrition as-
sistance and eligible for publicly supported programs do not
4605_Ch29_437-452 31/10/17 12:28 PM Page 444
444 PART IV ■ Service Delivery for the Aging Client
FIGURE 292 Adult day services benefit functionally impaired adults
through structured programming in a protected setting. (Courtesy of
the Benjamin Rose Institute, Cleveland, Ohio.)
participate in them. Reasons include the following: partici-
pation compromises independence or is seen as carrying the
stigma of charity; awareness of the programs is lacking; and
the food is unappealing or unsuited for special diets (U.S.
General Accounting Office, 2000). According to a National
Survey of Older Americans Act participants, 56 percent of
congregate meal users got half or more of their total food for
the day from the program, and over two-thirds indicated that
the program helps them remain at home. In addition, a
Government Accountability Office study found that 89 per-
cent of food insecure older adults received neither congregate
nor home-delivered meals (Lloyd & Wellman, 2015).
Adult Day Services
Adult day services are designed for older adults with long-
term care needs. They offer an array of health, social, and
support services in a protective setting during any portion of
the day, but less than 24 hours. The intent of adult day serv-
ices is to enable chronically ill adults to remain at home by
providing services to program participants and respite for
their nonworking informal caregivers or surrogate care for
their working ones (Nadash, 2003). The concept of adult day
services was imported from Great Britain. Today there are
5,685 adult day centers, an increase of nearly 20 percent in
just 4 years (National Adult Day Services Association, 2014).
Collectively they serve more than 260,000 participants daily
at an average cost of $70. The vast majority of centers are
nonprofit operations (Harris-Kojetin, Senguta, Park-Lee, &
Valverde, 2013). Nearly 30 percent are affiliated with larger
organizations, such as hospitals, assisted living, or skilled
nursing facilities (MetLife Mature Market Institute, 2012).
Most are located in urban areas, leaving many rural older
adults without adult day services as an option. A variety of
adult day services models have been identified:
■ medical: usually under the auspice of hospitals or nursing
homes and emphasizing rehabilitative and health services;
■ social: typically affiliated with social service agencies and
stressing recreation, nutrition, and functional mainte-
nance; and
■ special purpose: targeting older adults with specific problems
such as dementia or mental illness, and concentrating on
disease-specific interventions and participant safety.
Adult day services in the United States are funded through
multiple sources, including Medicaid, Older Americans Act,
Social Services Block Grant, United Way, local government,
and private dollars. They are not federally regulated, but many
states require licensure or certification. The majority of cen-
ters provide the following types of services: activities, exercise,
meals and snacks, social services, transportation, personal
care, nursing services, rehabilitative therapy, and medication
management (“Top ADC services, activities are identified,”
2001; National Adult Day Services Association, 2014). In
addition, most centers offer services to support caregivers,
including educational programs, caregiver support groups,
and individual counseling (MetLife Mature Market Institute,
2010). More recent enhancements to adult day services are
case management, extended hours and weekend capacity,
programs to meet the expectations of diverse cultures, high-
tech exercise programs, and more homelike environments
(MetLife Mature Market Institute, 2010; Velgouse, 2006).
The typical center user is a 76-year-old woman living
with another person (usually an adult child or spouse), both
functionally and cognitively impaired, and incontinent
(MetLife Mature Market Institute, 2012; Reifler, Henry, &
Cox, 1995). Consumer satisfaction for adult day services
tends to be high from both participants and their caregivers
(Baumgarten, Lebel, LaPrise, LeClerc, & Quinn, 2002).
However, adult day services have not been shown to broadly
affect health or mental status for participants (Gaugler &
Zarit, 2001).
Someone to Care
Ruth Jacob was 81 years old and had multiple health prob-
lems, including a heart condition, emphysema, and arthritis.
She took several medications and regularly visited her physi-
cian, with transportation and assistance from her nephew,
Jim, the only relative she has who lives nearby. Despite efforts
to stay well and active, Ruth was less and less able to do
routine tasks. Ruth’s poor health rendered her increasingly
homebound, isolated, and depressed. But even more worri-
some was Jim’s behavior. Recently unemployed and exhibit-
ing a drinking problem, Jim expected financial help from
Ruth, something she could not afford to do with less than
$900 income each month. At times, Jim became insistent,
occasionally threatening Ruth, once with a kitchen knife, if
she did not give him money. Jim also stole Ruth’s credit card,
running up about $6,000 in debt before the bank became
suspicious. In addition, because Jim had taken so much of
her money, Ruth had fallen behind in her rent and utility
bills. Now faced with eviction from her apartment of 15 years,
Ruth was afraid for the future.
A variety of supportive services exist; simply speaking, they
suggest that “someone cares” for older adults like Ruth.
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CHAPTER 29 ■ Community-Based Services 445

Collectively these services have three intents: regular contact
or emotional support, guidance, and protection. Various
supportive services are identified in Table 29-2. They are
described and the primary problems they impact and their
typical arrangements are discussed. One service, however,
requires separate attention because of its importance in
addressing the problem of elder abuse.
Adult Protective Services
Ruth could have benefited from any one of the supportive
services described in this section. Friendly visiting would have
offered regular contact with volunteers from the local senior
center. Telephone reassurance would alert someone to check
on her well-being if she failed to answer the prearranged call.
An emergency response device would enable Ruth to get im-
mediate assistance in the event of a fall. Financial management
would have helped with payment of daily bills and dealing with
creditors. Legal services may be able to forestall the eviction.
Finally, counseling, especially that offered in the home, might
help to alleviate Ruth’s anxiety and depression. However, even
if all of these supportive services were offered, Ruth still would
need help because of Jim. As a victim of psychological abuse
and financial exploitation, Ruth requires adult protective serv-
ices intervention. See Chapter 5 for a more detailed discussion
of elder abuse and adult protective services.
Someplace to Live
Tom and Mary Daly had lived in their current home for
53 years, enough time to raise three daughters and retire from
two jobs. It had served them well. Structurally sound and
nestled in an older suburb of a large metropolitan area, the
house had readily adapted to their changing needs.
This was no longer the case. During the past year Tom
suffered a stroke, and Mary fell and broke a hip. Now mobility
impaired and needing help with lifting and strenuous tasks,
two stories became impossible for Tom and Mary to navigate.
Maintaining the large house and yard were a strain, and
covering the cost of regular help became difficult in the face
of mounting medical bills. In addition, the neighborhood
was beginning to change. Nearby friends had moved away
or died, and crime became a concern, as several properties
converted from owner-occupied to rental. For the first time
Tom and Mary thought about leaving. It might be possible
to remain in their current residence with some of the accom-
modations identified in Table 29-3 along with home care
and supportive services. However, Tom and Mary preferred
moving, especially to a housing arrangement with available
services and people with whom to socialize.
Ninety-six percent of older Americans live in community
settings; only 3.5 percent reside in nursing homes or other
institutions. Of the 25.1 million households headed by some-
one aged 65 and older, 81 percent are owners, and 19 percent
are renters. Among older adults in community settings, just
2.7 percent live in planned housing that offers supportive
services to residents (U.S. Administration on Aging, 2013).
Fifty-seven percent of noninstitutionalized older adults
live with spouses, 71 percent of men and 45 percent of
women. Twenty-eight percent live alone, 35 percent of
women and 19 percent of men (U.S. Administration on
Aging, 2013). Nearly 90 percent of persons aged 65 and older
indicate that they want to remain in their home as long as
possible, and four of five believe that their current home is

TABLE 292 ■ Supportive Services for Older Adults

SERVICE DESCRIPTION CLIENT NEEDS ADDRESSED ARRANGEMENTS

Friendly visiting Regular companionship and
activity
Telephone reassurance Prearranged calls to check
need for help
Emergency response Devices to alert response
systems centers that help is needed
Financial management Assistance with daily money
matters, including bill
payment
Legal services Consultation or assistance in
legal matters
Counseling Treatment for emotional or
addiction problems
Few social contacts
Chronic health problems and few
social contacts
Health conditions that may require
immediate attention
Physical or cognitive limitations
preventing management of
household finances
Advocacy or representation about
eligibility in government programs,
like Medicare and Social Security, or
help with wills, probate, and
housing issues
Anxiety or depression due to recent
trauma or loss or substance abuse
problems
Function of a senior center, office on
aging, or religious institution
Function of a senior center, office on
aging, or religious institution
Monthly fee service of private businesses
or health-care organizations
Function of an accounting firm, social
service agency, or attorney
Function of legal services corporation
agencies, legal hotlines, or elder law
attorneys in private practice
Activity of community mental health
centers, social services agencies,
substance abuse treatment centers,
and professionals in private practice
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446 PART IV ■ Service Delivery for the Aging Client

TABLE 293 ■ Creating More Supportive Housing in Later Life

HOUSING STRATEGIES DESCRIPTION

Home modification
Home weatherization programs
Home-matching services
Homestead exemption
Utility or energy assistance
Home equity conversion
Home maintenance and repair
Rental assistance
Adaptations made to a residence to accommodate a person’s changing physical needs, such as adding grab
bars for tubs, lever handles on doors, and ramps at entrances
Assistance available to those who meet income eligibility guidelines to improve energy conservation in a
residence by such measures as adding insulation or caulking windows
Programs that link people who have housing space with individuals seeking housing, providing the
homeowner with added income, companionship, or help with chores
Government programs that offer reductions in property taxes for age or income-eligible older or disabled
homeowners
Various programs available for low-income persons to manage the costs of heating, cooling, and other utilities
through direct assistance, credits, deferred payments, or discounts
Reverse mortgages that turn the equity value of a house into a source of income without the need to sell or
move, with the loan usually paid to the homeowner in the form of monthly checks to meet expenses or
purchase services, and loan repayment with the sale of the house when the owner dies or moves
Programs that provide such minor repairs and maintenance as replacement of broken windows and new
plastering, usually for income-eligible persons to keep homes in good condition or to meet established
housing codes
Federal and state programs for income-eligible persons, enabling them to live in privately owned housing
and pay an established percentage of their home for rent, with the local housing authority administering
the program, paying the difference up to the amount established as fair market value

where they will live always (Farber et al., 2011). To help
facilitate aging in place, the World Health Organization
(2007) created the concept of Age-Friendly Cities and has
promoted it globally. Cities that have embraced the concept
promote safe mobility and have accessible outdoor space
and transportation, sources for meaningful roles and activity,
park availability, access to healthy food, and social interaction
options.
Older Americans change residence less than the rest of the
population. According to a U.S Census survey, only 6.3 per-
cent of persons age 55 and older have a desire to move
compared with 14.6 percent of those aged 16 to 34 years and
10.4 percent of those aged 35 to 54 years (Mateyka, 2015).
When older adults move, the vast majority remains in their
original county, typically to be near adult children or other
family members who play an important role in their lives (Haas
& Serow, 2002; MetLife Mature Market Institute, 2011).
There is a wide range of housing and neighborhood
options for Tom and Mary. Indeed, there has been a boom
in senior housing lately that is unlikely to slow anytime soon
(Bloomberg News, 2014). It is propelled by several factors,
including growth in households aged 75 and older, likelihood
of impairments with advancing age, growing acceptance of
such housing options as assisted living, shrinkage of available
caregivers, and continuing increases in long-term care costs.
In addition to housing options, grassroots neighborhood or
community approaches have emerged in recent years that
emphasize neighbors supporting one another as they age
through mutual assistance and opportunities to socially con-
nect. Ultimately it is hoped that such approaches will enable
older adults to age in place, prevent functional decline, receive
help when needed, and reduce social isolation (Blanchard,
2013–2014; Steptoe, Shankar, Demakakos, & Wardle, 2013).
The major types of housing and neighborhood options
available to older adults are identified and described in
Table 29-4. They include arrangements that allow individuals
to age in place (Ginzler, 2012; Greenfield, Scharlach, Lehning
Davitt, & Graham, 2013). Not every housing option is appro-
priate for every older adult. Several factors must be examined
in selecting housing options or living arrangements, including
impairment status, financial resources, social needs, personal
preferences, and long-range considerations. In addition, be-
cause the meaning of “home” is so important and individual
(Lustbader, 2013–2014), especially to older adults, housing
relocation should involve sufficient planning and preparation
to help ensure a positive transition and subsequent adjustment
in the new dwelling (Carroll & Qualls, 2014).
Implications for Physical and
Occupational Therapy
Occupational therapists have an important role to play in
community-based care (Scaffa, 2001). As is true in other care
sites, the primary emphasis is on sustaining and enhancing
function in those performance areas that are most valued by
the individual. Among the strategies that can be employed
are the following
1. Performance skills: Provision of education regarding
safety and community resources can enhance ability to
undertake values roles and to maintain self-care
(Painter & Elliott, 2004).
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CHAPTER 29 ■ Community-Based Services 447

TABLE 294 ■ Housing and Neighborhood Options for Older Adults

TYPE OF HOUSING DESCRIPTION

Public housing Government-subsidized housing complexes for income-eligible persons, including high-rise apartments and
townhouses
ECHO housing Elder cottage housing opportunity (sometimes called “granny flats or pods”)—small, free-standing, removable
dwelling located near a single-family home, usually to provide independent residence for an elderly parent close
to the house of an adult child
Accessory apartment Independent living quarters within a single-family home that includes a private sleeping area, kitchen, bathroom,
and sometimes a separate entrance
Shared housing A group of unrelated persons residing together, sharing common space, and pooling resources for household
maintenance, sometimes with staff support and often under the sponsorship of a voluntary organization or
government agency
Age-restricted A planned residential community for active older adults, usually having a mix of housing types and diverse amenities,
retirement community such as tennis courts and golf carts
NORC Naturally occurring retirement community—an organized program (including health promotion, social, and
recreational services) offered on-site for residents to age in place in a locale, like a neighborhood or apartment
complex, which has evolved to now primarily comprise older adults
Co-housing A residential development of housing units built around a common area that is jointly owned and shared, which
residents help design and operate in order to foster social interaction and inter-connectedness along with
individual privacy
Village model A paid membership association comprising community residents that is incorporated as a nonprofit organization
and operated by volunteers and staff who coordinate service delivery to address the diverse needs of older adult
members using prequalified providers at negotiated prices
Congregate care facility A private apartment in a planned retirement setting, with limited services provided in the rental fee, for persons who
need minimal assistance and require no continuous supervision, personal care, or nursing
Board and care Residences that for a monthly rental fee offer a protected environment, meals, and personal care to unrelated
persons who cannot live alone due to physical or mental impairments
Assisted living Unit within a planned residential setting that provides 24-hour supervision and various levels of assistance and types
of activities for persons requiring regular help but not continuous medical or skilled nursing care
Continuous care A planned residential arrangement that provides a range of housing options from independent housing to nursing
retirement community care as well as various supportive services and recreational programs through long-term contract in one location

2. Enhanced contexts: Safety evaluations and identifica-
tion of support services and resources can enhance
performance and enable elders to remain in the com-
munity if they desire.
3. Expanded or sustained quality of life: Assisting elders
in the community to identify meaningful occupations
can greatly enhance quality of life, as those to which
they are accustomed either diminish because of normal
life-course events or reduced capacity.
In fact, it can be (and has been) argued that the commu-
nity is the most natural site for occupational therapy inter-
ventions because of its focus on performance of everyday
occupations (Scaffa, 2001). There is a wide array of available
services, but elders are frequently confused by the lack of
coordination. Occupational therapists can undertake the kind
of comprehensive review of occupational performance that
identifies areas of current or potential functional problems
and can assist in developing strategies for sustaining perform-
ance for the longest possible period.
Physical therapists provide essential support to older adults
in community-based settings. Their interventions enhance
outcomes related to walking ability, physical capacity, and
balance (English, Manns, Tucak, & Bernhardt, 2014).
These abilities are essential to community mobility that
supports participation in activities, and to avoidance of
accidents like falls that can result in need for institutional
care. If institutional care has already occurred, the PT can
contribute to the individual’s reintegration into the com-
munity (Wojciechowski, 2014), focusing on such activities
as functional mobility.
INTERPROFESSIONAL PRACTICE
Coordinating Services
In community settings, service coordination can be a particular
challenge. There are overlapping services with similar missions,
and many older adults are unfamiliar with some or all of these
services. An important role for health care professionals,
including both PT and OT, is to help individuals navigate the
array of opportunities. One particularly useful strategy can be
providing a referral to a social worker, often through the local
area agency on aging.
4605_Ch29_437-452 31/10/17 12:28 PM Page 448
448 PART IV ■ Service Delivery for the Aging Client
SUMMARY
An aging society has increasing need for services that
promote the well-being and self-sufficiency of older adult
members. Assistance not provided by family and friends is
sought from formal care providers and housing options. A
vast array of community-based services has evolved in recent
decades to offer older adults something to do, someone to
care, and someplace to live. In addition, linkage resources
have emerged to connect individuals with services and serv-
ices with each other.
It has been suggested that the past 35 years represent a
period of unprecedented model building and experimentation
in service delivery to older adults. Certainly, vast sums of
public and private dollars were used to fund this effort, and
many scholars or practitioners were willing innovators.
Unfortunately, evaluation of the resulting programming has
mixed findings. Rarely has there been shown clear direction
for future growth. Even more problematic is that the Baby
Boomers have decidedly different interests than their prede-
cessors and are likely to have very different needs in their old
age. As the editor of The Gerontologist wrote in a special issue
devoted to the Baby Boomers, “Baby Boomers redefined each
stage of life as they experienced it…They will make demands
on the services and institutions designed to provide health
care, transportation, and housing to previous cohorts of older
people. Everything that we think we know about the aging
process…has the potential to be altered” (Pruchno, 2012,
pp. 149, 152).
In the decades ahead, some community-based services will
remain. Those that do will have demonstrated success at meet-
ing essential need and ability to transcend the idiosyncrasies
of individual generations. Other community-based services
will change and adapt to new generations, and still others will
be replaced by more relevant service and housing options.
In this sense, this chapter ends appropriately with a quo-
tation from The Tibetan Book of Living and Dying, “I ask
myself often: ‘Why is it that everything changes?’ And one
answer comes back to me: That is how life is” (Sogyal
Rinpoche, 1992, p. 25).
CASE STUDY
Marge Frost is 69 years old and lives alone in her apart-
ment of many years. She never married. An only child, her
parents died more than a decade ago. Until retiring last
year, Marge worked as a sales clerk at the local department
store. Arthritis had made it difficult to stand for long
periods of time, and diminished hearing had made it hard
to grasp what the customers said. Still, Marge hated to
retire. Although she earned little pay, she always enjoyed
the work and being around people all day. Now she found
herself lonely and depressed, with little useful or interesting
to do. In addition, meager Social Security benefits left
Marge with barely enough money to cover the rent, food,
and other essentials.
Questions
1. What seem to be Marge’s concerns?
2. What additional information is required to assess her
needs?
3. Which community-based services might be helpful
in this situation?
Critical Thinking Questions
1. Why is the continuum of care relevant in thinking
about services for older adults?
2. What influences the use of service by older adults?
3. What measures can be taken to overcome service
barriers?
4. Which community resources are designed to link
individuals with available services? What are their
limitations?
5. Contrast senior centers and adult day services.
Describe the kinds of older adults who might be
best served by each.
6. What changes can older adults make in their current
living arrangements to make them more accessible or
more affordable?
7. Identify various housing and neighborhood options
that exist for older adults. What is their availability
and use in your area?
8. In what ways are roles for occupational and physi-
cal therapists in providing care in the community
complementary?
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CHAPTER 30
Primary Care
Julie Richardson ■ Sarah Wojkowski

“Primary health care starts with people. Our common humanity compels us to respect
people’s universal aspiration for a better life. It compels us to respect the resilience
and ingenuity of the human spirit, and the great capacity of individuals and
communities to solve their own problems.
—Dr. Margaret Chan, Director-General of the World Health Organization, International
”
Federation of Red Cross and Red Crescent Societies, May 14, 2008

LEARNING OUTCOMES
By the end of this chapter, readers will be able to:
1. Define primary care and primary health care.
2. Articulate the differences between primary care and primary
health care.
3. Discuss potential models that could be used as a foundation
on which to construct and deliver primary care services for
older adults.
4. Describe how the Expanded Chronic Care Model (ECCM)
can be applied to rehabilitation in a specific primary care
setting in order to engage the health-care team and older
adult clients as partners in the delivery of care.
5. Discuss specific roles related to the functional assessment
of older adults for occupational therapists and physical
therapists working in a primary care setting.
6. Identify important areas for assessment, within primary care
settings, for occupational therapists and physical therapists.
Clinical Vignette
A primary care clinic with 15,000 patients employs one full-
time equivalent (FTE) occupational therapist (OT) and one
FTE physical therapist (PT), where clients do not require
a physician’s referral to book an appointment. The role of
the occupational therapist typically includes leading self-
management classes, consulting with the other health-care
providers, and using direct practice and consultation models
of care.
Today, you, the physical therapist will be seeing Mrs. Dottie
Brown for an initial assessment as part of your direct service
time. The electronic medical record (EMR) shows that
Mrs. Brown is a 75-year-old woman who lives alone in
community-funded housing. Mrs. Brown’s partner passed
away more than a year ago. She has few social supports
and has a limited pension, her only source of income. She
uses public transportation or walks to access services in the
community.
According to the physician’s note in the EMR, Mrs. Brown
has chronic bilateral leg pain, which is limiting her mobility
and preventing her from leaving her apartment. She also
has type 2 diabetes, with early sensation changes in her feet.
Mrs. Brown reported a decreased appetite, weight loss, and
an increased fear of falling at her last appointment, and
her physician suggested she start using a walker and to see
you, the therapist. According to the EMR note, Mrs. Brown
refused to try the gait aid. She did, however, follow through
on booking an appointment for rehabilitation services.
1. Why might you be seeing Mrs. Brown in a primary
care setting rather than a rehabilitation setting?
2. How you will collaborate with Mrs. Brown to develop
goals and a treatment plan?
3. What might be an effective team to work with
Mrs. Brown to improve her function?
Primary Care and Primary Health Care
Primary care (PC) and primary health care (PHC) are terms
that are often used interchangeably, while also are used to
describe distinct concepts (see Box 30-1) (Muldoon, Hogg,
& Levitt, 2006). In 2003, the World Health Organization
(WHO) noted,
No uniform, universally accepted definition of pri-
mary health care exists. There were ambiguities in the
Alma-Ata document in which the concept was dis-
cussed as both a level of care and an overall approach
to health policy and service provision. In high-income
and middle-income countries, primary health care is

453
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454 PART IV ■ Service Delivery for the Aging Client
BOX 301 Purpose of Primary Care
“Primary care brings promotion and prevention, cure and care
together in effective and socially productive ways at the interface
between the population and the health system. What needs to
be done to achieve this is ‘to put people first’: to give balanced
consideration to health and wellness as well as to the values and
capacities of the population and the health workers” (World
Health Organization, 2008a, p. 41).
mainly understood to be the first level of care. In low-
income countries where significant challenges in access
to health care persist, it is seen more as a system-wide
strategy. (p. 106)
Examples of the varied definitions of PC and PHC can
be found in both the academic and gray literature (Muldoon
et al., 2006; Richardson, Letts, Wishart, Stewart, & Law,
2006). Muldoon and colleagues (2006) identify the overlap-
ping concepts between the varied definitions for PHC and
PC and recommended that the concept of PHC should be
used to refer to a broader concept of health service delivery.
Specifically, the authors propose PHC should describe an
approach to health policy and service provision that includes
both services delivered to individuals and population-level
functions and which derives from core principles articulated
by the WHO (Muldoon et al., 2006). These core principles
include (WHO, 2003) the following:
■ universal access to care and coverage based on need,
■ commitment to health equity as part of development ori-
ented to social justice,
■ community participation in defining and implementing
health agendas, and
■ intersectoral approaches to health care.
For the purposes of clarity, Health Canada’s (2012) defi-
nitions of PHC and PC is used to make the distinction
between the two concepts:
Primary Health Care is an approach to health and a spec-
trum of services beyond the traditional health-care sys-
tem. It includes all services that play a part in health,
such as income, housing, education, and environment.
Primary Care is the element within primary health care
that focuses on health-care services, including health
promotion, illness and injury prevention, and the diag-
nosis and treatment of illness and injury.
AROUND THE GLOBE: Perspectives on Primary Care:
Integrating Mental Health Into
Primary Care—A Global Perspective
This report, developed jointly by the WHO (2008b) and the World
Organization of Family Doctors, presents the justification and
advantages of providing mental health services in primary care.
The report also provides advice on how to implement and scale-up
primary care for people with mental health issues and describes
how a range of health systems has successfully undertaken this
transformation. Detailed descriptions of best practices from around
the world are provided, along with 10 common principles for the
successful design and implementation of integrated mental health
services at primary care level.
Models of Integrating Rehabilitation
Professionals and Services in Primary Care
Several studies have proposed models for integrating reha-
bilitation professionals and services within primary care.
Although these models are not exclusive to the delivery of
services for older adults, they are important to consider in the
context of delivering services within primary care for the
assessment and management of function with this age-group.
McColl and colleagues (2009) completed a scoping review
(1995–2007) to describe the models of service delivery that
integrated rehabilitation within primary care. They reported
six models, including clinic, outreach, self-management,
community-based rehabilitation, case management, and
shared care. The most common model was clinic-based care
in which the OT or PT is colocated with physicians and other
members of the health-care team. Both professions deliver
care in their usual scope of practice, which is typically condi-
tion (diagnosis) based. Outreach services are usually delivered
from a clinic or institutional base and may include a mobile
team or satellite services to provide care for hard to reach
populations. Self-management programs involved educa-
tion and support provided by OTs and PTs to clients to
increase their confidence and skill in managing their own
conditions. The OTs and PTs delivering self-management
can be contracted by the primary care setting or employed
by the primary care setting. Community-based rehabilita-
tion, another identified model of primary care, can be used
to address issues of equity and inclusiveness by creating a
partnership with the community to increase the capacity
and autonomy to manage community health issues. The
case management model can be provided by OTs and PTs
integrated within primary care, whereby they manage re-
ferrals and assessments and the provision of services.
Shared care, the final model described, would involve a PT
or OT who worked as a generalist and who would link with
a specialist for a particular patient population to provide
care. This model involves inter-sectoral care, i.e., coopera-
tion between different sectors of the health-care system,
in this case primary care and acute care linking to optimize
coordinated care for the patient (McColl et al., 2009). All
of the models discussed above involve a patient-centered
care approach, and the management of a large number of
clients with a variety of conditions, including multimorbid-
ity. To date, occupational and physical therapy educational
programs in North America, both entry-level professional
and postgraduate, have not sufficiently addressed primary
care in the curriculums they offer.
4605_Ch30_453-470 31/10/17 12:27 PM Page 455
Theoretical Frameworks Used to
Understand Access to Health Services
An understanding of how and why individuals access and
utilize health services is important to the role of the OTs and
PTs because this information can be used to identify health
service needs and opportunities for program and service
development. A variety of theoretical frameworks can be
helpful to contextualize access and utilization of health serv-
ices (Aday, 1975; Andersen & Newman, 2005; Goddard &
Smith, 2001; McIntyre, Thiede, & Birch, 2009). The frame-
works of Andersen and Newman (2005) and McIntyre et al.
(2009) are briefly presented in this chapter to assist OTs and
PTs in analyzing and assessing the local needs of older adults
and in the development and implementation of rehabilitation
roles and programs in primary care.
A Conceptual Framework for Access
to Health Care
McIntyre and colleagues (2009) defined access to health care
as the empowerment of an individual to use health care,
which reflect the individual’s capacity to benefit from services,
given their circumstances and experiences in relation to the
health-care system. The framework (Figure 30-1) acknowl-
edges that individual differences may result in differential
use of health services. This framework also identifies that
differences in access may also occur when unequal access to
health services exists—as individuals make different choices
Dimensions
Availability
Factors Range of
services relative
to need
(Multiple layers of)
Underlying issues
Type of staff
Root
causes Scope of
practice
FIGURE 301 Access framework (McIntyre et al., 2009).
CHAPTER 30 ■ Primary Care 455
in relation to exercising their own empowerment to use the
service (McIntyre et al, 2009). According to McIntyre et al.,
policy-makers have an obligation not only to make the serv-
ices available, but to also empower individuals to use the
services when needed. To do this, a participatory process
involving the exchange of information between health system
decision-makers at various levels and community members
is required McIntyre et al. (2009).
The framework allows providers to understand opportuni-
ties and constraints that may influence health-care-seeking
behaviors of different individuals in different settings in an
integrated way and focuses on three domains of access:
■ Acceptability—cultural access to services; that is, the fit
between the provider and the patient including attitude
toward and expectations of each other.
■ Affordability—financial access to, or the ability to pay for,
services; that is, those who require the services have the
means to pay the provider for the services considering
aspects such as third-party insurance coverage.
■ Availability—the physical access to services; that is, are
primary care clinics open during the hours that people are
able to seek care, such as before or after work hours or on
weekends.
These three access domains interact to provide a systematic
method of evaluating how existing health-care services are
delivered. In addition, this framework also helps to critically
evaluate how change in one or more of the domains may
affect individuals’ health-seeking behaviors.
Access
Affordability Acceptability
Expectations
and attitudes of
providers to patients
(and vice versa)
Professionalisation
Training Power
relations
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456 PART IV ■ Service Delivery for the Aging Client
Theoretical Framework for Health Service
Utilization
Andersen and Newman (2005) presented a theoretical frame-
work for conceptualizing health service utilization that con-
siders both societal and individual determinants of utilization.
The framework proposes that there are individual and health
system effects as a result of the societal determinants of
utilization (Andersen & Newman, 2005). The framework
also considers aspect of health system utilization is to be
analyzed because the intent of use can result in very differ-
ent utilization analyses (Andersen & Newman, 2005). The
framework has four major components, and their relation-
ship to one another is considered as a way to view health
service utilization:
■ Societal Determinants—norms and technology
■ Health Services System—resources, such as volume and
distribution; organization (access and structure)
■ Individual Determinants—enabling (e.g., family, commu-
nity), predisposing (demographics, social structure, beliefs)
and illness level (perceived, evaluated)
■ Health Services Utilization—type (e.g., hospital vs. clinic),
purpose (e.g., primary prevention vs. tertiary care), and unit
of analysis (e.g., volume or episodic care)
This health service utilization framework is applicable
when considering health system use of older adults in primary
care settings. Occupational and physical therapists using this
framework need to consider the importance of (1) character-
istics of the health services delivery system; (2) changes in
medical technology and social norms relating to the defini-
tion and treatment of illness; and (3) individual determinants
of health service utilization (Andersen & Newman, 2005).
Critical analyses of each of these components assist health-
care professionals in identifying barriers or facilitators older
adults face when attempting to access primary care.
The Expanded Chronic Care Model
The global life expectancy at birth has increased for both sexes,
from 65.3 years in 1990 to 71.5 years in 2013 (Prince, Wu,
Guo, Robledo, Sullivan, & Yusuf, 2014). If the median rate of
change of the past 23 years continues, the global female life
expectancy will be 85.3 years and global male life expectancy
will be 78.1 years by 2030 (Prince et al., 2014). In addition,
the aging population is linked to the global burden of disease—
approximately 23 percent of the global burden of disease arises
in adults age 60 years and older (Prince et al., 2014). Approx-
imately 49.2 and 19.9 percent of the global burden of disease
is attributed to adults age 60 years and older, in high- and low-
and middle-income regions, respectively (Prince et al., 2014).
The leading causes of disease burden in older adults are car-
diovascular diseases, malignant neoplasms, chronic respiratory
diseases, musculoskeletal diseases, mental and neurological dis-
orders, infectious and parasitic diseases, unintentional injuries,
diabetes mellitus, digestive diseases, respiratory infections, and
sense organ diseases (Prince et al., 2014). Primary prevention
strategies for individuals who are currently younger than
60 years will improve the health of future cohorts of older
adults (Prince et al., 2014). To improve the disease burden,
effective primary, secondary, and tertiary prevention strategies
targeting older adults will need to be implemented (Prince
et al., 2014). Thus, while understanding barriers and facilitators
to accessing health care is important for the rehabilitation
professional in primary care, developing effective strategies to
prevent and manage the growing burden of chronic conditions
is also essential (Barr et al., 2003).
The Chronic Care Model (CCM; Wagner, 1999) is an
example of a multipronged approach to improve chronic dis-
ease management (Wagner, 2007). Quality improvement
teams in primary care who focused their attention on the
four components of the CCM: (1) self management support;
(2) delivery system design; (3) decision support; and (4) clinical
information systems—have had a positive effect on the care
of patients with diabetes, including decreased levels of
HbA1c and decreased rates of smoking (Barr et al., 2003).
The Expanded Chronic Care Model (ECCM; Figure 30-2)
was proposed in an effort to broaden the CCM through the
integration of population health promotion with the preven-
tion and management of chronic disease (Barr et al., 2003).
The ECCM supports the intrinsic role social determinants
of health have in influencing individual, community and pop-
ulation health, and demonstrates clear associations between
health-care systems and the community (Barr et al., 2003).
A comparison of the component parts and definitions of the
ECCM and the CCM can be found in Table 30-1.
Interpreting the ECCM
The ECCM comprises two sections. The two ovals in
Figure 30-2 represent the community and the health system.
These two sectors have a porous line between them to represent
the flow of ideas, resources, and people between the commu-
nity and the health-care system (Barr et al., 2003). The four
circles of self-management support, decision support, delivery
system design, and information systems are placed on this
line to reflect the integration and impact of these areas on the
community and the health system (Barr et al., 2003). The
proposed outcomes of the ECCM, which include individual,
community and population health outcomes, are reflected in
the rectangle flanked by the two ovals at the bottom of model
(Barr et al., 2003). This component of the model represents
improved outcomes as a product of the prepared proactive
practice team and the informed activated patient (Barr et al.,
2003). Achieving these outcomes requires positive and
productive interactions and relationships among individual
community members, health-care professionals, organiza-
tions, and community groups (Barr et al., 2003).
The ECCM and the Health-Care Professional
OTs and PTs in primary care need to consider how the services
they provide align and integrate with self-management support,
decision support, delivery system design, and information
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CHAPTER 30 ■ Primary Care 457

Community

Build Healthy
Public Place

Information
Create HEALTH Systems
Supportive
Environments SYSTEM
Self Management/
Develop Personal
Skills Decision
Strengthen Support
Community
Action
Delivery System
Design/Reorient
Health Services

Informed Prepared
Motivated Community
Activated Proactive
Community Partners
Patient Community

Population Health Outcomes/

Functional and Clinical Outcomes
FIGURE 302 The Expanded Chronic Care Model. (From Barr et al., 2003)

TABLE 301 ■ The Components of the Expanded Chronic Care Model

COMPONENTS OF THE EXPANDED CHRONIC CARE MODEL EXAMPLES

Self-management/develop
personal skills
Decision support
Delivery system design/
reorient health services
Information systems
Enhancing skills and capacities for personal
health and wellness
Integration of strategies for facilitating the
community’s abilities to stay healthy
Expansion of mandate to support individuals
and communities in a more holistic way
Creation of broadly based information
systems to include community data
beyond the health-care system
■ Smoking prevention and cessation programs
■ Seniors walking programs
■ Development of health promotion and prevention “best
practice” guidelines
■ Advocacy on behalf of (and with) vulnerable populations
■ Emphasis in quality improvement on health and quality-of-life
outcomes, not just clinical outcomes
■ Use of broad community needs assessments that take into
account:
■ Smoking bylaws

■ Walking trails

■ Reductions in the price of whole wheat flour

Create supportive Generating living and employment
environments conditions that are safe, stimulating,
satisfying, and enjoyable
Strengthen community Working with community groups to set
action priorities and achieve goals that enhance
the health of the community
■ Maintaining older people in their homes for as long as possible
■ Work toward the development of well-lit streets and bicycle
paths
■ Supporting the community in addressing the need for safe,
affordable housing

From Barr et al. (2003).

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458 PART IV ■ Service Delivery for the Aging Client
systems. Therapists need to think broadly to identify how
links with community organizations and resources, which
focus on both social services and health services, may facilitate
the delivery of care, and how to maximize available resources
to assist clients in reaching their rehabilitation goals. The
following are two examples of how OTs and PTs can use the
ECCM to guide the functional assessment of older adults in
primary care.
Registry Generation
According to the Agency for Healthcare Quality and Re-
search (AHRQ; 2015), registries aggregate data from numer-
ous sources, facilitating examination of large data sets to
guide practice. Providers can use registries to record critical
elements in the care plan, produce care summaries at the time
of a visit, and generate reminders to ensure proactive care
(AHRQ, 2015). The entire health-care team can use the reg-
istry to guide the course of treatment, anticipate problems,
and track progress (AHRQ, 2015). Registries have been
noted to be of particular importance in the management of
individuals with chronic conditions and have been identified
as being the foundation for the successful implementation of
the CCM. Landis and Galvin (2014) provided an example
of an interdisciplinary team that created a falls registry for
older adults who reported falling two or more times in the
past 12 months or who fell once and required a physician
visit. The generation of the registry was part of a larger project
to implement and assess a falls screening program in four pri-
mary care clinics in North Carolina, United States. The reg-
istry was updated monthly and reported on quarterly to track
whether older adults who had been screened for falling had
received appropriate follow-up care. The information on the
registry was used to proactively call/follow up with patients
who had been screened but had not received follow-up care.
OTs and PTs can work with their primary care teams to
identify and track risk factors as part of the functional assess-
ment of older adults in primary care. Many electronic medical
records (EMRs) include a search function that assists in the
generation of a patient list to capture relevant information to
form the registry, such as date of last appointment or report
of last fall. Registries also provide data to guide program
implementation, such as group education sessions on fall
prevention, and ensure that services being delivered meet the
client population needs.
Patient Navigation
In many primary care settings, the provision of direct service
to clients by OTs and PTs may be limited by caseload or
roster size, the number of patients affiliated with a primary
care practice. As a result, to maximize the provision of serv-
ices OTs and PTs need to assist clients in identifying, and
accessing community programs and resources. In the litera-
ture, this role is often referred to as a patient navigator. Free-
man (2004) noted that the ideal patient navigator is culturally
sensitive to the people of the community being served, able
to communicate and is sensitive and compassionate, knowl-
edgeable about the environment and system through which
the patient must move to obtain care, and highly connected
with critical decision makers within the system. The role
of patient navigation embraces the concept of interaction
between the community and the health-care system high-
lighted in the ECCM. For successful patient navigation, OTs
and PTs need to maintain a current inventory of available
community resources that can be used to help older adults
identify and access services. They also need to support an
older adult, as part of self-management principles, to select
and follow up with resources that they perceive to be of value
to their functional status.
Roles for Occupational Therapists
in Primary Care
The role of the occupational therapist within primary care is
to focus on the assessment and management of function as it
relates to activities of daily living in which patients need and
wish to participate (Donnelly, Brenchley, Crawford, & Letts,
2014). Specific examples of hallmark occupation-based inter-
ventions include the following:
■ Self-management of chronic conditions (e.g., diabetes,
chronic obstructive pulmonary disease) and prevention of
secondary complications
■ Health promotion and lifestyle modification to prevent
chronic conditions
■ Self-management of psychiatric conditions and promotion
of mental health
■ Management of musculoskeletal conditions, including pain
management
■ Safety and falls prevention within the home and commu-
nity environments
■ Promoting and ensuring access to community resources for
social participation and community integration
■ Palliative and end-of-life care to allow for quality of life
■ Driving and community mobility resources for older adults
■ Redesign of the physical environment to support partici-
pation in valued activities
■ Family and caregiver assistance and support. (Canadian
Association of Occupational Therapists, 2013; Metzler,
Hartmann, & Lowenthal, 2012)
In 2010, occupational therapists were integrated into
Family Health Teams (FHTs) in Ontario, Canada. These
teams are interdisciplinary cohorts that work together in
family health (primary care) settings to maximize high quality
interprofessional care. In her Muriel Driver lecture, Letts
(2011) noted that occupational therapists should consider
three questions when considering their role in primary care:
(1) how close occupation is to the role, (2) the strength of the
evidence to support the OT role, and (3) whether it is the
right time for change. Donnelly and colleagues (2014) ex-
plored roles using a multiple case study approach, in which
4605_Ch30_453-470 31/10/17 12:27 PM Page 459
case descriptions were gathered from OTs who had been in
their positions in FHTs for 3 to 18 months in one of four
rural or urban settings. Roles that involved care of older per-
sons that OTs described included home safety and cognitive
screening through primarily one-to-one care, with a strong
focus on home- and community-based assessments and in-
terventions. Chronic pain and chronic disease management
groups and leading a seniors program were also a focus of
care. Occupational therapy services were delivered through a
one-to-one delivery model, clinic-based encounters and
home and group visits. Home visits, as well as developing
more group-based programs, were seen as a strategy to ad-
dress the high need for OT services (Donnelly et al., 2014).
In a cross-case analysis of the data, the primary role of the
OT was that of a generalist practitioner. Interventions for
older adults included the cognitive assessment, falls preven-
tion and intervention, home safety, and driver screening.
Interventions, including those that were not exclusive to the
OT role, were coordination of services, discharge support,
linking to community programs and resources, and seating
and equipment assessment and prescription. It has been sug-
gested that OTs might fill the role of the need for increased
house calls in the province of Ontario (Sinha, 2013). There
is some evidence that OTs do not use standardized outcome
measures for care (Colquhoun, Letts, Law, MacDermid, &
Edwards, 2010), and it has been suggested that the use of
standardized measures within primary care settings by OTs
is imperative. Donnelly and colleagues (2014) reported that
14 standardized assessments were used by OTs in the pre-
ceding settings related to the assessment of pain, balance, oc-
cupational performance, cognition, motor and process skills,
and perception.
Roles for Physical Therapists
in Primary Care
A physical therapist’s role in primary care will vary depending
on the jurisdiction where the PT is practicing. One vision for
the PT’s role in primary care settings was broadly defined as
including the following:
■ diagnosis and treatment of acute and chronic conditions,
■ chronic disease management,
■ self-management educator,
■ case management,
■ health promotion and prevention across the life span,
■ individual and community education/consultation to other
health-care professionals, and
■ research, education, and policy (College of Physiothera-
pists of Alberta, Alberta Physiotherapy Association, and
Canadian Physiotherapy Association, 2007).
Each of these roles can be considered in the context of
the assessment of older adults’ function in the PC setting.
For example, a PT may be a first point of contact in a primary
care setting for an acute musculoskeletal injury that is limiting
CHAPTER 30 ■ Primary Care 459
participation of an older adult. Depending on jurisdictional
scope of practice, the PT could be responsible for the initial
assessment of the older adult and referral for diagnostic
testing. This first point of contact model could allow for
improved access to physicians for other patients, through
utilizing the knowledge and expertise of a PT related to
musculoskeletal injuries. Five years after the implementation
of direct access to PT in the Netherlands, the workload for
general practitioners did not decrease; however, patients who
had direct access to PT had fewer treatments than patients
who sought a physician referral for PT services. In addition,
faster access to care was provided for acute injuries, which
may result in more favorable outcomes for the client
(Swinkels et al., 2014). In addition, Deshpande, Dodson,
Gorman, and Brownson (2008) provided examples of how
PTs can lead or participate in interventions, including policy
development and primary prevention aimed at increasing the
physical activity of populations. They provide examples
population-based interventions to improve the health of a
population (functional status of the older adult) such as the
concept of active living as a way of life that integrates physical
activity into the daily routine (Deshpande et al., 2008). This
concept is an important consideration for older adults who
may face barriers of health problems, lack of access, or poor
knowledge about the role of physical activity for the preven-
tion of disease (Deshpande et al., 2008). Thus, a PT assessing
the functional status of an older adult in primary care could
work with the individual to identify ways to maintain and/or
maximize physical activity (e.g., housework) in a safe and
enjoyable manner through understanding the environments
in which the individual lives and interacts.
INTERPROFESSIONAL PRACTICE
Linking General Physician Practices With
Occupational and Physical Therapists
A pre–post pilot study evaluated an innovative falls prevention
intervention and tested its feasibility in practice. Existing
chronic disease management elements were used to link two
general physician practices, one in urban Sydney and one in
semirural New South Wales, with occupational and physical
therapists in private practice who provided falls prevention
intervention for eight older people (aged ≥75 years). The
authors found the program had encouraging outcomes at
the 3-month follow-up visit and determined the approach
was feasible and potentially effective in reducing falls risk
in a primary care setting (Mackenzie & Clemson, 2014).
Patient-Centeredness in Primary Care
A combination of factors necessitates health-care delivery
system reforms. Common factors across the globe include
unsustainable public and private health-care spending
growth, increased prevalence of chronic health conditions,
and a rising demand for health-care services due to the aging
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460 PART IV ■ Service Delivery for the Aging Client
population; in the United States an additional factor is the
growth in the number of people with health insurance
(American Occupational Therapy Association, 2014). The
Affordable Care Act and other health-care reform initiatives
have focused on increased integration and coordination of
care delivery as ways to achieve the “Triple Aim” goals of
reform (American Occupational Therapy Association, 2014),
specifically: improving the individual experience of care,
improving the health of populations, and reducing the per
capita cost of care (Berwick, Nolan, & Whittington, 2008).
Fundamental components of health-care reforms include en-
hanced focus on primary care and interprofessional teams of
providers (American Occupational Therapy Association,
2013a), and the Institute of Medicine (2001) emphasized
patient-centered care as one of six domains of quality health
care, arguing that patient-centeredness is better for patients
and makes the provision of care more satisfying for health-
care professionals.
Multimorbidity
The global rise in noncommunicable chronic diseases will
cause an associated rise in the prevalence of disability and will
be responsible for 75 percent of all deaths by 2030 creating
the most significant public health problem of the 21st century
(Blair, Sallis, Hutber, & Archer, 2012; WHO, 2011). The
majority of older persons experience multiple comorbid dis-
eases (Hung, Ross, Boockvar, & Siu, 2011). Musculoskeletal
diseases, such as osteoarthritis, are the second most prevalent
cause of disability worldwide; they affect all sociodemo-
graphic strata (WHO, 2011) and result in barriers to main-
taining optimal function as a component of health or health
outcomes. Musculoskeletal conditions create an enormous
societal economic burden through direct health expenditure,
treating the sequelae of these conditions, and indirectly as a
result of lost productivity (Woolf, Erwin, & March, 2012).
Recovery from musculoskeletal impairments associated with
chronic diseases and other long-standing conditions occurs
within the three stages of the rehabilitation process: adapta-
tion, readjustment, and redefinition (Stucki, Cieza, &
Melvin, 2007; Walton, Macdermid, & Neilson, 2010). There
is an opportunity to transform the health-care crisis through
the introduction of multisector rehabilitation strategies that
are known to produce a medium effect with little or no risk.
Physical Function as a Primary Health
Outcome
Recent literature has advocated that function should be as-
sessed as a primary health outcome and included as the sixth
vital sign (Bierman, 2001; Richardson et al., 2012). Func-
tional status is a major concern for older adults with chronic
illness(es) because it is central to maintaining independence
and should be a prime health outcome. There is increasing
awareness about how the relationship between physical func-
tion and a person’s overall health status will inform the ability
of the health-care team in assessing functional status and im-
proving care for older persons. Physical function and mobility
status are predictive of independence, autonomy, and survival
for the older person and need to be a central aspect of assess-
ment in primary care (Studenski et al., 2011). An initial step
in making assessments in primary care more salient to appro-
priate health outcomes in the older adults would be to im-
plement tests of function (Richardson et al., 2012). As OTs
and PTs have enhanced skills and expertise in assessing func-
tion, they are well suited to enact these assessments in primary
care settings.
The monitoring of health outcomes of older adults with
functional limitations in primary care, through the imple-
mentation of a universal model to categorize older persons
into functional subgroups, would facilitate empirically driven
decision making about prognosis and treatment interventions
(Min & Shekelle, 2012). A model called FRAME (Func-
tional Reserve Assessment Map for Elders) could be used as
the framework to provide clinically meaningful assessment of
physical function in primary care (Min & Shekelle, 2012). A
simple but informative measure of functional status is needed
by therapists to classify older persons being seen in primary
care settings so that OTs and PTs are able to understand and
track patient trajectories.
The increasing evidence about gait speed shows that it can
be used as a measure of mobility disability and health status.
Changes in gait or walking speed are predictive of the onset
of further disability and dependency (Cesari et al., 2005;
Guralnik et al., 2000) and of overall survival (Studenski et al.,
2011). As a result, gait speed is often used as an indicator of
health status. A recent review of measures used to assess gait,
balance, and mobility in older adults assists clinicians to assess
and select outcomes in these three areas to use in practice
(Middleton & Fritz, 2013).
Andrews and colleagues (2010) reviewed distances and
velocity issues for community ambulation and found the task
that usually concerns older persons most in relation to walk-
ing speed is how quickly they need to walk to cross a road.
The critical speed cited for this task is 1.14 meters/second.
To undertake various activities within the community that in-
volve walking, the average distances required to walk vary from
200 to 600 meters (Andrews et al., 2010). A meta-analysis
of 86 studies about gait speed found that both self-selected
and maximal gait speed are valid measures; however, self-
selected gait speed has greater reliability (Rydwik, Bergland,
Forsén, & Frändin, 2012).
A self-reported measure developed to identify problems
of preclinical mobility, the frequency and method with which
everyday tasks are undertaken, can also be used to identify
four levels of mobility limitation: no mobility limitation,
preclinical mobility limitation, minor manifest mobility
limitation, and major manifest mobility limitation, that last
of which consists of two levels—a great deal of difficulty
or unable to manage even with help (Manty et al., 2007).
This assessment has excellent predictive validity and requires
the patient to self-report on the level of difficulty on three
4605_Ch30_453-470 31/10/17 12:27 PM Page 461
tasks: walking 0.5 km, walking 2 km, and climbing up 1 flight
of stairs (Manty et al., 2007). Additional information on
assessment can be found in the online ancillaries. The iden-
tification of dismobility, or very slow gait speed (0.6 m/s or
slower), would be beneficial for client outcomes and useful
for clinicians as a standardized approach to classifying and
managing patients in primary care. This approach may lead
to interventions to address underlying impairments, such as
decreased muscle strength or muscle mass, and may lead to a
greater understanding of the underlying medical condition
on the older adult’s functional status (Cummings, Studenski,
& Ferrucci, 2014). Additional information about mobility
and about strategies for maintaining mobility can be found
in Chapters 11, 16, and 32.
Self-Management and Behavior Change
A self-management agenda has been adopted as a solution to
address the rise in chronic health conditions and aging popu-
lation. The goal of this self-management agenda is to empower
patients to be actively involved in managing their health
issues, which is a transition from medical management to
behavioral management (Lindsay & Vrijhoef, 2009; D. Taylor
& Bury, 2007). Occupational and physical therapists are
increasingly integrating the chronic disease management
approach (Jansma, Twillert, Postema, Sanderman, & Letttinga,
2010), with some research being undertaken with disease-
specific groups such as stroke (Jones & Riazi, 2011).
AROUND THE GLOBE: Chronic Disease Self-Management
Programs
Several chronic disease self-management programs have been
implemented globally. For example, the aim of the Flinders Model
in Australia is to provide a consistent, reproducible approach to
assessing the key components of self management that achieves
the following:
■ improves the partnership between the client and health
professional(s),
■ collaboratively identifies problems and therefore better (e.g.,
more successfully) targets interventions,
■ is a motivational process for the client and leads to sustained
behavior change,
■ allows measurement over time and tracks change, and
■ has a predictive ability, that is, improvements in self-management
behavior as measured by the PIH scale, relate to improved health
outcomes.
From Flinders Human Behavior and Health Research Unit, 2006, p. 1–2.
A recent scoping review, which examined the use of
self-management for chronic disease delivered by OTs and
PTs, identified issues such as education, physical activity and
strengthening exercises, pain management, fatigue management,
risk factor modification, dyspnea management, ergonomics,
CHAPTER 30 ■ Primary Care 461
relaxation, energy conservation, joint protection, and assistive
devices (Richardson et al., 2014). Therapists also addressed
issues related to nutrition, medication, and emotional man-
agement (stress management), communication techniques,
and cognitive-behavioral techniques. Telephone support
along with the intervention was often offered in primary care
(Bendixen, Levy, Olive, Kobb, & Mann, 2009; Bourbeau
et al., 2003; Effing, Kerstjens, Vander Valk, Zielhuis, & Vander
Palen, 2011; King, Strycker, Toobert, Bull, & Glasgow,
2006; Maltais et al., 2005; Pariser, O’Hanlon, & Espinoza,
2005; Stenstrom, 1994). Strategies used to deliver self-
management interventions also involved some aspect of
behavioral change, such as goal setting, barrier identification,
problem-solving, goal modification, peer support, action
planning, and self-regulation (Maes & Karoly, 2005;
Richardson, Dal Bello-Haas, Loyola-Sanchez, Macdermid,
& Sinclair, 2013). Disease-specific outcomes were used to
evaluate the intervention in some studies and included out-
comes such as knowledge, function, emotional well-being,
cognition, physical activity, quality of life, health status, work
absenteeism, patient and provider satisfaction, health service
utilization, caregiver burden, adherence to joint protection
and energy conservation techniques and impairment meas-
ures such as pain, sleep, disease activity, glycemic control, and
muscle strength. Eighteen studies measured self-efficacy as a
way of determining whether participants’ confidence had
played a role in increasing the self-management of symptoms
and behavior change. These included studies of patients with
arthritis (Callahan et al., 2008; Hammond, Bryan, & Hardy,
2008; Hammond & Freeman, 2004; Laforest et al., 2008),
chronic pain (Hurley et al., 2007; Jessep, Walsh, Ratcliffe, &
Hurley, 2009), general chronic disease (Richardson et al.,
2010; Siu, Chan, Poon, Chui, & Chan, 2007), and coronary
artery disease (Izawa et al., 2005). Eleven of these studies
reported increases in self-efficacy. Only two studies used
standardized outcomes to assess self-management behaviors
(Cohen, van Houten Sauter, De Vellis, & McEvoy DeVellis,
1986; Richardson et al., 2010). Performance measures used
to assess outcomes included hand-grip strength, walking
speed, mobility, lower extremity performance, endurance
(step test, stair climbing), and function (functional lifting).
The self-management program described by Coleman and
colleagues (2008) is an example of how self-management pro-
grams incorporating musculoskeletal principles and rehabilita-
tion strategies should be structured and implemented (Coleman
et al., 2008, 2012). Health professionals, including OTs and
PTs, can be involved in the delivery of self-management as
they are able to model a more detailed knowledge about the
condition and adapted functioning (Coleman et al., 2008).
In addition, Coleman and colleagues emphasize the impor-
tance of the skill and expertise offered by health professionals
rather than the empathy and support offered by lay leaders.
Long-term improvements have been reported for patients
who undertook the Osteoarthritis of the Knee (OAK) program
which have not been demonstrated in other arthritis-focused
self-management programs (Coleman et al., 2012). An
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462 PART IV ■ Service Delivery for the Aging Client
important barrier identified for people participating in the
People With Arthritis Can Exercise (PACE) program was
the lack of physical challenge provided by the program
(Callahan et al., 2008). This is easily rectified in programs
delivered by PTs who can use their expertise in musculoskele-
tal function to tailor interventions to the needs of participants.
A clinical trial that delivered a multicomponent intervention
to persons with chronic disease aged 44 years and older in
primary care reported on the delivery of a derivative of the
Stanford Model to incorporate rehabilitation principles. The
interventions included discussion about assistive devices and
home safety and elaboration about the principles of exercise.
Workshops addressed the foundational skills of chronic dis-
ease self-management: acute versus chronic conditions;
components of the symptom cycle1; three core components
of self-management tasks, medical management, role man-
agement, and emotional management; developing a self-
management action plan; and problem-solving steps to
institute and complete plan successfully (Richardson & Letts,
2004). Strategies that could be used to break the symptom
cycle such as management of fatigue and energy conservation,
muscle relaxation, and communication skills were also dis-
cussed. At the end of the 6-week I Am Able self-management
program, participants sought opportunities to continue with
their healthy behaviors and management techniques. Two
programs were developed to assist with this ongoing support
and all participants were invited to join the newly established
Activity and Wellness group and/or walking group. Self-
management (SM) and self-efficacy (SE) measures were used
to evaluate the effect of the I Am Able CDSMP. Assessment
of internal consistency for these measures ranged from 0.7 to
0.8 (SM) and 0.8 to 0.9 (SE), and test–retest reliability was
R = 0.6 to 0.9 (SM) and R = 0.7 to 0.9 (SE) (Lorig et al.,
1996).
The feasibility of OPTIMAL, an occupational therapy–
led self-management support program designed to address
the challenges in a primary care setting of living with multiple
chronic conditions, was evaluated using a randomized con-
trolled trial (intervention group, n = 26, mean age = 65);
waitlist control group, n = 24, mean age = 67.5] (Garvey,
Connolly, Boland, & Smith, 2015). The OPTIMAL inter-
vention, a 6-week community-based program that focused
on problems associated with managing multimorbidity,
comprised weekly group meetings in local community health
centers, peer support, goal setting and prioritization based on
patient preferences, and occupational therapy interventions,
including self-management, fatigue and energy management,
managing stress and anxiety and maintaining mental health
and well-being, keeping physically active, healthy eating,
managing medications, effective communication strategies,
1The
symptom cycle refers to a number of symptoms, such as pain, stress,
fatigue, emotional distress, and tense muscles, that interact and cause a
vicious cycle in chronic disease to make the experience of the disease
worse. Patients are made aware of strategies to break the symptom cycle.
and goal setting. One of the weekly sessions incorporated
education on physical activity delivered by a physiotherapist,
and another incorporated medicine management, delivered
by a pharmacist. A significant improvement in frequency of
activity participation, perceptions of activity performance and
satisfaction, self-efficacy, independence in daily activities, and
quality of life were found. Additionally, the intervention
group had significantly higher levels of goal achievement,
following the intervention (Garvey, Connolly, Boland, &
Smith, 2015).
✺ PROMOTING BEST PRACTICE
The Short-Form Patient Activation Measure (PAM)
The PAM is a 13-item measure that assesses patient self-
reported knowledge, skill, and confidence for self-management
of one’s health or chronic condition. Reliability estimates
ranged between 0.77 and 0.83. Validity testing showed that
preventive behaviors, disease-specific self-management
behaviors, and consumeristic behaviors were all strongly linked
with activation scores and that activation score corresponds to
an activation Level from 1 to 4:
Level 1—Starting to take a role: Individuals do not feel
confident enough to take an active role in their own health.
They are predisposed to being passive recipients of care.
Level 2—Building knowledge and confidence: Individuals
lack knowledge and understanding of their health or
recommended health regimen.
Level 3—Taking action: Individuals have the key facts and are
beginning to take action but may lack confidence and the
skill to support their behaviors.
Level 4—Maintaining behaviors: Individuals have adopted new
behaviors but may not be able to maintain them in times of
stress or health crisis (Hibbard, Mahoney, Stockard, & Tusler,
2005).
Lifestyle Conditions and Interventions
The increase in chronic conditions such as heart disease, di-
abetes, hypertension, stroke, obesity, and cancer can partially
be related to the lack of physical activity and increased seden-
tary lifestyles (Dean, 2009a). Both OTs and PTs focus on
exercise, activity, and maximizing mobility, which are low
risk, noninvasive interventions that promote wellness both
within and outside of a health condition (Dean, 2009b;
Donnelly, Benchley, Crawford, & Letts, 2013; Richardson
et al., 2010, 2012). Therapists working in primary care set-
tings are in a central position to understand an older adult’s
concept of health and health goals because they are in contact
with clients over a long period. Part of OT and PT practice
in primary care settings should address modifiable risk fac-
tors associated with lifestyle such as smoking, sleep, stress,
depression, exercise, and activity levels. Many of these issues
can be raised during the client interview and discussion of the
presenting problem, which may be sustained or worsened by
these lifestyle behaviors. In the case of an older adult with
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CHAPTER 30 ■ Primary Care 463

osteoarthritis, for example, being overweight and participat-
ing in a minimal amount of activity may lead to the exacer-
bation of symptoms and disability. Interaction with older
adults about these issues requires therapists to develop skills
to formally address behavior change and competencies to
address these issue with culturally diverse client groups (Dean,
2009a). Health coaching and motivational interviewing are
two approaches that may be useful to address lifestyle issues
encountered by therapists in primary care.
Health Coaching and Motivational
Interviewing
Health coaching (HC) has been defined as using health
education and health promotion within the context of coaching
to maximize a person’s well-being to optimize the likelihood
of achieving their health-related goals (Palmer, Tubbs, &
Whybrow, 2003). HC is founded on several well-established
schools of behavior change: self-efficacy (Bandura 1977), the
Transtheoretical Model (Prochaska & Velicer, 1997), and
motivational interviewing (MI; Rollnick & Miller, 1995). It
is considered an established method used to support client
self-management to sustain behavior change and associated
health related outcomes (Huffman, 2007; Olsen & Nesbitt,
2010; Vale, 2003; Wolever al., 2013).
A pilot study (Coach2Move) assessed the use of coaching,
together with MI, to increase physical activity and self-
management, using three patient-tailored intervention pro-
files. This approach was rated highly by both PT and older
adult clients, and a positive trend for physical activity, frailty,
quality of life, and mobility outcomes was found (de Vries
et al., 2015). A pre–post study, which included older adults
(n = 17), used HC in a group format (Dufour et al., 2014).
Participants initially had an individual HC session with a
registered PT to address difficulties in functioning and
current activity levels, and to discuss the benefit of making a
positive behavior change. Self-efficacy and confidence in
changing behavior were discussed. The group-based pro-
gram included HC sessions, circuit-based exercise training,
and guided relaxation techniques, two times per week for
8 weeks. Specifically, the HC sessions were approximately
30 minutes, designed to facilitate group participation through
brainstorming, sharing ideas, and problem-solving. Weekly
topics included weight management, nutrition, stress, exercise,
sleep, flare-ups, fatigue, and fear and emotions. Weekly case
scenarios were used to elicit positive and negative behavior
patterns, barriers to change, and strategies to produce change
(Dufour et al., 2014). Participants used the cases to reflect
on similar issues in their own lives and to develop potential
solutions. A certified health coach, who was also a PT trained
at the Institute for Optimizing Health Outcomes, facilitated
all individual and group HC sessions. Both self-reported and
performance measures showed positive trends (Dufour et al.,
2014).
Collaborative care in the clinical encounter between the
therapist and older adult can be enhanced by using an approach
that considers the client’s clinical needs, priorities, and values.
A guide to how this approach can be implemented is outlined
by O’Connor, Stacey, and Légaré, (2008) (see Figure 30-3).
Motivational Interviewing
MI has been developed based on a framework Miller and
Rollnick (1991) known as the Transtheoretical Model of
Change (Miller & Rollnick, 2012). MI facilitates the client
through the five stages of change necessary to undertake

Primary Clinician’s Role Goal Patient’s Role

To diagnose the patient’s
clinical needs, discuss options,
screen for decisional and
implementation difficulties,
and refer to coach as needed
Informed decision making To identify and communi-
based on clinical priorities cate informed values and
and patient’s priorities and priorities shaped by their
values social circumstances

FIGURE 303 A coach’s role in
collaborative management. (From
O’Connor, Stacey, & Legare, 2008).
Coach’s Role
To improve patient’s confidence and the skills needed to participate in
his or her clinical care
Skills
Consultation preparation skills: raise questions and concerns;
communicate and negotiate with doctors
Deliberation skills: clarify decisional needs (uncertainty, knowledge,
values, support) and use information, clarify and communicate values
and priorities, and access support and handle pressure
Implementation skills (motivational interviewing): increase motivation
to change and strengthen self confidence; channel resistance to change
and overcome barriers
4605_Ch30_453-470 31/10/17 12:27 PM Page 464
464 PART IV ■ Service Delivery for the Aging Client
health-related behavioral change: precontemplation, contem-
plation, preparation for change, action, and maintenance
(Miller & Heather, 1998). The five general principles of MI
include the following:
■ Expressing sympathy: The clinician expresses that ambiva-
lence is normal and integrates reflective listening, acceptance,
and understanding of the client’s position and circumstance.
■ Development of discrepancies: The clinician determines
and understands the client’s goal of change and discusses
the outcomes from present behavior and outcomes that
would result from behavior change.
■ Avoiding arguments: MI should not lead to dissension
between the therapist and the client because this leads to
resistance to change in behavior, judgmental comments,
and labeling, which may lead to defensiveness.
■ Rolling with resistance: It is important that collaborative
mutually negotiated solutions that support the client’s con-
tributions are undertaken.
■ Support self-efficacy: The client is responsible for choosing
and initiating change, and hope is essential in the various
alternatives explored. An understanding by the client that
knowledge about behaviors lead to certain outcomes is
important (Shinitzky & Kub, 2001).
MI has been established as an important approach to risk
reduction (Hancock, Davidson, Daly, Webber, & Chang,
2005) and has been used by OTs and PTs, largely to increase
self-efficacy for exercise. Reviews of MI that support health
professionals’ involvement in addressing behavior change in
clients using MI, show that this approach may be more effec-
tive than traditional education or advice-based interventions
(Britt, Hudson, & Blampied, 2004). Further, a meta-analysis
which examined RCTs of MI for health outcomes in primary
care populations found that as few as one session using MI
increased readiness to change and movement toward a health
goal; the effect size associated with the outcomes was related
to the professional credentials of the intervention deliverer
(VanBuskirk & Wetherell, 2014). Another systematic review
and meta-analysis of RCTs examined whether MI led to
increased physical activity, cardiorespiratory fitness, or
functional exercise capacity in people with chronic health
conditions. Small to moderate effect sizes were found for
physical activity but were inconclusive for the latter two out-
comes (O’Halloran et al., 2014). A recent RCT examined a
multicomponent intervention to increase physical activity in
people with rheumatoid arthritis. The intervention included
education in which MI was delivered by a PT and self-
regulatory sessions delivered by a nurse; the control group
received education only. The results showed that although
physical activity increased in the intervention group at the
end of the 5-week trial and at the 6-month follow-up com-
pared with the control, there were no changes in functional
status or disease activity (Knittle et al., 2015). In summary,
MI as a therapeutic intervention is a useful process for pri-
mary care therapists to use to with older adults with chronic
disease.
Cognitive Behavioral Therapy
Integration of the biopsychosocial model of health by OTs
and PTs has been identified as being beneficial for the man-
agement of chronic musculoskeletal conditions. Specifically,
including this approach acknowledges the importance of
cognitive, emotional, and behavioral factors as they influence
engagement in therapy, management of pain, and return to
activity. Cognitive Behavioral Therapy (CBT) is a short-term
psychological therapy that challenges maladaptive thinking
patterns and thoughts. It has been used in several conditions.
For example, a recent qualitative study outlined a program
for a Pain Coping Skills Intervention (PCST) that used a
CBT intervention delivered by PTs, in conjunction with
exercise, for persons aged 55 years and older who had knee
pain from osteoarthritis (Neilsen, Keefe, Bennell, & Jull,
2014). CBT training took place during a 3- to 4-day work-
shop, followed by formal mentoring, and feedback about
practice from a psychologist for 3 to 6 months during the
clinical trial. The PCST specifically involved identifying
negative thoughts (e.g., using thought records), challenging
negative thoughts and developing calming statements,
problem-solving, using distraction and imagery techniques,
coping skills maintenance, and developing recognition for
prevention. The results showed that PTs could be trained
to competently deliver a PCST program and that the PTs
felt it added an extra dimension to their clinical practice
(Neilsen et al., 2014). The CBT approach is another in-
tervention that can be integrated into primary care practice
for older adults who have established maladaptive behav-
iors associated with physical and associated emotional con-
ditions within rehabilitation interventions (Neilsen et al.,
2014).
Patient Satisfaction
Beattie, Dowda, Turner, Michener, and Nelson (2005) de-
fined patient satisfaction in the field of rehabilitation as “a
construct reflecting the overall experience of an individual
receiving examination and treatment in a given environment
during a specific time period” (p. 1047). Patient satisfaction
has been found to be associated with increased return to
services (Beattie, Nelson, & Heintzelman, 2011). Patient
satisfaction within their primary care experiences may be
more important for older persons with chronic conditions
because they have long-term experiences with health
providers and require greater continuity of care and greater
trust in the care provider. The Patient Satisfaction Ques-
tionnaire (PSQ-18; Marshall & Hays, 1994), an 18-item
instrument with seven subscales, a short-form version of
the 50-item PSQ-III, can be used to assess this outcome.
Internal consistency of the subscales have been reported
(0.64–0.77), and correlations of 0.9 or higher with the sub-
scales of the PSQ-III were found. Minor modifications
have been made to the PSQ-18, so the questions refer to
satisfaction with rehabilitation services, rather than medical
4605_Ch30_453-470 31/10/17 12:27 PM Page 465
services and questionnaire has been used in clinical trials
(Richardson et al., 2010).
The Integration of Technology to Maximize
Service Delivery
Technology use within primary care has grown to manage
the ongoing demand for health services. Telerehabilitation,
the delivery of rehabilitation services through information
and communication technologies, may include assessment,
monitoring prevention, interventions supervision, education,
and consultation (Brennan et al., 2010). Information technol-
ogy has been proposed as an approach to improve the func-
tional independence of older adults with a chronic disease
(Weiner et al., 2003). Telerehabilitation allows older adults
to be more active in their own health care (Czaja & Charness,
2006), and information technology can help to address the
complex and often fragmented care that they experience
(Weiner et al., 2003). It may also provide solutions for older
adults living in rural communities or for those who have diffi-
culty accessing health-care services (American Occupational
Therapy Association, 2013b).
Web-based personal health records (PHRs) are a health
information technology that can be used to manage personal
health information to allow secure communication between
patients and their health-care providers and to facilitate
rehabilitation, self-management, and preventive programs.
A PHR has been defined as “an electronic application through
which individuals can access, manage and share their health
information, and that of others for whom they are authorized,
in a private, secure, and confidential environment” (Markle
Foundation, 2003, p. 14). Patient health-care records may
promote greater engagement with self-management programs
(Young, Willis, Cameron, & Geana, 2014) as well as care,
providing patients with greater access to information and
improved communication with their health-care providers
(Grewal, 2014). However, older adults have been slower to
adopt the use of the PHR compared with younger persons
due to lower technology expertise (Nagle & Schmidt, 2012;
Nazi, Hogan, McInnes, Woods, & Graham, 2013), computer
anxiety, lower computer confidence, poorer fine motor skills,
and reduced short-term memory (Macpherson, Dhaliwal, &
Richardson, 2014; M. Taylor et al., 2013).
The PHR can be used to alter the trajectory of the func-
tional decline experienced by older adults. The PHR within
health interventions has improved the health of older adults
with chronic conditions when used by older adults to main-
tain functional independence in their community (Leveille
et al., 2008; Monsen et al., 2012). Self-monitoring delivered
through PHRs has the potential to identify functional decline.
A small cohort study described how PTs used the PHR to
self-monitor function as a form of self-management pro-
grams (Richardson et al., 2012). However, whether use of
a PHR for self-monitoring of function as a form of self-
management results in improved health outcomes needs
further study (Richardson et al., 2012). This is consistent
CHAPTER 30 ■ Primary Care 465
with other research suggesting that individuals with chronic
diseases and disabilities are most interested in PHR use and
are highly motivated to use a PHR to manage their high
health-care needs (Archer et al., 2011).
Telephone communication has also been used to deliver
rehabilitation and may be a consideration for therapists in
primary care. In the United Kingdom, patients from primary
care were referred to a service called Physiodirect. They were
provided with an assessment and advice for musculoskeletal
disorders. The sample included a group of older adults.
Participants received care more quickly than the usual care
group, and there were equivalent clinical outcomes that were
acceptable to patients (Salisbury et al., 2013). The training
undertaken by PTs providing this service has been described
elsewhere (Bishop, Gamlin, Hall, Hopper, & Fostera,
2013). In Australia, telephone interventions (6–12 calls over
6 months), in addition to usual care, are also being evaluated
in trials in patients with osteoarthritis to maximize adherence
to the PT program, which is equivalent to the delivery of
health coaching using the telephone (Bennell et al., 2012).
Integration of Occupational Therapy and
Physical Therapy Within the Primary Care Team
Integration of either occupational therapy or physical therapy
within the interdisciplinary team in primary care settings
often requires education of team members, physicians, resi-
dents, and other patient care providers about the professions
and their scope of practice and has been described in the
literature (Richardson, Letts, Wishart, Stewart, & Law,
2006). Other strategies to facilitate integration of OTs and
PTs include posting patient case studies on Web-based EMR
that detail rehabilitation specific interventions and participa-
tion by therapists in interdisciplinary problem-based small
group learning. In a primary care trial, PTs offered formal
education sessions to medical residents, with topics including
scope of practice of physical therapy, assessment and special
tests for the upper extremity, a review of the anatomy of the
shoulder, assessment and special tests for the lower extremity,
a review of the anatomy of the knee, and acupuncture
(Richardson et al., 2006). Designated space within the team
charting room is essential to provide opportunities to consult
with other team members on specific topics, conference on
individual cases, provide advice and clinical expertise, provide
assistance with assessments of clients, or to review special
tests. Occupational therapists have also used brochures,
information booths, and formal and informal opportunities,
engaging a physician champion and maximizing collaborative
practice to enhance the profile of the profession in primary
care (Donnelly et al., 2014).
SUMMARY
Occupational therapists and physical therapists are the ex-
perts within the interprofessional primary care team to assess
and address older adults function. As the population ages and
4605_Ch30_453-470 31/10/17 12:27 PM Page 466
466 PART IV ■ Service Delivery for the Aging Client
the prevalence of chronic conditions rises, OTs and PTs,
with their knowledge and skills, are well poised to play key
roles in maximizing functional independence of older
adults. Physical therapists and OTs need to engage in mul-
timodal interventions, which should be monitored by stan-
dardized outcomes, and are strongly encouraged to consider
a system to classify function to track functional change over
time, thereby enhancing communication by primary care
teams. Technology can increase the access to services and
decrease cost. In collaboration with the other members of
the health-care team, OTs and PTs can work with older
adults to optimize their functional independence and age
successfully.
CASE STUDY
Mr. Bill Johnson is 66 years old and has three chronic
conditions: coronary artery disease (he had coronary by-
pass surgery 2 years ago), hypertension, and depression.
Mr. Johnson experiences pain in his lower back, knees,
and hips. He identifies several activities on the Patient-
Specific Functional Scale that he would like to improve:
crouching, walking up stairs, balance and posture, and
having more consistent and restorative sleep. He has
started exercises before but has always given up after a
few weeks. Mr. Johnson likes to be active and likes to take
long walks with his dog, but he is finding this more diffi-
cult because of pain. He has had two falls in the past
year, which he attributes to the back, hip, and knee pain.
Mr. Johnson has noticed he is more cautious doing some
activities, such as showering and vacuuming. He would
also like to get back to biking, which he has been unable
to do because of his pain, and he is also starting to notice
some arthritis in his hands.
Mr. Johnson lives with his wife in their home, which is
a bungalow, and their two children live close. Mr. Johnson
enjoys woodworking and looking after his large property,
but has been less interested in these activities during the
past 3 months. Mr. Johnson is a patient of a Family Health
Team, a primary care team that has 15,000 patients,
12 physicians, and an interprofessional health-care team,
including a full-time physiotherapist and OT.
Questions
1. How would you determine whether there were com-
munity services or activities that Mr. Johnson might
benefit from, and how might you coordinate care
with the community settings?
2. How would you use the Coaching Framework out-
lined by O’Connor and colleagues (2008) to plan a
management strategy for Mr. Johnson?
3. What approach would you use to monitor patients,
such as Mr. Johnson, in the Family Health Team
practice?
Critical Thinking Questions
1. Describe primary care and primary health care in
your own words.
2. If you were an OT or PT in a primary care practice
of 17,000 patients, how would you outline to the
director that you were going to monitor changes in
physical function?
3. What are the similarities and differences between the
frameworks proposed by McIntyre, Thiede, and
Birch (2009) and Andersen and Newman (2005)?
4. How would you use the seven components of the
Expanded Chronic Care Model to provide services
within a primary care setting by rehabilitation
services?
5. You introduce a group-based self-management pro-
gram based on rehabilitation strategies. How would
you assess whether this group-based intervention is
effective?
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“We are what we repeatedly do. Excellence, then, is not an act, but—Aristotle
LEARNING OUTCOMES
By the end of this chapter, readers will be able to:
1. Understand the history and influences on the home health-
care arena.
2. Describe the services covered under the Medicare home
health-care benefit.
3. Cite the eligibility criteria a beneficiary must meet to qualify
for home health care.
4. List and explain regulations and legislation that drive home
health care with emphasis on therapies.
5. Describe the payment and audit challenges specific to
therapy in home health care.
6. Explain the competency and documentation requirements
for a home health-care therapist.
7. Describe the OASIS tool and its use and purpose in the
home health-care arena.
Clinical Vignette
Omar Ali Bey is a 68-year-old retired postal worker who lives
in a small two-story bungalow in an inner-city neighborhood.
The home has three bedrooms and one bathroom, all on the
second floor. He has had diabetes for 3 decades and recently
underwent a left, below knee amputation secondary to his
diabetes. Mr. Bey was fitted with a prosthesis, had 2 weeks
of inpatient rehabilitation with physical therapy and occupa-
tional therapy, and has now been discharged to his home. His
wife, also 68, has rheumatoid arthritis and macular degener-
ation and struggles to take care of herself. Their three children
live within several miles of them but have full-time jobs and
adolescent children at home; although the family is emotion-
ally close and supportive, the children have limited time to
provide instrumental assistance.
1. What are some issues that are of immediate concern
regarding Mr. Bey’s ability to manage in his home?
2. Are there roles for occupational therapy and physical
therapy in addressing those issues once Mr. Bey is dis-
charged from the hospital, and if so, what might that
role be?
CHAPTER 31
Home Health Care
Missi Zahoransky
a habit.
”
H ome health care has grown in popularity in the
United States and around the world (Kuluski,
Williams, Berta, & Laporte, 2012) because it has proven to
be a cost-effective and quality-measured option for patients
with illness, injury, or other conditions, often due to older
age, disability, or chronic conditions. As the aging popula-
tion increases and the availability of informal caregivers,
friends, or family members to assist diminishes, the need for
home health-care services grows. In addition, factors such
as increased use of technology, surgical and pharmaceutical
advances, and better understanding of epidemiology and dis-
ease patterns have all contributed to increasing life expectancy
and quality of life, allowing more persons to remain at home
(Palm, 2014).
AROUND THE GLOBE: Home Health Care in Europe
In Europe, the development of “home nursing and home help
are bound up with the emergence of complex systems of
welfare, social security, and health care that have followed
different trajectories and given rise to different patterns of
funding and provision within each country” (Tarricone &
Tsouros, 2008, p. 9). Tarricone and Tsouros, in this WHO study,
also cited the professional and consumer criticism of large
institutions that grew in the 1950s and 1960s across Western
Europe and the Nordic countries. These criticisms led policy
makers to look for ways to “deinstitutionalize” needed care in
these countries, thus giving rise to the development of home
health care.
Variations both in the philosophical presentation and funding
of home health care can be seen across European nations. For
example, Belgium, France, Italy, Portugal, Spain, and the United
Kingdom have a model “in which the ‘health’ component of
home health care is part of the health-care system and the ‘social’
component is part of the social system” (Tarricone & Tsouros, 2008,
p. 13). In contrast, Denmark, Finland and Sweden tend to believe
that all home health-care services, whether health or social based,
should be provided under one organizational structure (Tarricone
& Tsouros, 2008).
471
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472 PART IV ■ Service Delivery for the Aging Client

History of Home Health Care that occupational therapy was the only category for which
additional spending was associated with lower admission
in the United States rates (Rogers, Bai, Lavin, & Anderson, 2016). The researchers
speculated that this finding was due to the OT focus on
The concept of home health care is not new. The home-care
safety in the home environment.
model was first seen in the mid-1800s in England, imple-
mented with the assistance of Florence Nightingale to estab-
lish a school to educate nurses to provide care in a person’s Cultural Competence and Patient-Centered Care
home environment (Friedman, 2006). This concept of care
The evolution of patient-centered care and cultural competence
provision “in the home” expanded to the United States in the
has expanded from Lipkin’s description of a patient-centered
late 1800s, although the nursing services were initially seen
interview as one that “approaches the patient as a unique human
as a joint endeavor with community-based nursing care.
being with his own story to tell, promotes trust and confidence,
Home health care was recognized by insurance agencies in
clarifies and characterizes the patient’s symptoms and concerns,
the early 1900s, which allowed the growth of home health-
generates and tests many hypotheses that may include biological
care agencies in the United States. The Great Depression of
and psychosocial dimensions of illness, and creates the basis for
1929 caused a slowing of that growth, however, and it was
an ongoing relationship,” which speaks to the relationship of
not until the mid-1900s that the home health-care market
the health-care provider and the patient (Lipkin, Quill, &
was able to bear additional growth and development. Part of
Napodano, 1984, p. 277). Although the term patient-centered
this growth and development occurred in many areas of
care dates back to the early 1960s, the term cultural competence
health care, including occupational therapy, physical therapy,
began appearing predominantly in articles since the late 1990s.
and speech language pathology.
Cultural competence extends to understanding specific enact-
Much of the home health-care growth was due to hospital
ment of occupations (Figure 31-1), something that can more
systems’ inability to manage the growing number of patients
readily be accomplished in the client’s familiar environment.
with chronic diagnoses (Grindel-Waggonner, 1999), and
The increased emphasis on patient-centered care and
the federal government began to recognize that a form of
cultural competence addresses the way patients are treated
national health insurance would be needed. By 1965, the
not only by the individual provider but also by the overall
Medicare and Medicaid programs were signed into law;
health-care system. The focus on alleviating ethnic and racial
among other benefits, the programs provided coverage for
disparities is a comfortable fit in the provision of home
home health-care services for those over age 65 and for
certain other populations (see Chapter 3 and discussion that
follows for further details). In the 1980s, diagnostic-related
groups (DRGs) were implemented to classify patients into
groups, which were used to predict costs and thus determine
reimbursement to hospitals. As a result, length of stay for
hospitalized patients decreased, while the number of patients
discharged into the community with greater needs increased.
This shift in the model of care directly affected the growth of
the home health-care industry. Today’s advanced technology,
cost-containment initiatives, and increased competencies allow
for the provision of services in the home environment that were
previously exclusively provided in the in-patient setting.

✺ PROMOTING BEST PRACTICE

Economic Impact of Home-Based Occupational Therapy
Visits
Occupational therapy home visits for patients post–
cerebrovascular accident were compared with hospital-based
interviews. The main outcome was quality-adjusted life years.
The study found that home visits are more expensive than
hospital-based visits but are more effective (Sampson, James,
Whitehead, & Drummond, 2014). Although the study examined
home visits made before the person’s discharge, it seems likely
that similar outcomes would be derived from home health
visits after discharge. FIGURE 311 Observing the client in his or her environment can
A study of spending for care of patients with heart provide important information about how specific occupations are
failure, pneumonia, or acute myocardial infarction found accomplished. imtmphoto/iStock/Thinkstock
4605_Ch31_471-488 31/10/17 5:32 PM Page 473
health-care services because care in the client’s environment
reflects his or her preferred and familiar surroundings and
habits. Therapists in home health need both universal knowl-
edge and specific knowledge regarding cultural groups encoun-
tered in a practice area (Saha, Beach, & Cooper, 2008). Bonder
and Martin (2013) recommended learning about culture-
specific beliefs both from online and print resources and using
principles of ethnographic interviewing to learn how those
beliefs are enacted by a particular individual and how to
ascertain when their beliefs differ. Cultural competence and
patient-centered care are particularly central in home health
care. Home is an important element in retaining a sense of
control and meaning (Sixsmith et al., 2014). Home offers
both symbolic and practical opportunities to create meaning.
Thus, providing care in the client’s own environment allows
for close observation of cultural and personal values and
beliefs. The therapist can, and must, incorporate those factors
into assessment and intervention strategies. A client’s self-
care needs are influenced by the kinds of clothing he or she
typically wears, foods she or he prefers, and personal and
cultural guidelines about strategies for cleanliness.
Overview of Important Legislation
The Medicare program extends health-care coverage to
Americans aged 65 or older, people younger than age 65 with
certain disabilities, and people of all ages with end-stage renal
disease (ESRD), and Medicaid provides health-care coverage
to low-income children deprived of parental support, their
caretaker relatives, the blind, and individuals with disabili-
ties (Centers for Medicare and Medicaid Services [CMS],
2013). Greater detail about these programs can be found in
Chapter 3. The following provides a brief review.
There are two components of Medicare: Hospital Insur-
ance (HI) commonly called Part A and Supplementary
Medical Insurance (SMI), which has two parts: Part B and
Part D. Medicare also has a Part C component, which is
an alternate coverage option for Part A and Part B. Here
we focus on the elements of Medicare as they relate to
home health-care provision. Other factors are discussed in
Chapters 32 and 33.
The components of Medicare that address home health
care include the following:
Medicare Part A covers costs for Medicare-certified home
health care and hospice care.
Medicare Part B covers costs for doctor’s services, outpa-
tient care, therapy services and some specific home
health-care costs.
Medicare Part C (Managed Advantage) is an alternate
for Part A and Part B coverage and is provided
through private insurance, which Medicare must
approve. Part C may also include the Part D drug
benefit.
Medicare Part D is a stand-alone prescription drug cov-
erage plan that became fully operational in 2003.
CHAPTER 31 ■ Home Health Care 473
The Health Insurance Portability and
Accountability Act of 1996 (HIPAA)
HIPAA (U.S. Department of Labor, 2004) amended several
laws to provide federal rules to improve “portability” of cov-
erage in insurance markets and created the Medicare Integrity
Program with dedicated funding to program integrity initia-
tives. This act was initiated to protect beneficiaries’ health
information and is monitored and enforced by CMS as well
as the Office for Civil Rights.
The Balanced Budget Act of 1997 (BBA)
The BBA directly impacted Medicare beneficiaries by ex-
panding preventative benefits, providing a large range of ben-
eficiary protections, and offering a new market of Medicare
managed care choices with a coordinated open enrollment
process. This act required CMS to develop a new prospective
payment system (PPS) for Medicare services in home health
care, and directed initiatives in research and demonstration
projects to slow Medicare spending and create innovative
approaches to payments and service delivery.
The Affordable Care Act (ACA)
The Affordable Care Act of 2010 (HHS.gov, 2014) con-
tains numerous provisions affecting the Medicare program.
Title VIII of the ACA is specific to home care as a self-
funded, voluntary program to address a future disability and
the inability to perform basic activities of daily living
(ADL). This benefit would allow coverage for care to enable
the person to remain at home. Funding for this provision
has been contentious, so it is not fully implemented as
of the publication of this book. Further, as this book goes
to press, there is considerable uncertainty about the future
of the ACA. The current congress has made attempts to
repeal the Act, and while at this time those attempts have
failed, there remains concern about its structure. Many laws
are subject to modification over time, so, as discussed in
Chapter 3, therapists must remain current and aware of
political actions.
The Improving Medicare Post-Acute
Care Transformation Act (IMPACT)
The Improving Medicare Post-Acute Care Transformation
Act (IMPACT) of 2014 requires home health (and other
agencies) to report specific standardized data related to qual-
ity of care and resource use (cms.gov, 2015). It has three
broad aims: better care; healthy communities; and affordable
care. Its specific domains of emphasis are:
■ Skin integrity
■ Functional status (including cognitive function)
■ Medication reconciliation
■ Incidence of falls
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474 PART IV ■ Service Delivery for the Aging Client
■ Transfer of information and patient preferences during care
transitions
■ Resource use
■ Discharge to the community
■ Risk of readmission
These have clear and evident implications for OT and PT
goals for individual patients and in program planning.
Home Health-Care Agencies
and Medicare
For this chapter, the discussion of home health-care services
is specific to traditional Medicare-certified home health care
that focuses on skilled nursing and therapeutic services. Al-
though there are other organizations that use the title “home
health care” when describing their services, they generally
provide private duty care—sometimes called home care—
such as housekeeping services, transportation, or companion-
ship. These latter services are most often paid for privately or
out-of-pocket, but some insurance plans or state Medicaid
programs may cover some of these services. For home health
care, Medicare remains the single largest payer, and although
a home health-care agency (HHA) may service patients
with a variety of payer sources to participate in the Medicare
program, all patients must be treated under the same regula-
tory guidelines established by Medicare. It is critical for
occupational therapists (OTs), physical therapists (PTs), and
speech language pathologists (SLPs) to be familiar with the
guidelines because failure to meet specific criteria could result
in a denial of coverage that would be harmful to the client.
As defined by CMS (2014a) a Home Health Agency is
an organization that:
■ is primarily engaged in providing home health care—
skilled nursing services and other therapeutic services;
■ has policies established by a group of professionals (asso-
ciated with the agency or organization), including one or
more physicians and one or more registered professional
nurses, to govern the services that it provides;
■ provides for supervision of above-mentioned services by a
physician or registered professional nurse;
■ maintains clinical records on all patients;
■ is licensed pursuant to State or local law, or has approval
as meeting the standards established for licensing by the
State or locality;
■ has in effect an overall plan and budget for institutional
planning;
■ meets the federal requirements in the interest of the health
and safety of individuals who are furnished services by the
HHA; and
■ meets additional requirements as the Secretary finds neces-
sary for the effective and efficient operation of the program.
(para. 2)
In the home health-care world two distinct “conditions”
must be met: the role of the home health-care agency and
the circumstances of the home health-care patient who is a
Medicare beneficiary.
Criteria for Medicare Reimbursement to Home
Health Agencies
The Medicare Benefit Policy Manual, Chapter 7 §20 (2014b),
states that to be reimbursed for the provision of home health
services a HHA must meet specific criteria. The following list
of the criteria must be met on all counts by the HHA:
1. The person to whom the services are provided is an
eligible Medicare beneficiary.
2. The HHA that is providing the services to the benefi-
ciary has in effect a valid agreement to participate in
the Medicare program.
3. The beneficiary qualifies for coverage of home health
services as described in §30 (Conditions Patient Must
Meet to Qualify for Coverage of Home Health Services).
4. The services for which payment is claimed are covered
as described in §40 (Covered Services Under a Quali-
fying Home Health Plan of Care) and §50 (Coverage
of Other Home Health Services).
5. Medicare is the appropriate payer.
6. The services for which payment is claimed are not
otherwise excluded from payment.
Criteria for Coverage of Home Health Services
for Medicare Beneficiaries
To qualify for the Medicare home health benefit, under
§§1814(a)(2)(C) and 1835(a)(2)(A) of the Act (Social Secu-
rity Administration, n.d.), a Medicare beneficiary must meet
all the following criteria:
1. be confined to the home,
2. be under the care of a physician,
3. be receiving services under a plan of care established
and periodically reviewed by a physician,
4. be in need of skilled nursing care on an intermittent
basis or physical therapy or speech-language pathol-
ogy, or
5. have a continuing need for occupational therapy.
For any skilled services (nursing, occupational therapy,
physical therapy, and/or speech pathology) to be covered
under the home health benefit of Medicare, a beneficiary’s
eligibility for home health-care services must be established
at the time of start of care (SOC). Eligibility is met if the
beneficiary required the services of skilled nursing, speech-
language pathology or physical therapy or the continued
need for occupational therapy. Although occupational therapy
alone may not establish eligibility for Medicare beneficiaries,
it is a covered skilled service. Once program eligibility has
been determined a beneficiary may be discharged from
skilled nursing, speech-language pathology or physical
therapy and occupational therapy may remain as the only
service involved.
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INTERPROFESSIONAL PRACTICE
Social Work and Home Health Aides Under
Medicare
Medical social services and home health aide services are
considered dependent services and are only covered under the
home health-care benefit if they are provided as an adjunct to
a skilled service (CMS.gov, 2014a).
Individual patients’ needs vary, so these criteria may be
met individually or in tandem. Eligibility is confirmed if the
beneficiary requires the services of skilled nursing, speech-
language pathology, or physical therapy at any time during
the current certification period or prior certification period.
This causes confusion because although occupational therapy
(unlike physical therapy and speech therapy) does not estab-
lish initial Medicare home health eligibility, it is a skilled
service and can qualify the patient for continued home
health care and for dependent services. There is no specific
number of services required to establish eligibility, but for
occupational therapy to continue as the only service, the first
occupational therapy visit must occur after the qualifying
service’s first visit and before the qualifying service’s dis-
charge visit. Once program eligibility has been determined,
a beneficiary may be discharged from skilled nursing;
speech-language pathology or physical therapy and occupa-
tional therapy may remain as the only service involved.
Medical social services and home health aide services are
classified as dependent services and are only covered under
the home health-care benefit if they are provided as an
adjunct to a skilled service.
Here is an example of the ways in which these rules affect
care: Mrs. Smith is admitted for home health-care services
with orders for nursing, occupational therapy, physical
therapy, and a home health aide on October 1. Nursing
discharges the patient on October 20th and physical therapy
discharges the patient on November 6 because the patient
no longer needs these services. The OT has performed the
required reassessments and has determined the need for
continued occupational therapy services. The OT contin-
ues treatment as stated in the plan of care and as a skilled
service “qualifies” the home health aide services. Upon
discharge, the OT completes the Outcome and Assess-
ment Information System (OASIS) discharge, as described
subsequently.
A second example: A patient returns home post-fall with
a head contusion. The physician orders skilled nursing for
staple removal, physical therapy, and occupational therapy to
evaluate and treat for fall prevention and home safety. Under
Medicare requirements, the nurse must “open” the case. The
patient is seen on Tuesday and nursing plans to return in
3 days for staple removal. Physical therapy and occupational
therapy evaluate the patient on Wednesday and Thursday.
Physical therapy discharges after the evaluation but occupa-
tional therapy remains on the case to address safety, durable
medical equipment (DME) needs in the bathroom (where
CHAPTER 31 ■ Home Health Care 475
the fall occurred) and would like to see the patient two
times per week for 3 weeks. Nursing returns on Friday and
discharges nursing services. Because the criteria for eligibility
were met, the continued need for occupational therapy serv-
ices is covered.
Confined to Home
The confined to home requirement is generally referred to
by practitioners as “being homebound.” A patient’s resi-
dence is “wherever he or she makes his or her home. This
may be his or her own dwelling, an apartment, a relative’s
home, a home for the aged, or some other type of institu-
tion” (CMS §30.1.2, 2014b). In this language, institution
refers to community-based institutions, such as assisted
living facilities, whereas hospitals, skilled nursing homes,
and long-term care facilities do not qualify as a patient’s
residence. Medicare requires that for a beneficiary to be
eligible to receive home health services, a physician must
certify that the patient is confined to his/her home. While
the beneficiary does not have to be bedridden, their condi-
tion must be such that there is the inability to leave home,
leaving home would require a considerable and taxing effort
and/or leaving the home is for short and infrequent periods
of time (Box 31-1). Health-related care is an uncontested
reason for leaving the home but Medicare has further clar-
ified that “occasional absences from the home for nonmed-
ical purposes, e.g., an occasional trip to the barber, a walk
around the block or a drive, attendance at a family reunion,
funeral, graduation, or other infrequent or unique event
would not necessitate a finding that the patient is not
homebound if the absences are undertaken on an infrequent
basis or are of relatively short duration and do not indicate
that the patient has the capacity to obtain the health care
provided outside rather than in the home” (CMS, §30.1.1,
2014b, chapter 7).
BOX 311 Criteria for “Confined to Home”
1. Criterion 1: The patient must either:
■ Because of illness or injury, need the aid of supportive de-
vices such as crutches, canes, wheelchairs, and walkers;
the use of special transportation; or the assistance of an-
other person in order to leave their place of residence.
OR
■ Have a condition such that leaving his or her home is
medically contraindicated.
If the patient meets one of the Criteria 1 conditions, then the pa-
tient must ALSO meet both additional requirements defined in
Criteria 2.
2. Criteria 2:
■ there must exist a normal inability to leave home; and
■ leaving home must require a considerable and taxing
effort. (CMS, 2013)
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476 PART IV ■ Service Delivery for the Aging Client
Documentation of homebound status is an important part
of the patient record. The reporting includes patient report
as well as clinical observation and assessment of the patient’s
status; both physical and mental. This documentation con-
tains verbiage such as “inability to go up and down steps to
safely exit home” or “with light mobility patient presents with
increased dyspnea which impacts ability to leave home unat-
tended or without maximal assistance” (CMS, 2012b). If any
question should arise by the payer related to homebound
status, it will be proper and adequate documentation that will
establish such status
The requirement that the patient be homebound raises
some significant issues in terms of occupational therapy and
physical therapy interventions. After all, both disciplines
are concerned with maximizing function and quality of life.
Remaining permanently homebound would not be consistent
with these goals. But reimbursement will not be provided for,
say, a focus on community mobility. Therapists must think
carefully about how they might assist clients to regain func-
tions that would allow them to participate more fully in life
beyond the home, in the context of regulations that pro-
hibit this as a therapy goal. As an example, a PT might
encourage the patient to practice climbing stairs to enter
or exit the home, and an OT may address mail retrieval. In
this context, the patient is performing at an optimal level
and preparing for advancement from home-care services
(and increasing her or his walking distance in the home as
a mechanism for increasing physical capacity that might
later facilitate movement outside the home). Although this
kind of movement outside the home is consistent with
Medicare regulations, therapy-related trips further into
the community—to the grocery store, the bank, a senior
center—would make the client ineligible as no longer
homebound.
Under the Care of a Physician
Medicare has a clear expectation that any beneficiary re-
ceiving home health-care services is under the active care
of the physician who is responsible for the plan of care and
in most instances, is the same physician certifying eligibility
(42 CFR 424.22–§30.3, 2012b). In 2010, CMS mandated
that “prior to initially certifying the home health patient’s
eligibility, the certifying physician must document that he
or she, or an allowed non-physician practitioner (NPP) had
a face-to-face encounter with the patient” (CMS, 2014b
Chapter 7, §30.5.1). An NPP is defined as follows:
■ a nurse practitioner or clinical nurse specialist who works
in collaboration with the certifying physician,
■ a certified nurse-midwife, or
■ a physician assistant under the supervision of the certifying
physician.
Although an NPP may see the patient, it is the physi-
cian’s responsibility to document the encounter per guide-
lines and the face-to-face rule is a stringent condition for
HHA payment.
Skilled Nursing Care in Home Health Care
Skilled nursing services are covered when a patient’s condi-
tion requires the skills of a nurse, for example, providing
wound care, to improve a condition, maintain the patient’s
current condition, or prevent or slow further deterioration. If
the skills of a nurse are not deemed necessary for care, usually
because they can be performed by patient or caregiver, then
these services would not be covered (CMS, 2014b, §40.1.1).
Occupational Therapy, Physical Therapy, and Speech-
Language Pathology in Home Health Care
In 2010, Medicare specifically addressed the role of therapy
and refined 42CFR 409.44. For therapy services to be in-
cluded under the home-health benefit the “inherent complex-
ity of the service is such that it can be performed safely and/or
effectively only by or under the general supervision of a skilled
therapist” (CMS, 2014b, §40.2.1). This necessitates that the
therapy practitioner have a clear and concise understanding
of documentation to demonstrate compliance with this
standard.
“The development, implementation, management, and
evaluation of a patient care plan based on the physician’s
orders constitute skilled therapy services when, because of
the patient’s clinical condition, those activities require the
specialized skills, knowledge, and judgment of a qualified
therapist to ensure the effectiveness of the treatment goals
and ensure medical safety” (CMS, 2014b, §40.2.1). Further-
more, “where the specialized skills, knowledge, and judgment
of a therapist are needed to manage and periodically reeval-
uate the appropriateness of a maintenance program, such
services would be covered, even if the skills of a therapist were
not needed to carry out the activities performed as part of the
maintenance program” (CMS, 2014b, §40.2.1). In basic
terms, the therapy services must be consistent with the sever-
ity of the patient’s need and must be reasonable and neces-
sary. The home health-care medical record must clearly reflect
these principles.
In 2013, a groundbreaking lawsuit changed the founda-
tion of therapy provision in home health care. Jimmo v.
Sebelius alleged that care was being denied to a beneficiary
based on an “improvement standard,” which was in direct
conflict to Medicare’s assertion that there are cases where “no
improvement is expected but skilled care is nevertheless
required to prevent or slow deterioration and maintain a
beneficiary at the maximum practicable level of function”
(CMS, 2014d, p. 1). This lawsuit inferred that Medicare con-
tractors were denying cases based on the patient’s potential
for improvement, not on the individual’s needs. The result of
this lawsuit was that the law mandated that the criteria for
coverage for services be based on the individual’s need for
skilled care and not the patient’s restorative potential. A court
approved corrective statement in 2017 further emphasized
the key elements of the Jimmo decision (Center for Medicare
Advocacy, 2017). More detail about this case can be found
in Chapter 3.
4605_Ch31_471-488 31/10/17 5:32 PM Page 477
Reasonable and Necessary
Any therapy service must be reasonable and necessary to the
treatment of the patient’s illness or injury or to the restoration
or maintenance of function that has been affected by illness
or injury. The decision regarding whether services are reason-
able and necessary is the responsibility of the entity that pays
the home health agency and is based on the beneficiary’s plan
of care, the medical record (including OASIS), all documen-
tation, and diagnoses. Medicare policy states that while a “pa-
tient’s particular medical condition is a valid factor in deciding
if skilled therapy services are needed, a patient’s diagnosis or
prognosis should never be the sole factor in deciding that a
service is or is not skilled” (CMS, 2014b, §40.2.1). For exam-
ple, let’s examine two patients with the same diagnosis. Both
Mrs. S and Mrs. J have returned home after hip arthroplasty.
Mrs. S is married and able to dress herself and, with her hus-
band’s assistance, can bathe and manage light instrumental
ADL (IADL). Mrs. J lives alone and is unable to shower or
manage IADL and does not have any available assistance. The
occupational therapy evaluation would be reviewed by the
payer source to determine the services needed were reasonable
and necessary. It would be appropriate to assume that although
both situations may involve the services of an OT, Mrs. J
would be a candidate for longer duration of services.
Impact of Regulations on Therapy
Provision
Home health-care therapists must understand the legislative
and regulatory guidelines under which they provide service. The
State Operations Manual, section 2183.3 (2014c), states: “The
HHA staff should be knowledgeable about the HHA’s policies
and procedures, the regulatory requirements related to their role
in the delivery of care in an HHA, and be able to identify the
difference in services they provide for the HHA and other pro-
grams, departments, or entities of the organization” (p. 127).
CMS has developed regulations or “rules” for both the
home health-care agency and the beneficiary. Conditions for
Coverage (CfCs) are criteria a beneficiary must meet to be
eligible for coverage of services under Medicare. There are
CfCs for all areas of practice in health care. Conditions of
Participation (CoPs) are regulatory mandates that a provider
must comply with in order to participate in the Medicare and
Medicaid program. The CoPs are minimum health and safety
standards that must be continually and measurably be met
by the provider to remain in the Medicare and Medicaid
programs. These CoPs are changed from time to time, as is true
for many criteria in the Medicare and Medicaid regulations.
The changes in requirements “would focus on the care delivered
to patients by home health agencies, reflect an interdisciplinary
view of patient care, allow home health agencies greater flexi-
bility in meeting quality care standards, and eliminate unnec-
essary procedural requirements” (Federal Register, 2014). The
intent of the regulatory mandates is to ensure quality care
provision and protection of the safety of the beneficiaries.
CHAPTER 31 ■ Home Health Care 477
The Code of Federal Regulations (CFR; CMS, 2012b) is
made up of overarching numbered sections (“Titles”) and
subparts. The home health information is under Title 42:
Public Health of the CFR Part 484 deals with home health
care. This is often written as 42 CFR. Part 484. To allow for
ease in finding specific regulations, suffixes are also applied.
There are generally two terms used when discussing regulatory
guidelines: conditions and standards. As mentioned under the
survey section, conditions are global in nature and are made
up of standards. For example §484.55 is the condition “Com-
prehensive assessment of patients” but has many standards that
are included and are separately surveyed and assessed. These
standards are denoted with suffixes and titles i.e., §484.55(b)
Standard: “Completion of the comprehensive assessment.”
The Role of OT, PT, and SLP in the Survey
Process
As defined in the State Operations Manual section 2180E
(2014c), for a home health-care agency to participate in the
Medicare program it must meet federal mandates as well as
all state licensure and practice regulations. The agency must
demonstrate to the federal government that it has met or
exceeded the Medicare CoPs and all other regulations cited
in the CFR (CMS, 2012b). CMS can terminate an agreement
with a provider that does not meet federal standards.
Agencies providing home health care are subject to periodic
surveys to ensure that they are following all the guidelines
developed by CMS. OTs and PTs have an important role in
ensuring that they have received proper referrals, completed
OASIS (described subsequently) and other assessment proce-
dures. This information could provide useful insight into areas
in which an individual agency might be having difficulties.
Patients’ Rights and Confidentiality
The entire home health-care staff must understand patient’s
rights and issues regarding confidentiality. Many home
health-care patients are overwhelmed at the initial visit, so it
is common for them to have questions regarding this
throughout the course of therapy treatment. They have the
right to expect effective explanation of agency policies and
regulatory requirements.
Under HIPAA law, patients have the right to protection
of their records and may request a copy of their medical
record at any time. The Freedom of Information and Protection
of Privacy Act (USA.gov, 2014) addresses the rights of patients
and agency obligations and is often used as a guide for agency
policy development.
The Role of the Therapist in Communication
and Plan of Care
Standard 42 CFR 484.14(g), Coordination of Patient Serv-
ices, requires documentation in the clinical record of how
practitioners communicate pertinent information within the
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478 PART IV ■ Service Delivery for the Aging Client
team. Examples of this coordination may include communi-
cation via case conference, telephone, in person or via voice-
mail, including a written summary to the patient’s physician
as required.
INTERPROFESSIONAL PRACTICE
Coordination of Care Plans
For the successful provision of services and capturing
outcomes and correct reimbursement levels coordination
and information sharing is critical. The advent of electronic
documentation makes care coordination involving multiple
disciplines much easier than had been the case previously.
Coordinating patient care requires focus and planning.
Baxter and Markle-Reid (2009) noted that “to ensure inter-
professional collaboration, time must be taken to develop the
team to ensure that each member understands their own role
as well as the roles of the other team members and that
together they share a common vision and goal when devel-
oping the patient’s plan of care” (n.p.).
Standard 42 CFR 484.18(a), Plan of Care (POC) (CMS,
2012b), addresses the standard that an agency must meet
when developing a plan of care. All appropriate disciplines
(i.e., nursing, OT, PT, SLP, social work) share assessing the
patient’s immediate and long-term needs in the development
of the individualized POC. This POC should not be con-
fused with the individual disciplines’ POC developed after
an assessment. For the purpose of this section and when dis-
cussing a Medicare POC, the understanding is that the term
POC means the beneficiary’s care plan inclusive of all needs
and services to be provided. The POC must be reviewed in
consultation with other professionals and signed by the physi-
cian at least every 60 days.
As described in the Medicare Benefit Policy Manual,
Chapter 7, Section 30.2.1, the POC must contain all perti-
nent diagnoses, including the following:
■ the patient’s mental status;
■ the types of services, supplies, and equipment required;
■ the frequency of the visits to be made;
■ prognosis;
■ rehabilitation potential;
■ functional limitations;
■ activities permitted;
■ nutritional requirements;
■ all medications and treatments;
■ safety measures to protect against injury;
■ instructions for timely discharge or referral; and
■ any additional items the HHA or physician choose to
include.
Specific to the delivery of therapy services, if the POC
includes a course of therapy treatment (CMS, 2014b):
■ The course of therapy treatment must be established by the
physician after any needed consultation with the qualified
therapist.
■ The plan must include measurable therapy treatment goals
that pertain directly to the patient’s illness or injury and the
patient’s resultant impairments.
■ The plan must include the expected duration of therapy
services.
■ The plan must describe a course of treatment that is
consistent with the qualified therapist’s assessment of the
patient’s function.
The evaluating therapist must understand the nuances of the
home health-care arena and be able to clinically assess and
accurately predict the outcomes that therapeutic intervention
will achieve.
Therapy Services and Therapy Assistants
CoP 42 CFR 484.32, Therapy Services (CMS, 2012b), is a
condition specific to all therapy services and states that, “any
therapy services offered by the HHA directly or under
arrangement are given by a qualified therapist or by a quali-
fied therapy assistant under the supervision of a qualified
therapist and in accordance with the plan of care.” This con-
dition further delineates the therapist’s role in assisting the
physician in evaluating the patient’s function (both physical
and mental), assisting in development of the POC, develop-
ing the clinical record, advising and/or consulting with family
and team members, and supervising the therapy assistant.
Standard 42 CRF 484.32(a) (CMS, 2012b), Supervision
of Physical Therapy Assistant and Occupational Therapy
Assistant, defines the roles and responsibility of the super-
vising therapist as well as the therapy assistant. Although the
federal regulations do not specify how often a supervisory visit
must be performed, many state practice acts are specific and
many home health-care agencies define guidelines in their
policies and procedures.
The Initial Visit and Comprehensive
Assessment
Standard 42 CFR 484.55(a) (CMS, 2012b), Initial Assessment
Visit, mandates that an initial assessment visit be performed
to determine eligibility for the home health-care benefit and
to identify the immediate needs of the patient. There are also
guidelines about who can complete the assessment, and its
timing.
The initial assessment must be performed within 48 hours
of referral, within 48 hours of patient’s return home, or on a
physician-ordered start of care date. Similar to the compre-
hensive assessment requirement, for patients receiving only
nursing services or both nursing and therapy services, a
registered nurse (RN) must perform the initial assessment
visit. Under Medicare law in therapy-only cases a PT or SLP
may perform the initial assessment visit, but an OT cannot.
This is because Medicare does not allow for eligibility to be
established based on the need for occupational therapy only.
Under 42 CFR 484.55(a)(2) the mandate for a therapist per-
forming the initial assessment visit states: “When rehabilitation
4605_Ch31_471-488 31/10/17 5:32 PM Page 479
therapy service (speech language pathology, physical therapy,
or occupational therapy) is the only service ordered by the
physician, and if the need for that service establishes program
eligibility, the initial assessment visit may be made by the
appropriate rehabilitation skilled professional.”
Occupational therapy may qualify a beneficiary for eligi-
bility under other programs and in those instances the occu-
pational therapist could perform the initial assessment visit.
A home health-care agency may choose to have an RN
perform all initial assessment visits, regardless of services
ordered, and some state practice acts may require this. Con-
versely, a therapist may not perform the initial assessment
visit if nursing services are ordered at the SOC. This applies
to any nursing services that may be ordered. For example,
a patient returns home with surgical sutures that are to be
removed by nursing on Day 7 after admission to home-health
services, but there are no other nursing needs identified after
the one visit. Because of the need for skilled nursing care at
SOC, the patient is considered a nursing patient, and nursing
must perform the initial assessment visit regardless of number
of ordered visits.
CoP 42 CFR 484.55 (2012b), Comprehensive Assess-
ment of Patients, mandates each beneficiary must receive a
patient-specific comprehensive assessment that reflects the
patient’s current health status accurately, supports the devel-
opment of a plan of care and must justify the beneficiary’s
need for skilled home health-care services including home-
bound status and discharge needs. Furthermore, this CoP
mandates that the comprehensive assessment must incorpo-
rate the current OASIS (described subsequently) data items
for all Medicare and Medicaid beneficiaries receiving skilled
services except for:
■ those under age 18;
■ any beneficiary receiving maternity services;
■ any beneficiary receiving housekeeping or chore services only;
■ any beneficiary receiving only personal care services until
further notice;
■ beneficiaries for whom Medicare or Medicaid insurance is
not billed.
Although a comprehensive assessment with included
OASIS items is mandated, CMS requires the individual
home-health agency to develop a tool that is best matched to
its patient population. The OASIS items should be integrated
into a working document and should never simply be at the
beginning or end of a comprehensive assessment. Because
the OASIS data items have been developed and refined over
the years based on clinician feedback as well as audit findings
and legislative changes, these items are an integral part of an
agency’s comprehensive assessment. If a patient is receiving
skilled services but these services are reimbursed by insurance
other than Medicare and Medicaid, the comprehensive
assessment is still required, but the collection of OASIS data
is not. Private-duty patients receiving only homemaker,
chore, or companion services do not require a comprehensive
assessment (CMS, 2012a).
CHAPTER 31 ■ Home Health Care 479
Timeliness of the Comprehensive Assessment
Medicare mandates that the comprehensive assessment must
be completed in a timely manner and defines this timeframe
as no later than 5 calendar days after the SOC. The SOC date
is the first billable home health-care visit. The OT may not
be the one completing the comprehensive assessment, but he
or she is a critical part of painting a true picture of the patient.
The outcome and financial rationale is that the more accurate
the picture of the patient, the easier it is to measure true
progress and predict the necessary agency costs of care
provided.
Persons Performing the Comprehensive Assessment
If nursing is ordered at the SOC, a registered nurse must
perform the SOC comprehensive assessment. As mentioned
earlier, due to the establishing of eligibility requirement, for
therapy-only cases, a PT or SLP can perform the SOC com-
prehensive assessment upon admission of the patient to an
agency. If occupational therapy can establish eligibility (as
with some insurances and some Medicaid programs), then
occupational therapy may also perform the SOC comprehen-
sive assessment. If occupational therapy is active on a case
and the OT’s continued involvement continues to establish
eligibility, the OT can complete any subsequent assessments
throughout the patient’s entire course of home care.
The comprehensive assessment must be updated and
revised as needed but no less frequently than as follows:
1. The last 5 days of every 60 days, beginning with the
first billable visit (start-of-care date); this applies to
each 60-day episode that a patient incurs. This assess-
ment is performed by the appropriate discipline (can
be an occupational therapist) and is to determine the
patient’s current status as well as justify the need for
continued home health services.
2. A comprehensive assessment may be required earlier if
there is a
■ patient-elected transfer or
■ discharge and return to the same home health agency
during the 60-day episode timeframe.
3. Within 48 hours of the patient’s return home from a
hospital admission or return home from an inpatient
stay (which could be a hospital, skilled nursing facility,
or other inpatient setting).
4. Within 48 hours of the patient discharge from the
home health agency, patient transfer to an inpatient
facility, or death at home.
OTs and PTs must be competent and knowledgeable in
completing a comprehensive assessment and OASIS data
collection because they are responsible for ensuring its com-
pletion. They are also permitted to perform any subsequent
assessments during the episode(s) of care. More importantly,
the data collected and analyzed by a therapist at the time of ini-
tial evaluation are crucial to depicting the patient’s current level
of function and ability to improve. A good interprofessional
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480 PART IV ■ Service Delivery for the Aging Client
model would incorporate this sharing of information into the
comprehensive assessment to clearly establish an accurate
picture of the patient.
Standard 42 CFR 484.55 (c) (CMS, 2012b), addresses
medications and management of medications. This is a re-
quirement that applies to assessment of all patients whom an
agency serves, regardless of payer source and OASIS require-
ments. This standard mandates that the comprehensive as-
sessment must include a review of all medications, including
over-the-counter, that the patient is currently taking. This
review is performed to identify potential adverse effects and/or
drug reactions. OTs, PTs, and SLPs are expected to be aware
of the medications a patient is taking, and documentation
should reflect the monitoring of medication changes by all
disciplines involved. For example, on therapy-only cases, an
agency may have the therapist call the office and review the
medications with a nurse over the phone to determine any
significant issues. In another instance, if the therapist learns
during a routine home visit that the patient is now taking a
new drug, the therapist must communicate this information
as outlined in agency policy. Depending on the policy, the
therapist might need to call the nursing supervisor or write
an update in the medical record.
OASIS
In 1999, CMS mandated that a home health-care agency
must collect and transmit data for all adult patients (with the
exception of maternity or pediatric patients) who receive
skilled services reimbursed by Medicare or Medicaid. The
instrument, OASIS, (CMS, 2014e), mentioned earlier, is a
group of standard data elements developed over decades of
research funded by CMS and the Robert Wood Johnson
Foundation and the New York State Department of Health
(CMS, 2014e). OASIS data are designed to allow systematic
comparison of measurement of a patient’s status at two time
points.
Not all OASIS items are completed at every time point,
and CMS (2014e) defines which items are required at each
time point. All of the OASIS assessments, except Transfer
to Inpatient Facility and Death, are expected to be performed
during a home visit with direct observation/interaction of the
patient. OASIS data collection happens at the following
points:
■ Start of care
■ Resumption of care following inpatient facility stay
■ Recertification within the last 5 days of each 60-day recer-
tification period
■ Other follow-up
■ Transfer to inpatient facility
■ Discharge from home health care
■ Death at home
As with the Comprehensive Assessment, OASIS data
collection can only be completed by an RN, PT, SLP, or OT.
A licensed practical nurse, physical or occupational therapy
assistant, social worker, or aide cannot collect OASIS data.
OASIS data address two primary areas: reimbursement
and performance. The collected data establish a model of
payment that is further discussed under the Therapy Thresh-
old. In terms of performance, collection of reported data that
allows the government to collect, analyze, and publish specific
findings on agencies as a “report card.” In this era of technol-
ogy, there are a multitude of sites where a consumer, referral
source, or specific discipline can assess information on how
an entity or individual is rated compared with similar services.
In home health care, the main source is the Medicare.gov
website Home Health Compare (2014b), where agency care
outcomes are reported. In late 2015 and early 2016, a star-
rating system was initiated and published on home-care
agencies to assist the consumer.
Occupational and physical therapy play a vital role in the
ratings; the best scores result from quality, evidenced-based
best practice.
The OASIS tool was designed to evolve with time, med-
ical advances, payment restructuring, and industry needs
(CMS, 2014e). This evolution happens with feedback from
agencies, industry experts, and individuals. With each new
addition the OASIS guidance manual is updated to ensure
practitioners and agencies are aware of the expectations for
the data collection and to provide guidance and strategies to
complete specific questions. Once a revised OASIS has been
implemented, an HHA must use the new data collection tool
to remain eligible in the Medicare and Medicaid program.
Although OASIS revision is driven by various factors,
there are times that an ancillary policy can affect implemen-
tation. In October 2014, OASIS-C1 was to be implemented,
but on April 1, 2014, enactment of the Protecting Access
to Medicare Act of 2014 (PAMA) delayed the adoption of
International Classification of Diseases, 10th Revision, coding
until late 2015. Due to the extensive revisions in the new
OASIS C2 collection tool a new Guidance Manual was
published in its entirety (CMS, 2014g). For all intents and
purposes, while there are descriptors to identify the current
version, it is common to just refer to the data collection tool
as OASIS.
Documentation
With rising health-care costs and increased scrutiny by payers
and the public, therapists must be sure to properly document
care. Documentation is extremely important to demonstrate
continual communication, effectiveness of services provided,
beneficiary response to treatment, and the ongoing assess-
ment of any need to change the plan of care.
Through objective documentation, therapists can demon-
strate that they have implemented evidence-based treatment
that drives best practice that will increasingly be required in
any future home health-care reimbursement models. It plays
a key role in justifying the need for skilled therapy. In the
two recognized venues of home health-care therapy, rehabil-
itative and maintenance, quality documentation is essential to
payment. For rehabilitative therapy, documentation supports
4605_Ch31_471-488 31/10/17 5:32 PM Page 481
(a) the patient’s condition has the potential to improve and
(b) the expectation that improvement is attainable in a
reasonable period of time. For maintenance therapy, docu-
mentation supports that the skills of a therapist are needed
to maintain current function or prevent, or slow further
deterioration.
Confirmation of homebound status, measurable and
attainable goals, written clinical notes reflecting progress
toward goals and response to treatment, timely and thorough
reassessments, and comprehensive discharge summaries are
minimum standards that must be met. CMS has specific
policy directives that are routinely updated to reflect best
practice captured within the documentation.
Ultimately, the home-health record must justify the need
for skilled services. This justification is initiated at the evalu-
ation and continues throughout the entirety of the therapy
intervention. Specific to the provision of therapy services,
CMS states that, “To ensure therapy services are effective, at
defined points during a course of treatment, for each therapy
discipline for which services are provided, a qualified therapist
(instead of an assistant) must perform the ordered therapy
service” (CMS, 2014b, §40.2.1). Using methods that are
objective and allow for successive comparison of measurable
data, a therapist must assess and compare a patient’s func-
tional level at specifically mandated time points.
Initial Evaluation
The initial evaluation serves to elicit baseline data for the
therapist to determine the patient’s skilled needs, establish
measurable and attainable goals, and anticipate rehabilitation
progress and serves as the foundation for subsequent docu-
mentation. The evaluation addresses both physical and men-
tal status, and the interpretation of the acquired data serves
as the justification and individualization of the occupational
therapy, physical therapy, and speech-language pathology
POC. Note that this evaluation goes beyond the OASIS to
incorporate specific concerns of the individual disciplines:
ability to complete self-care occupations, safe ambulation in
the home and adequate physical capacity for function, and
ability to communicate effectively. Objective tests and meas-
urements should be used whenever possible and should be
used consistently at the various time points. Selecting the
appropriate tests and measurements has two components:
(1) tests and measures appropriate for the demographic
clientele of the agency and (2) the therapist’s clinical judg-
ment to determine which tests and measures are most ap-
propriate for the patient. These requirements are consistent
with occupational therapy, physical therapy, and speech-
language pathology professional guidelines, which focus on
the individual needs of the client. As just one example, the
Occupational Therapy Practice Framework: Domain and
Process (3rd ed.; American Occupational Therapy Associ-
ation [AOTA], 2014) indicates that “the evaluation process
is focused on finding out what a client needs and wants to
do” (p. S13).
CHAPTER 31 ■ Home Health Care 481
Reassessment
In 2011, CMS changed the world of therapy by implementing
a new policy on therapy reassessments: Therapy reassessments
were to be performed on or close to the 13th or 19th therapy
visits or at least every 30 days. CMS’s expectation was that
this policy change would ensure more qualified therapist in-
volvement for beneficiaries receiving high amounts of therapy.
In 2015, CMS responded to industry feedback and concern
and finalized changes to the regulation at §409.44 to eliminate
the 13th- and 19th-day rule and require reassessments be per-
formed by a qualified therapist from each ordered discipline at
least every 30 days or if clinically indicated. An OT, PT, or SLP
(not an assistant) must provide the ordered therapy service and
functionally reassess the patient. The new policy is discipline
neutral, which means where more than one therapy is being
provided, each discipline has its own reassessment clock. This
does not change the need for interdisciplinary communication
but allows for increased ease in focusing on patient care by
reducing anxiety over “exact” visit count. The 30-day “clock”
begins on the evaluation date and resets with each reassessment
performed. There is no specific timeframe for when the visit
needs to occur; clinical practice drives appropriate timeframes.
As mentioned earlier, it is important to use the same tests
and measures over time to be able to accurately document
progress toward patient goals or lack thereof. This reassessment
includes a summary of the therapist’s clinical assessment of ef-
fectiveness of current therapy and any modifications needed to
the plan of care. A primary way that OTs in home health care
demonstrate improvement is the measurement of levels of
assistance in ADL and IADL. Although measuring levels of
assistance required, the OT must ensure that each measure is
distinctly related to a functional activity with factors such as
response to assistance and projected potential future gain. In
physical therapy, progress is demonstrated through changes in
physical capacity such as range of motion, muscle strength, or
endurance related to ability to function in the home. In speech
therapy, progress can be demonstrated through changes in areas
of verbal expression, cognition, and auditory comprehension.
The CoPs state that the medical record must contain clin-
ical and progress notes. Under the billing component, the
HHA must bill each visit as a line-item on the bill. This
mandates that each visit note must “stand-alone” and justify
the skilled need. This justification occurs by properly docu-
menting assessments, treatment and training, outcomes of
intervention, patient response or change in behavior, com-
munication among the home health-care team, and plan for
next visit. A well-written note paints a picture of the patient
and allows auditors or reviewers to clearly understand the
rationale for the need for skilled therapy services.
Payment Systems and Reimbursement
All practitioners must understand the payment system in
which they provide services. There are many third-party payers
of home health-care services, but Medicare is the largest and
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482 PART IV ■ Service Delivery for the Aging Client
sets the standards for all other payers. Although it is crucial
for therapists to comprehend the payment criteria for coverage
of specific therapy services, it is critical to our continued
success in home health care to understand the global picture
of the reimbursement system. OTs, PTs, and SLPs do not
practice in a silo in the home health-care arena, and their
actions and documentation affect the greater whole of a home
health-care agency. Understanding the reimbursement struc-
ture for a home health-care agency solidifies practitioners’ value
and makes them vital members of the home health-care team.
Therapy Thresholds
One of the most prominent features of the home health-care
payment system is the additional payment for therapy uti-
lization. The therapy reimbursement system became compli-
cated in 2007 when the prospective payment system (PPS)
was refined to reflect concerns and changes. In 1999, HHAs
had shifted from a fee-for-service model of reimbursement
to a PPS where higher reimbursement was given if the total
count of combined therapy visits was greater than 10. This
was the first step in reflecting payment based on the volume
of delivered therapy services. If a patient received 10 or more
therapy visits (of any combination of occupational therapy,
physical therapy, and speech language pathology), the HHA
received a “bonus” payment. The initial intent of this payment
was to ensure that patients were not denied the higher cost
of therapy services by a HHA. Unfortunately, this led to
some undesirable practice patterns, and over the first 5 years
of PPS, the amount of 10+ therapy visits increased steadily.
These changes led to additional refinement of the PPS
system specific to therapy utilization. On January 1, 2008, a
three-tier reimbursement system was established based on
three therapy thresholds (6, 14, and 20 visits). In 2012, home
health-care PPS was further refined and adjustments in in-
creases of money at specific visit numbers were implemented
while maintaining the three established visit tiers.
The number of projected therapy visits is captured on the
OASIS at the start of care and confirmed when the final
claim is submitted. Because of the complexity of PPS, a
change in projected therapy visits can influence multiple as-
pects of the billing (in home health care, referred to as Health
Insurance Prospective Payment System or HIPPS) coding
and can cause challenges for agencies to monitor and adjust
to. This supports the involvement of therapies when complet-
ing the Comprehensive Assessment with OASIS inclusion.
It would be in the best interest of a HHA to accurately “pro-
ject” the therapy need based on the therapist’s analysis and
findings from their plans of treatment. This requires the
timely evaluation by the therapist to have accurate reflection
within the mandated 5-day completion window for OASIS.
Part B Outpatient Therapy Services
In the context of providing services in the home, some areas
of services can overlap and/or cause confusion. Part B outpa-
tient therapy is such an area, with primarily two scenarios.
Scenario A: Provided by Another Provider
According to CoP §484.10: Patient Rights; the HHA must
advise the patient, in advance, of any services they will be
providing as well as the frequency of these services (e.g.,
skilled nursing, therapy, home health aide). Home health-
care therapy services (Part A) must be provided directly, or
under arrangement with, the HHA and cannot be billed to
Part B while a patient is active with a HHA. Common areas
of overlap that occur specific to therapy are when a beneficiary
begins outpatient therapy from one provider while under a
home health plan of care of another provider. In this instance,
the home health agency will receive payment, and if the
outpatient provider does not have a written contract or agree-
ment with the home health-care agency, the outpatient
provider will not be reimbursed, regardless of amount of
services provided.
Scenario B: Provided by a Home Health Agency
An HHA can also choose to offer outpatient services through
the agency. There are several general rules or guidelines for
the provision of these services. Part B outpatient services
are billed using specific procedure codes, and they mandate
different procedures within the agency. A valid POC must
be reviewed by the therapist and doctor every 30 days, docu-
mentation requirements are different, and a different billing
procedure is used. A beneficiary must no longer be receiving
any home health-care services under Part A to be able to ini-
tiate and bill outpatient therapy (Part B). In particular, if a
patient continues to need therapy and is making progress
toward the goals but is no longer homebound, providing
outpatient therapy in the patient’s home can provide the
additional needs to be met and can encourage completing the
POC by the therapist who is familiar with the patient.
Section 4541(a)(2) of the Balanced Budget Act (1997)
requires that all claims for outpatient rehabilitation services
be reported using the Healthcare Common Procedure Coding
System (HCPCS). In Medicare Part A home health care, a
HHA is reimbursed an episodic rate established by OASIS
data and the patient’s needs (CMS, 2014b). For outpatient
Part B therapy, Medicare has an allowed charge that is the
lower of the actual charge or the Medicare Physician Fee
Schedule (MPFS). A beneficiary would need to meet his or
her Part B deductible, and a coinsurance payment is involved.
For example, an OT is seeing a patient post–cerebrovascular
accident under Medicare Part A for home health-care ther-
apy. The patient has made good progress, and the OT has
concluded in collaboration with the PT that, with continued
therapy, the patient can reach independence and increase
overall quality of life. Upon arrival to the home, the OT is
told by nursing that the patient is routinely leaving the home
and is no longer homebound; because he does not meet the
criteria for coverage, he will be discharged from Part A home
health care. The OT calls the physician to receive an order
for Part B occupational therapy and physical therapy, and a
new POC is developed to reflect the goals appropriate for the
patient. In this scenario, the HHA can bill for Part B therapy
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CHAPTER 31 ■ Home Health Care 483

services because the patient has been discharged from Part A As you have seen in previous chapters, older adults can
services, requires continued therapy and has the signed orders lose physical capacity rapidly during an acute illness. The
of the physician. physical therapist must ensure that the client has sufficient
muscle strength to use the toilet, get in and out of the shower,
get up from a chair, move from living room to bedroom, and
Other Sources of Payment
so on. Physical therapy focused on toileting, transferring, and
Although Medicare is by far the most frequent payer for locomotion has been shown to improve function in all these
home health services, there are an array of other options areas as measured by OASIS (Kim, Gordes, & Alon, 2010).
(Eldercare Network of Northern Colorado, n.d.). The At the same time, the individual may return home dis-
Veteran’s Administration and Medicaid are other federal couraged, anxious about safety, and concerned about his or
funders. The federal government also provides block grants her ability to prepare a meal and complete other ADL and
to states that are then used to cover specific services. A num- IADL tasks (Figure 31-2). These can be critical factors for
ber of private insurance companies offer long-term care attention from the occupational therapist, who must help the
insurance that includes a home-health benefit. A variety of client figure out routines that work, organization of tasks and
community initiatives have been implemented around the the environment that support accomplishment of needed
United States; these vary widely in terms of the services occupations, and address client values and performance
provided. Finally, individuals who have the resources to do patterns (Siebert & Vance, 2013). In addition, OT may focus
so can self-pay for care. on management of chronic conditions, helping clients set
up habits and processes for medication management, for
example, or addressing meal preparation in the context of
What Intervention Looks Like special diets for diabetes or high blood pressure.
The configuration of the home can affect physical capacity
A wide array of issues may be identified during assessment
requirements. Thus, there are times that environmental mod-
that guide the plan of care. As you have seen, there are com-
ification or supportive equipment can enhance the client’s
mon elements involved in assessment but also discipline-
function (Renda, 2012a, 2012b). Walkers, shower benches,
specific considerations. For example, in occupational therapy,
and other so-called durable medical equipment can be pro-
completion of an occupational profile is a vital component in
vided through Medicare if a need is identified. As with other
the identification of patient concerns and needs (AOTA,
areas of intervention, there are clear guidelines for evaluating
2014). Establishing a plan that addresses these concerns
need and securing equipment (CMS, 2014b), but their pro-
based on the scope of expertise of each discipline is important
vision can make a significant difference in the client’s recovery.
to ensuring that overall goals are met.
A particular concern is prevention of falls (Chase, Mann,
Wasek, & Arbesman, 2012). Identifying person (e.g., strength,
Therapy and Data Collection endurance, balance) and environment (e.g., lighting, hazardous
Given the opportunity in home health to assess and intervene
function in the client’s familiar environment, theoretical
models with relevance to occupational performance, including
the Person–Environment–Occupation Model (Christiansen
& Baum, 1997) or Lawton’s (1983) Ecological Model of
Aging focus on the fit between individuals and environments.
Likewise, the International Classification of Functioning,
Disability, and Health (WHO, 2008) and the Nagi Model of
Disablement (Nagi, 1965) help physical therapists frame an
approach to information gathering and intervention. These and
similar models that emphasize the relationship between per-
sonal traits and environmental supports and barriers suggest a
focus on two main directions for treatment: enhance individual
skills or create a more supportive environment (or both). These
models frame the kinds of assessments that might expand on
or enhance the data collection required by Medicare.

Intervention
Assessment leads to therapeutic goals. In the case of home
health care, those goals focus on supporting the individual’s
return to the best possible function in his or her environment,
or minimizing any additional functional loss.
FIGURE 312 Home health clients may need assistance with activities
of daily living when they first leave an acute care setting. Dean
Mitchell/iStock/Thinkstock
4605_Ch31_471-488 31/10/17 5:32 PM Page 484
484 PART IV ■ Service Delivery for the Aging Client
surfaces) factors that might contribute to falls, and addressing
these through physical therapy emphasizing balance and
physical capacity and environmental modification can return
older adults to independent function and reduce the risk of
reinjury.
It is also important that the occupational therapist iden-
tifies and supports informal care providers who can assist
the individual (Kelly, Wolfe, Gibson, & Feinberg, 2013;
O’Sullivan, 2015). Too often, these caregivers, usually family,
provide a wide array of supportive interventions with little or
no recognition or training. Identifying community resources
that can assist them once home health care has been termi-
nated can make a tremendous difference in function and
quality of life for the older adult and the informal caregiver.
An additional consideration is balancing safety and auton-
omy (Denson, Winefield, & Beilby, 2013). Although it is
important to promote safety, some older adults value auton-
omy more highly and are willing to accept a higher level of
risk to maintain their independence. This may result in con-
flict with worried family members, and therapists can help
establish compromise solutions, keeping in mind, of course,
that the older adult is the client.
All these factors can be readily addressed in the client’s
familiar environment, as can be seen in the case study at the
end of this chapter. In many situations, the eventual goal is
to terminate treatment because the individual has recovered
sufficiently that he or she is no longer homebound and can
resume many or all previous activities.
Measuring Quality and Best Practice
As has been noted throughout this book, identification of
best practice strategies is vital to effective therapy. Physical
therapy has strongly encouraged the application of emerging
knowledge in assessment and intervention (Levac, Clegg,
Camden, Rivard, & Missiuna, 2015). A primary tenet for
provision of occupational therapy is the delivery of services
in the context of best practice (AOTA, 2014). In addition,
these measures serve as part of agencies’ public “report card.”
In home health care, three types of quality measures result
from OASIS data: Process Measures, Outcome Measures,
and Potentially Avoidable Events. Therapists need to be
aware of all the measures but must have a clear understanding
of the following: Outcome measures are generally described as
patient-driven results. They are improvement measures as
well as utilization measures. How does a patient respond to
care? What are the outcomes at the end of a defined service
provision? What is the patient’s functional level in specific
areas? Process measures are used to evaluate the HHA and the
use of evidence-based care for the patients it serves. Are
admissions timely? Does an agency use risk assessment tools
for pain, falls, depression, and pressure wound development?
Clinical care for specific diagnoses (i.e., heart failure, diabetes,
pressure wounds) is measured under process measures. When
a diagnosis is captured under the process measure section, it
can generally be assumed that the area has been identified by
CMS as an area of concern or interest generally related to
increased money, service provision, or rehospitalizations.
Process measures are generally considered under the control
of the HHA so directly impact an agency’s quality of care.
INTERPROFESSIONAL PRACTICE
Multidisciplinary Intervention
Collaborative occupational and physical therapy intervention
focused on home modification, problem-solving, energy
conservation, fall recovery, balance, and muscle strength
training supported improved quality of life for community-
dwelling older adults with functional difficulties. These benefits
were retained at 1-year follow-up (Gitlin et al., 2006).
Many of these measures are directly related to therapy
(e.g., measures are in place related to ADL, pain, medication
management) and impact practice patterns. One area of
measurement in health care is structural characteristics.
Structural characteristics include physical structure but also
address administrative and operational processes that direct
patient care. Understanding and analyzing structural charac-
teristics allow an agency to “increase the probability of pro-
viding specified kinds of care, which in turn improves the
probability of obtaining positive changes in the health and
well-being of individuals and populations” (Donabedian,
2005, n.p.).
Process measures and outcome measures addressed by
the federal government will change over time, but the intent
remains the same and regardless of the items reported: the
bottom line relates back to accurate collection of information
on OASIS. The ability to collect and analyze data specific to
an agency’s population will allow for the provision of high-
quality care. These measures will be used not only from the
public side to “evaluate” the quality of a HHA, but will also
be used to define the future of individualized agency payment
for value-based purchasing (VBP) or performance-based
payment (PBP).
Therapists must generate data specific to their own disci-
plines, in addition to drawing on OASIS and other mandated
assessments. Randomized controlled trials have become the
gold standard for such investigation, although a variety of
qualitative approaches may be more helpful in ascertaining
quality of life and patient satisfaction. Existing research
provides support for an array of occupational therapy and
physical therapy interventions. For example, Lewin, De San
Miguel, Knuiman (2013), studying home health care in
Australia, found that both function and quality of life improved
on the basis of such intervention. A study of telerehabilitation
in home health likewise found significant improvement in
physical and cognitive function, independence, and health-
related quality of life (Levy, Silverman, Jia, Geiss, & Omura,
2015). There is some evidence that both occupational therapy
(Craig, 2012) and physical therapy (Kim et al., 2010) are
underutilized in home health care. Certainly, there is limited
research on efficacy and outcomes. Therapists may need to
4605_Ch31_471-488 31/10/17 5:32 PM Page 485
extrapolate from related literature (e.g., outcomes of inter-
vention for specific chronic diseases; program evaluations for
aging-in-place efforts; evaluation of community-based inter-
vention). The evidence that does exist supports the value of
therapeutic interventions
SUMMARY
Home health care offers several significant advantages in
helping older adults maximize function. Patients may manage
differently in a familiar environment compared with their
performance in clinical settings, and their cultural beliefs and
habits can be incorporated into care.
However, home health services are heavily regulated by
Medicare and Medicaid laws that oversee many aspects of
care. The patient’s eligibility for care, requirements for eval-
uation and goals, and coverage of specific services are all reg-
ulated with specific criteria. In particular, home health is
covered only for patients who are homebound, limiting the
areas in which therapists can address function.
Therapists must know and conform to regulations if their
clients are to receive maximal access to and benefit from serv-
ices. It is important, too, to be aware that regulations change
regularly, and therapists must be alert to these alterations.
CASE STUDY
Mrs. Eleanor Borden is a 92-year-old widow who was
admitted to the hospital with a fever and shortness of breath.
Upon admission, she was diagnosed with exacerbation
of her chronic congestive heart failure and urinary tract
infection. She also has a history of hypertension, surgical
history of coronary artery bypass grafting (3, and bilat-
eral cataract surgery. She was discharged to a skilled
nursing facility where she received nursing and occupa-
tional and physical therapy for 10 days. Her Medicare
Managed Care denied further skilled inpatient coverage,
and she was discharged to her ranch-style home with
basement laundry. There were orders for home health-
care skilled nursing, occupational therapy, and physical
therapy.
Nursing: The nurse performed the initial visit on
Monday and established eligibility for the home health-
care benefit. The patient’s daughter and son-in-law
were present for the visit, but Mrs. B lives alone. Mrs. B
reported that before the hospitalization, she was inde-
pendent in taking care of herself at home, but her daugh-
ter helped with the grocery shopping and errands because
Mrs. B had never learned to drive. The nurse began the
OASIS and established nursing goals and informed the
patient she would see her two times a week for 2 weeks
as patient medical status was becoming stable. The
daughter informed the nurse that they would check in
daily on her mother and help her as needed. The nurse
plans to complete the comprehensive assessment within
CHAPTER 31 ■ Home Health Care 485
the mandated 5-day window after she incorporates the
findings of the OT and PT and determined projected
therapy visits.
Physical Therapy: The PT completed a home evalua-
tion on Tuesday and assessed the patient’s needs and
safety. Before hospitalization, Mrs. B was an independent
ambulator and is motivated to return to that level, even
though the nursing home gave her a quad cane. The PT
evaluation determined that Mrs. B was able to ambulate
with supported ambulation 40 feet before her step length
decreased, she had a loss of balance, and she became short
of breath. To leave the home, she has three steps out the
front door and two steps into the garage. Her Tinetti score
was 20 of 28, which indicates a risk for falls. The PT
determines that she has generalized weakness and debility
from her illness that is affecting her functional mobility
and safety within her home. The PT will see Mrs. B two
times for 3 weeks, and goals were established with the
client’s input.
Occupational Therapy: The OT completed her eval-
uation on Wednesday and emphasized functional in-
dependence and safety with all ADL and IADL. Of
particular concern was the patient’s desire to shower
independently. Mrs. B describes her “before hospital” day
where she rose at 5:30 a.m., showered, prepared her
breakfast, and then performed light housekeeping and
laundry; her washing machine and dryer are located in
the basement. After lunch she reports that she liked to
walk outside to get the mail and then read the paper. She
“took a quick nap” before making dinner, and after clean-
ing the dishes, reports that she fell asleep in her chair
until the news and then went to bed where she is up “on
and off” throughout the night. The OT evaluation finds
that Mrs. B needs minimal assistance from her daughter
for ADL and that the family is currently performing all
IADL for the patient due to her fatigue level. Mrs. B
scores a 7 of 10 for the functional reach test, which indi-
cates a fall risk. Mrs. B is motivated and wants to return
to her prior level of function. The OT discusses goals with
patient and family and will see the patient two times a
week for 3 weeks. The OT communicates with the nurse
and PT regarding findings of evaluation and occupational
therapy POC.
Questions
1. What further evaluation might the OT need to
complete?
2. What further evaluation might the PT need to
compete?
3. What kinds of interventions might be helpful?
4. What might be helpful in the context of Mrs. B’s
diagnosis of CHF?
5. What would the therapy documentation look like
for this patient?
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486 PART IV ■ Service Delivery for the Aging Client
Critical Thinking Questions
1. Throughout this chapter, legislative and regulatory
requirements have been repeatedly emphasized. Why
might these be essential in providing effective home
health care?
2. What are some elements of the various regulations
that might help promote good care for the client?
3. What are some elements of the various regulations
that might interfere with good care for the client,
and how might therapists minimize these negative
consequences?
4. What are some aspects of home health care that
make interprofessional communication particularly
vital?
5. What are some elements of home health care that
make it uniquely effective in promoting patient
independence?
6. How might the OT and PT gather information that
would support the value of their interventions in
home health settings?
7. Where do you think home health fits in the contin-
uum of services for older adults, and how might
therapists help elders find out about these services?
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4605_Ch32_489-506 31/10/17 12:41 PM Page 489
Vanina Dal Bello-Haas
In his 87th year of life, the great Michelangelo Buonarrotti (1475–1564) was believed
to have said, “Ancora imparo” (“Still, I am learning”)
LEARNING OUTCOMES
By the end of this chapter, readers will be able to:
1. Relate the demographics of disability in the older adult
to the extent of problems that may be encountered during
rehabilitation.
2. Outline the unique aspects of rehabilitation as they relate
to the older adult.
3. Discuss the different team approaches to the rehabilitation
of the older adult and the complementary relationship
between occupational therapy and physical therapy.
4. Define comprehensive assessment as it relates to rehabilita-
tion of the older adult.
5. Review common assessment tools and interventions used
in older adult rehabilitation settings.
6. Discuss the personal and environmental factors that may
enhance or impede the rehabilitation process.
7. Describe the various delivery systems in which rehabilitation
of the older adult can take place and the related reimburse-
ment issues.
8. Consider the psychological impacts of trauma and illness on
the rehabilitation process.
9. Outline rehabilitation issues for older adults with preexisting
conditions.
Clinical Vignette
My Uncle Alphonse
When we were little he always had candies in his pocket
and would take us for ice cream. He always played lots of
games, card games, sports, board games as long and as often
as we all wanted to play.
When I was older, he was interested in what I wanted to
do when I grew up, who I was dating, and what I did for fun.
He had the biggest laugh. My mother says he also has a bad
temper when they were growing up, but I never saw it.
When I was 14, he married Sophia, who was a fashion
model and very cool. A few years later, he had babies of his
own, but he was still interested in our lives and what we were
doing. He was an importer/exporter; he traveled all over the
world. He loved work, he said, and he loved play, and he
CHAPTER 32
Rehabilitation
■ Joyce Tryssenaar
loved people, he loved his nieces and nephews and his own
children, and God. He lived a big life. He had lots of strong
opinions but could laugh at himself too. He danced at my
wedding, toasted my bride, and later spoiled my own children
as he had spoiled me. He took up waterskiing and golf and
bird watching. He said he wanted to live life to the fullest
each and every day.
When he was 67, he fell off his roof and hurt his back.
With his back injury, he experienced significant pain and dis-
ability for the first time in his life. The loss affected all areas
of his life and his health and resulted in grieving and depres-
sion. He focused his life on a search for a cure. He tried
acupuncture, and cold packs, and drugs, and prayer, and mas-
sage, and psychotherapy, and naturopathy, and finally he
tried surgery in the hope that he would have less pain and a
better quality of life. Unfortunately, the surgery resulted in
permanent lower limb paralysis, and my Uncle Alphonse had
to go to rehabilitation to learn to live independently again.
1. As you read the story of Uncle Alphonse, what are you
thinking and feeling? Pay attention to how your world-
view and values might inform your perspective.
2. What do you anticipate the primary issues for Alphonse
would be?
3. How do you think the rehabilitation process would
unfold in the next 6 months to a year?
T here are many definitions of rehabilitation. Rather than
one universally accepted definition, some consider
rehabilitation too complex to define because rehabilitation
lacks a unifying conceptual framework (Stucki, Cieza, &
Melvin, 2007). The World Health Organization (WHO;
2011) defines rehabilitation as “a set of measures that assist
individuals, who experience or are likely to experience
disability, to achieve and maintain optimum functioning in
interaction with their environments” (p. 96). Rehabilitation
is typically considered a continuous process aimed at enabling
people to maximize, restore, and maintain their optimal
physical, sensory, intellectual, psychological, and social
functional levels (Figure 32-1). Through a client-focused
489
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490 PART IV ■ Service Delivery for the Aging Client
partnership, usually involving several health-care profession-
als and including family and caregivers whenever possible,
rehabilitation provides people with the tools they need to
attain the highest possible level of independence and self-
determination. Rehabilitation includes providing for and
restoring activity limitations and participation restrictions,
relearning previous skills, and learning how to adapt to dif-
ferent circumstances to compensate for the loss or absence
of a function or for a functional limitation (adapted from
WHO, 2006).
Rehabilitation can be carried out in a variety of settings,
and the scope, types, and intensity of services provided, the
type of patients served, and the overall philosophy and focus
of the program offered within each setting can vary. Thus,
rehabilitation will involve a variety of health-care professionals
working within and across various health- and social-care
sectors. The key to successful rehabilitation of the older adult
involves the accurate identification of problems and needs, an
understanding of the relationship between identified problems
to impaired body functions and structures, activity limitations
and participation restrictions, and the influence of personal
and environment factors that may positively or negatively
influence rehabilitation interventions and overall outcomes.
Disability in Older Adulthood
With increasing age, the potential for disability increases,
with the greatest number of disabilities affecting most of the
very old. The WHO estimates that 20 percent of those 70
and older, and 50 percent of those 85 and older have some
sort of disability. The most common causes are chronic
diseases, injuries, mental impairments, malnutrition, and
Out In
Goal fulfillment
No
Yes
Team
Family
Reassessment
Evaluation Client
Analysis
Caregiver
Management and care:
Alleviating consequences
of activity and
participation limitations
communicable diseases such as HIV/AIDS (WHO, 2011).
Chronic conditions may lead to severe and immediate
impairments, as well as progressive activity limitations that
gradually decrease an older adult’s ability to care for him or
herself (Fried & Guralnik, 1997). Although disabilities may
be relatively minor, more than one-third (34.9 percent) of
those aged 80 years and older report needing assistance
because of a disability (Administration on Aging, 2005). An
orderly progression of disability has been reported in older
adults age 75 and older, with self-care activities dependent
on lower extremity function being lost before activities that
are dependent on upper extremity function (Jagger, Arthur,
Spiers, & Clarke, 2001; Spector & Fleishman, 1998).
Bathing is typically the first activity of daily living (ADL)
with which older adults have difficulty, followed by general
mobility, toileting, dressing, transfer from bed, transfer from
chair, and feeding (Jagger et al., 2001). As well, there is a
strong association between disability status and health status.
Among those age 65 and older with a severe disability,
68 percent reported their health as fair or poor. In those with
no reported disability, only 10.5 percent reported their health
as fair or poor (Administration on Aging, 2005).
Disability among older people has been reported to be
declining in some, but not all, countries. For example, a
declining trend in severe disability has been reported in the
United States, Italy, and the Netherlands, the trend seems to
be stable in Australia and Canada, but increasing in Sweden
and Japan (Organization of Economic Cooperation and
Development, 2013).
A proportion of older adults have “geriatric syndromes”
co-occurring with chronic diseases or conditions (Lee, Cigolle,
& Blaum, 2009). Geriatric syndromes typically have more
than one cause, involve several different body systems, and
Assessment
Identification of the client’s
problems and
Analysis
needs
Measurement
Planning
Goal-setting
FIGURE 321 Rehabilitation: A
Intervention: continuous process. (Adapted from
Reducing activity and Lokk, J. [1999]. Geriatric rehabilitation
participation limitations revisited. Aging: Clinical and Experimental
Research, 11, 353–361.)
4605_Ch32_489-506 31/10/17 12:41 PM Page 491
often contribute to one another. Because chronic conditions,
compounded by geriatric syndromes, have significant impli-
cations for rehabilitation of the older adult, it is critical for
the occupational and physical therapist to be able to recognize
the signs and symptoms of geriatric syndromes, such as
urinary incontinence and falls (see Chapters 12–17). Coro-
nary artery disease, congestive heart failure, and diabetes
mellitus are chronic conditions that have been found to
co-occur with urinary incontinence and injurious falls in
adults aged 65 and older (Lee et al., 2009).
Psychological Consequences
of Disabling Events
Many older adults seen for rehabilitation are adjusting to real
and perceived losses from the sequelae of disabling events—
traumas, conditions, and illnesses. These losses range from
those sustained at the impairment level, such as range of
motion, balance, strength, endurance to intrapersonal losses,
such as the loss of a sense of self, loss of valued roles, loss of
relationships, and loss of power leading to activity limitations.
Finally, the older adult who faces disabling events can expe-
rience losses affecting participation such as the disengage-
ment from meaningful activities such as volunteer work,
the loss of living independently, and financial losses. Loss is
defined as irrevocable and can be any valued object—a loved
person, a job, status, home, a cherished possession, and
health—whereas grief is our response to loss and often
includes the loss of the future as we expect it (Bruce &
Schultz, 2001). Loss can be sudden, gradual, anticipated,
temporary, or permanent. The concept of nonfinite loss
is contingent on development and time and involves a
process of realization that occurs over an individual’s lifetime
(D. L. Harris & Gorman, 2011).
Trauma and illness can have devastating impacts on the
lives of people who experience them, as well as on the lives
of their caregivers (Kristofferson, Lindqvist, & Nilsson,
2011). These include a loss of sense of self, diminished quality
of life, anxiety, and grief. For example, a person with a stroke
may feel the loss of physical and cognitive competence (loss
of sense of self), feel isolated and different because he or she
now uses a wheelchair (the loss of connectedness that results
from stigma and discrimination), experience a loss of power
(loss of independence in self-care), and have lost valued roles
(driving, social activities).
INTERPROFESSIONAL PRACTICE
Six Important Factors for Therapists to Consider
When Working With Loss and Grief Issues (From
Drench, 2006)
1. The importance of dialogue and relationship for healing and
transformation. A busy therapist may not feel he or she has the
time to spend talking about grief if that is what the individual
requires, but it is essential for transformation to occur.
CHAPTER 32 ■ Rehabilitation 491
2. A focus on process as opposed to outcome.
3. The importance of the process of life review. Older adults
often wish to review their lives, and loss may bring the need
for life review to the forefront.
4. Confronting the nature of absence and emptiness.
5. Comforting through touch (as appropriate) and other
physical means (e.g., tissues, cups of tea).
6. Being present to what is experienced rather than the need
for change.
Providing a hope-charged environment and making
available opportunities to engage in meaningful occupations
can be a means of reworking expectations and creating
resilience within the person. All of the preceding strategies
are dependent on what the person wants, but it is the occu-
pational and physical therapist’s responsibility to assess and
support the individual in his or her experienced loss and
resulting grief.
Aging With a Preexisting Disability
The prevalence of persons aging with preexisting disabilities
is increasing rapidly as medical interventions allow individu-
als to not only survive but to live longer. Rehabilitation can
be a very different process for the therapist when working
with someone who has had numerous experiences with
rehabilitation. Positive previous experiences allow care-
givers to work in a collegial relationship with the client
(i.e., the client has developed expertise in managing his or
her condition and is open to the rehabilitation experience
and the therapist respects his or her expertise). Negative
prior experiences may challenge the therapist to process
these experiences before moving forward and to be sensitive
to how these past experiences may affect current and future
rehabilitation.
AROUND THE GLOBE: Older Adults With Intellectual
Disabilities
A long-term study conducted in Israel found older adults with
intellectual disability were similar to other older adults in regard to
age-associated conditions and needs. Aging burden may be more
complex, as many individuals live with family members who are
also aging (Kandel, Merrick, Merrick-Kenig, & Morad, 2009).
A Belgian study found accommodation and support aging
people with intellectual disabilities requires adaptation of staff
approaches to care (Maes, & Van Puyenbroeck, 2008).
A European study found older workers with limiting disabilities
may be more satisfied with wages, tenure, and working in the
private sector compared to nondisabled older individuals (Pagan,
2011).
Living in rural and remote areas adds geographical challenges
for both individuals aging with a preexisting mental disability and
their caregivers (Tryssenaar & Tremblay 2002).
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492 PART IV ■ Service Delivery for the Aging Client
Issues for Persons With Intellectual Disability
The life expectancy of most individuals with intellectual
disability now approximates the general population (Coppus,
2013). Individuals with Down syndrome are also living
longer, with a life expectancy within the 60-year range
but have several comorbidities related to aging with Down
syndrome (Glasson, Dye, & Bittles, 2014). Living longer
means that these individuals will also face the same age-
related health concerns as the general population (Perkins &
Moran, 2010). Some potential rehabilitation challenges for
persons with intellectual disability include negative experi-
ences with institutions in their childhood, lack of supportive
relationships, and limited services and programs. Salvatori,
Tremblay, and Tryssenaar (2003) found age-related health
issues facing both older adults and their aging parents
contributed to increased caregiver burden and the need for
permanency planning. Like many older persons, older indi-
viduals with intellectual and developmental disabilities may
experience lower levels of healthy behaviors, making health
promotion an important approach for these populations
(Heller, Fisher, Marks, & Hsieh, 2014).
Issues for Persons With Serious Mental Illness
Persons aging with serious mental illness are living longer,
although their life expectancy is less (life expectancy was gen-
erally approximately 15 years shorter for women and 20 years
shorter for men) compared with the general population
(Nordentoft et al., 2103). Lawrence and Kisely (2010) argued
that inequalities in health-care access and service delivery are
a significant factor in this increased mortality rate for persons
with serious mental illness.
Rehabilitation practitioners need to be aware that among
individuals with mental illnesses, there are usually concomi-
tant physical health problems that become part of the aging
process. In a qualitative study of family members of individ-
uals aging with serious mental illness (Tryssenaar & Tremblay,
2002), one participant reported “My husband has been
classified as a mild schizophrenic, but he also had a major
stroke 212⁄ years ago, so he now has both a physical disability
and a mental disability” (p. 260). This study also found that
participants reported ongoing concerns that physical health
needs were not considered with a prior mental illness diag-
nosis. The challenges of maintaining and enhancing the
physical health of persons with serious mental illness have
also been documented in the nursing literature (Robson,
Haddad, Gray, & Gournay, 2013).
Issues for Persons With Physical Disabilities
Jeppsson Grassman, Holme, Taghizadeh Larsson, and
Whitaker (2012) explored the nature of aging with a disabil-
ity using a life course perspective. This perspective adds
insight to the lived experience of disability and aging of
adults with disabilities. Recognition of the individual’s
expertise in living with his or her preexisting condition must
be considered in rehabilitation. Exploring these common
health problems, while keeping in mind the natural processes
of aging, is part of the challenge for therapists working in
rehabilitation. There is some evidence that older adults
with physical disabilities experience higher levels of pain and
that this pain interferes with their ability to participate in
meaningful activities (Molton et al., 2014). Persons aging with
spinal cord injury typically experience an inactive lifestyle,
which contributes to deconditioning and secondary health
conditions; thus rehabilitation aftercare is vital in the preven-
tion of secondary health complaints (van der Woude et al.,
2013).
What Makes Older Adult Rehabilitation
Unique?
Rehabilitation of the older adult presents several unique
aspects for therapists. The older adult client frequently pre-
sents with multiple diagnoses or pathologies in combination
with changes associated with normal aging. The interaction
between conditions and normal aging may exacerbate impair-
ments and limitations, and may affect the response to some
rehabilitation interventions. Many of the occupational per-
formance or functional problems experienced by an older adult
are the result of interactions between decreased physiologic
reserve, an acute or chronic illness, and the environment in
which the person resides. As the numbers of diseases increase,
there is increasing risk of problems with activities of daily
living (ADL; Mor et al., 1989; Verbrugge, Lepkowski, &
Imanaka, 1989), instrumental ADL (IADL; Mor et al., 1989;
Verbrugge et al., 1989), and mobility (Campbell et al., 1994;
Guralnik et al., 1993; Verbrugge et al., 1989; Verbrugge,
Lepkowski, & Konkol, 1991).
Chronological Versus Physiological Aging
As has been mentioned in many previous chapters, chrono-
logical age is not always a reflection of physiological age.
There is a great deal of heterogeneity and variability in
overall presentation and functional limitations in older adults,
secondary to differences in decline in the physiologic systems,
such as cognitive, neuromuscular (e.g., strength), cardiovas-
cular, sensory (e.g., vision), and other physical functions
and the number and extent of health conditions, impairments,
and limitations (see Part II, Sections 1 and 2). For example,
Ms. Laura Jemkins is 75 years old. She has osteoporosis and
decreased physical mobility, and she had a stroke that has lim-
ited the use of her dominant hand and arm. Using a variety
of compensatory techniques, adaptive devices, and family sup-
port, she continues to garden, play cards, and do the majority
of her usual activities. On the other hand, Mr. Sam Elgin,
who is 65 years old, has impaired vision and hearing and early
cognitive impairments, and he does not participate in many
of his usual activities even with the provision of adaptations,
compensatory strategies, and environmental supports.
4605_Ch32_489-506 31/10/17 12:41 PM Page 493
Progressive Versus Catastrophic Disability
The incidence of a catastrophic event precipitating activity
and participation limitations is less likely for an older adult.
Older adults are more likely to experience progressive dis-
ability, and thus, they may be more likely to need rehabilita-
tion intermittently over time. Rates of progressive disability
increase with age and are greatest for those age 85 and older
(Guralnik, Ferrucci, Balfour, Volpato, & DiIorio, 2001).
Biological and Other Factors
Biological factors may have important effects on the devel-
opment of frailty (Fried et al., 2001). Frailty is considered an
age-related loss of physiologic reserve; thus, even minor stres-
sors can result in disproportionate functional consequences,
and potentially, on the ability of frail, older adults to respond
to rehabilitation. See Chapter 17 for more information on
frailty. Depression and cognitive impairment, both of which
are associated with poor functional outcomes, are common
in older clients undergoing rehabilitation (Wells, Seabrook,
Stolee, Borrie, & Knoefel, 2003a). Financial resources may
be more limited in older adults, and caregivers (often older
adults) may also have some decline in function themselves.
Thus, the abilities of the person providing care also need to
be assessed and considered as they relate to the rehabilitation
management plan.
Management
Management may not be directed to vocational or educa-
tional outcomes that typify rehabilitation for middle-aged
and younger adults, and at times rehabilitation may be more
focused toward prevention of further decline, rather than
restoration. Because of the higher incidence of chronic diseases
in older adults, overall rehabilitation management should
take into account interventions aimed at chronic disease
management and disease prevention and promotion of health
and wellness, so that older adults can learn to live with their
condition and become actively involved in its management.
Regardless of these unique features, there are basic principles
of rehabilitation for older adults that need to be kept in mind
(Box 32-1).
The Rehabilitation Team
The most important member of the team is the client: the
older adult. Rehabilitation is maximized when a comprehen-
sive and holistic approach, with input from the family and
caregivers and a variety of skilled professionals, is used. Evi-
dence highlights the importance of eliciting family and client
input when setting goals. Studies have found poor agreement
on goals between older clients, family members, and the
health-care team regardless of setting (Bogardus et al., 2001;
Glazier, Schuman, Keltz, Vally, & Glazier, 2004; Rockwood,
Graham, & Fay, 2002). Although there was agreement in
CHAPTER 32 ■ Rehabilitation 493
BOX 321 Basic Principles of Rehabilitation for Older
Adults
■ Use a client-centered focus—set realistic, individualized
goals
■ Include caregivers and family members whenever possible
■ Use a team approach
■ Address primary impairments, activity, and participation
limitations
■ Prevent secondary impairments, activity, and participation
limitations
■ Address health promotion and wellness needs
■ Emphasize optimal functional independence
■ Consider interclient variability
■ Consider how personal and environmental factors may
influence overall management and outcomes
some goal categories, there was substantial disagreement
about areas of main concern and priority. In addition, clients
and caregivers tended to identify more goals, especially in the
areas of medical care, psychosocial issues, spirituality, future
planning (Glazier et al., 2004), and related to leisure, social
interaction, behavior, and function (Rockwood et al., 2002).
Explicit goal setting is a central component in the rehabili-
tation of older adults. Goals should be informed by careful
evaluation of the client and precede all rehabilitation inter-
ventions. A rehabilitation goal is a precise statement and
should be constructed so that its achievement is unambiguous
(Box 32-2).
AROUND THE GLOBE: Rehabilitation Goals of Disabled
Elders
A prospective, multicenter cohort study of 209 individuals over
65 years of age (mean age = 79.9) from geriatric wards and units
in three German hospitals, and two Austrian hospitals examined
aspects considered important related to health condition and
hospitalization. Data related to expectations, desires, hopes,
goals; and fears, doubts, or problems were collected using a
semistructured questionnaire. Most frequently stated goals were
related to mobility/walking, autonomy, decreased pain, returning
home, and general condition improvement. Multivariate analysis
determined shorter length of inpatient stay and goal attainment to
be significant predictors for improvement in overall functioning
(Kus, Müller, Strobl, & Grill, 2011).
Teams may be multidisciplinary (MD), interdisciplinary
(ID), or transdisciplinary (TD), and although the terms are
often used interchangeably, they each have a specific mean-
ing. MD teams are discipline oriented, with each team mem-
ber responsible for his or her own unique scope of practice,
and the team’s outcome is the sum of each team member’s
efforts. In ID teams, team members are involved in problem-
solving beyond the scope of their own discipline. The whole
4605_Ch32_489-506 31/10/17 12:41 PM Page 494
494 PART IV ■ Service Delivery for the Aging Client
BOX 322 Essential Components of Rehabilitation Goals
■ Meaningful—appropriate to circumstances of the client and
the problems identified
■ Individualized
■ Mutually agreed upon—negotiated among client, family,
caregivers, and the rehabilitation team
■ Clearly communicated
■ Realistic—challenging, but achievable
■ Measurable
team identifies goals for the client; once identified, each team
member then works toward goal attainment within their
scope of practice. Within TD teams, one team member is
chosen to be the primary leader or therapist depending on
the specific needs of the client. The team leader is responsible
for care delivery regardless of his or her discipline, and other
team members contribute information and recommendations,
necessitating cross-training and flexibility of health-care
professionals (Latella, 2000). The health-care professionals
who make up the rehabilitation team vary greatly depending
on the care setting and the needs of the client, but typically
include a geriatrician (a physician who specializes in geriatric
medicine) or a physiatrist (a physician who specializes in
physical medicine and rehabilitation), rehabilitation nurses
and/or a geriatric nurse practitioner, a social worker (SW),
physical therapist (PT), occupational therapist (OT), and
support personnel. Rehabilitation nurses are also considered
to be specialists in the nursing field. “Rehabilitation nurses
are defined by a unique skill set, which entails the knowledge
Psychiatrist Psychologist
Physical
Occupational
therapist
therapist
Speech
language
pathologist
Nutritionist Family
Nurse Client
Pharmacist Caregiver
Specialists
(e.g., neurologist)
Geriatrician
Recreation
Podiatrist
therapist
and understanding of chronic illnesses and conditions that
cause disability and a focus on helping patients recover
as much function as possible through the formulation and
implementation of interventions and evaluating outcomes”
(Camicia et al., 2014, p. 3). Other health professionals, such
as psychologists, speech-language pathologists (SLPs), audi-
ologists, nutritionists, recreational and respiratory therapists,
and pharmacists, are also frequently part of a team that may
evaluate and manage care for the older adult (Figure 32-2).
In some countries, team members have specialized skills
or specialist certification. For example, in the United Kingdom,
geriatricians and rehabilitation nurses may have specialized
skills in stroke or orthogeriatric rehabilitation; in Canada,
physiotherapists may be Clinical Specialists in Seniors
Health; and in the United States, physical therapists may
be Geriatric Certified Specialists (GCS) and occupational
therapists may be Board Certified in Gerontology. Research
has found that for some populations (e.g., people with stroke),
a dedicated setting or specialist unit produces better out-
comes than general wards or “roving” team members (Quinn,
Dawson, Walters, & Lees, 2009).
Although some older adults requiring rehabilitation do
not present with complex needs, the majority do have multi-
faceted issues. Interdisciplinary teams are an essential com-
ponent of practice in the rehabilitation of older adults in
part because no one person or discipline can have expertise
in all the areas of specialty knowledge needed for the most
effective care of clients with complex disorders (Ham, Sloane,
Warshaw, Potter, & Flaherty, 2014). An interdisciplinary
approach is particularly recommended when dealing with
specific client populations with chronic and complex condi-
tions (McKinlay, Gray, & Pullon, 2013).
Chaplain
Audiologist
Social
worker
Dentist
Orthotist
Case
manager
FIGURE 322 The rehabilitation team.
4605_Ch32_489-506 31/10/17 12:41 PM Page 495
✺ PROMOTING BEST PRACTICE
Interdisciplinary Teams
On the basis of a systematic review of the literature and the
perceptions of staff working in community-based care services
offering care for older adults in preventing admissions and
facilitating early discharge, a framework identifying characteristics
and competencies that support effective interdisciplinary team
work was developed. These characteristics include the following:
positive leadership and management attributes; communication
strategies and structures; personal rewards, training, and
development; appropriate resources and procedures; appropriate
skill mix; supportive team climate; individual characteristics that
support interdisciplinary team work; clarity of vision; quality and
outcomes of care; and respecting and understanding roles
(Nancarrow et al., 2013).
A discussion paper presents basic principles and personal
values that characterize interprofessional team-based care and
is intended to help guide clinicians, patients, administrators,
and other stakeholders in health-care seeking high-value
team-based care that focuses on the goals and priorities of
patients and their families. Four themes to guide the growth
of team-based health-care delivery are outlined in the conclu-
sion (P. Mitchell et al., 2012).
The Geriatrics Interdisciplinary Advisory Group (2006)
suggested that a team approach can also be a means of improv-
ing treatment efficiency and meeting the health needs of the
community. Although each individual profession makes a
unique contribution to rehabilitation, “it must be acknowl-
edged that it is the sum of individual team members’ contri-
butions and team collaboration that makes the greatest positive
difference in client care outcomes” (Ontario Association of
Non-profit Homes and Services for Seniors, 2000, p. 9).
Effective teamwork requires that members bring their respec-
tive specialized knowledge and skills to the situation, recognize
and appreciate the contribution of each individual member, take
part in decision making, and assume responsibility for their own
decisions and team decisions. Good communication among
team members greatly enhances the effectiveness of the overall
management plan delivery, and cooperation and coordination
among team members should be seamless. Although coordina-
tion of effort between rehabilitation team members may be diffi-
cult to achieve, evidence suggests a comprehensive rehabilitation
team positively influences outcomes for older adults (Perkins &
Moran, 2010; Stott & Quinn, 2013).
✺ PROMOTING BEST PRACTICE
Discharge Planning
An interesting case study presents an ethical analysis of a
discharge planning situation encountered in a Canadian older
adult inpatient rehabilitation setting. Ethical difficulties faced
by the interprofessional team as they attempted to balance
commitment to client safety with the client’s values and
priorities are described (Durocher & Gibson, 2010).
CHAPTER 32 ■ Rehabilitation 495
Coordinating the Rehabilitation Team
Case Management
Case management is a process that comprises a variety of
consecutive collaborative phases that culminates in ensuring
clients have access to available and relevant resources neces-
sary to attain identified goals. Key elements of the case man-
agement process include the following:
■ client identification (screening),
■ assessment,
■ stratifying risk,
■ planning,
■ implementation (care coordination),
■ monitoring,
■ transitioning, and
■ evaluation (Marfleet, Trueman, & Barber, 2013).
Case management for older adults is a central part of reha-
bilitation in many nations including Australia, Canada, Italy,
New Zealand, Sweden, the United Kingdom, and the United
States (Bernabei et al., 1998; Hébert, Durand, Dubuc, &
Tourigny, 2003; Hokenstad & Johansson, 1996; Lim,
Lambert, & Gray, 2003).
Case management is based on the assumption that
people with complex health problems need assistance in
using the health-care system effectively and efficiently.
Older adults often use multiple health-care providers and
require varied social services to help them live independ-
ently. During the course of rehabilitation, many clients
will require services from several health-care professionals.
To ensure that the correct interventions are applied in the
correct order and that complications, delays, and duplica-
tions are avoided, a large number of decisions will have to
be coordinated. This means that decisions must be made
in full awareness of many other client care issues, such as
client preferences, postdischarge resources in the client’s
home, availability of family and caregivers, community
resources, and so forth.
The case management approach appoints an individual or
a small team, who may or may not also be responsible for the
direct provision of hands-on care, to take responsibility for
guiding the client through this complex process in the most
efficient, effective, and acceptable way. Although the way the
term “case manager” is used varies around the globe (e.g.,
referring to a generic or descriptive term, a position title or
professional qualification, or a certification or credentialing),
the Case Management Society International (cmsa.org,
2008–2016) uses “case manager” to identify an individual
whose primary role is to facilitate the case management
process. Within this case management process, a case
manager navigates, as applicable, each element of the case
management process taking into consideration the client’s
individual, diverse and special needs, including aspirations,
choices, expectations, motivations, preferences and values,
and available resources, services, and supports (Marfleet,
Trueman, & Barber, 2013).
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496 PART IV ■ Service Delivery for the Aging Client

Case managers facilitate communication between health-

care providers and ensure that services are not duplicated,
while required services are provided, as a means to ensure that
case management offers a practical, one-step approach to
helping clients coordinate their care. There is no widely
agreed model of case management, and models may employ
nurses, nurse practitioners, social workers, or other health-
care professionals, such as occupational or physical therapists,
to be case managers. Case management has been applied with
success to patients in complex settings (Rosemann et al.,
2007; Sandberg, 2013). Research in countries including Italy,
the United Kingdom, and the United States has found
positive benefits to using a case management approach for
older adults, including decreased levels of institutional care,
high levels of client satisfaction, decreased functional decline
and depression, improved quality of life, decreased length of
stay, and lower levels of hospital admission rates (Dieterich
et al., 2010; Eklund et al., 2013; Gensichen et al., 2006;
Rosemann et al., 2007).

The Occupational Therapy–Physical

Therapy Partnership
The unique partnership between the professions of occupa-
tional therapy and physical therapy developed from the
growth of rehabilitation medicine after World War II. At
that time, Behm and Gray (2011) indicate the rehabilitation
movement was oriented toward helping individuals with
chronic illnesses and conditions to live productive lives and
initiated the use of the treatment team made up of profes-
sionals trained in rehabilitation.
The shared history of the professions, the common bodies
of knowledge, and the focus on rehabilitation grounded in
ongoing entry-level and continuing education experiences
anchor the occupational therapy and physical therapy part-
nership (Figure 32-3).

INTERPROFESSIONAL PRACTICE
Tele-Technology
A multifactorial, individualized, occupational and physical
therapy intervention delivered via tele-technology or in-home FIGURE 323 Physical and occupational therapists often cotreat to
visits to 65 community-dwelling older adults with new mobility achieve a client’s rehabilitation goals. (Courtesy of the Geriatric Day
devices was found to improve mobility self-efficacy irrespective Hospital, specialized Geriatric Services, Saskatoon Health Region,
of delivery mode (Sanford et al., 2006). Saskatoon, Saskatchewan, with permission.)

internationally by wide variation in availability, type, level,

Delivery Systems
Rehabilitation can be carried out across a continuum of set-
tings, such as in a hospital, an outpatient clinic, in the client’s
home, or in other community settings. In some instances,
older adults living in assisted living facilities may receive
home health services, or attend outpatient rehabilitation even
though assisted living facilities themselves do not typically
offer their own rehabilitation care. Settings are characterized
scope, and content of care provided. For example, in the
United Kingdom, rehabilitation services can be classified
under an umbrella term “intermediate care.” Intermediate
care is a range of services designed to facilitate transition
from hospital to home and from medical independence to
functional independence, and models of service can include
community assessment and rehabilitation teams, “hospital at
home,” “hospice at home,” rapid response teams, and nurse-led
units (Lees, 2004). Scope of rehabilitation services within
4605_Ch32_489-506 31/10/17 12:41 PM Page 497
each setting can vary from country to country and community
to community, with larger metropolitan communities offering
more specialized services compared to rural community set-
tings. Intensity of services ranges from one to eight hours a
day, and one to three days per week of treatment to seven days
per week of treatment. A variety of external factors, including
reimbursement (McCue & Thompson, 1995; J. M. Mitchell
& Scott, 1992), have been found to affect rehabilitation care
differentially across settings. The most thoroughly studied
aspect of older adult rehabilitation is the care setting, and
better outcomes have consistently been shown for older clients
treated in specialized units (Cohen & the GAP Committee
on Aging, 2002; Ellis, Whitehead, O’Neill, Langhorne, &
Robinson, 2011; Stuck, Siu, Wieland, Adams, & Rubenstein,
1993). Chapters in Section IV further describe service delivery
in various settings focused on care of older adults.
Acute Care
Many older adults become disabled by an acute illness such
as a stroke, fractures, or pneumonia and require emergency hos-
pital admission for medical care. Acute hospitalization is often
associated with a decrease in occupational performance, and
research has found that up to 60 percent of older hospitalized
patients experience functional decline (Bergman et al., 1997;
Boyd et al., 2009; Hébert, 1997; M. Rosenberg & Moore,
1997), up to one-third experience declines in their ability to
perform ADL, and many do return to their preadmission
level of function following discharge (Gill, Allore, Holford, &
Guo, 2004; Sager et al., 1996). In the acute care setting, med-
ical stabilization and determination of a medical diagnosis is
the priority, and management may include surgery, medica-
tion, and initiation of therapies. Due to cost factors, older
adults requiring longer term rehabilitation are usually referred
to other settings/facilities for management. Thus, a typical
route of entry to rehabilitation is through an acute-care, com-
munity-based hospital. Because length of stay is often short,
the role of the therapist in the acute-care setting is often to
assist in the identification of appropriate discharge plans, and
planning for discharge usually begins at the initial therapy visit.
Dedicated geriatric units, designed specifically to prevent
functional decline and related complications in older adults
admitted to the hospital for an acute event are known as acute
care for elders (ACE) units. A systematic review and meta-
analyses of ACEs found that this model of care, when intro-
duced during the acute illness or injury phase, had significant
beneficial effects over usual care. Benefits included reduction
in falls, delirium, functional decline, length of hospital stay,
discharge to a nursing home, and costs, as well as an increase
in the number of discharges to home (Fox et al., 2012).
Transitional Care Facilities and Units
Transitional care facilities and units provide intermediate
care or post-acute care. In the United States, skilled nursing
facilities (SNFs), subacute units, or transitional care units are
the most commonly described settings; however, they vary in
CHAPTER 32 ■ Rehabilitation 497
the degree of services provided. Medicare-certified SNF units
may be located in freestanding nursing homes or in hospitals,
although hospital units are commonly referred to as subacute,
swing bed, transitional care, or restorative care units. Clients
cannot access SNF units directly without a hospital stay.
Need for rehabilitation is a major criterion that qualifies an
individual for SNF, and although clients in SNF settings
must receive daily rehabilitation skilled services such as
physical therapy, occupational therapy, or speech-language
therapy, no time requirement for that therapy is imposed.
Clients must demonstrate measurable progress during the
duration of the stay, and thorough documentation is essential
to demonstrate the need for continued care.
Rehabilitation Units
Characteristically, geriatric rehabilitation units (GRUs) are
distinct units housed within community hospitals, freestand-
ing rehabilitation hospitals, or long-term care facilities and
are staffed by multidisciplinary teams specializing in the
management of the medical, social, physical, psychological,
and economic well-being of older adults. The philosophy of
GRUs emphasizes both the physical and emotional elements
of client care (Hoenig, Nusbaum, & Brummel-Smith, 1997).
Geriatric assessment units (GAUs) and GRUs have many
similarities, as both provide rehabilitation with an interdis-
ciplinary team trained in the care of the elderly, with attention
to medical, psychosocial, and functional issues. Management
plans are established and reviewed in regular team meetings
with therapeutic and rehabilitative teams. However, in a
GAU, there tends to be more emphasis on medical treatment
and evaluation, and rehabilitation goals are usually short
term. Within a GRU, there is a greater emphasis on longer
term rehabilitation and achieving maximal function (Wells,
Seabrook, Stolee, Borrie, & Knoefel, 2003b). In some set-
tings, for clients to be admitted to a rehabilitation unit, they
must be medically stable and able to tolerate at least 3 hours
of intervention a day, 5 or 6 days a week. As with transitional
care facilities, clients must demonstrate measurable progress
during the duration of the stay, and thorough documentation
is essential to demonstrate the need for continued care. Once
clients have maximized their rehabilitation potential, they may
be discharged home. If returning home is not feasible, then a
long-term-care facility is the typical discharge placement.
Discharge to a long-term-care facility can be predicted by the
presence of medical complications, lower functional status at
discharge from the acute facility, and severity of impaired gait
status. In long-term care, individuals may participate in less
intense therapy programs and may later be transferred to a
rehabilitation unit. As described in Chapter 33, rehabilitation
units may often be located in long-term care facilities.
Day Hospital Care and Adult Day Care Facilities
The first day hospital (a U.K. term) for older adults was
opened in the United Kingdom in 1952 (Farndale, 1961) to
augment inpatient services. The model has since been widely
4605_Ch32_489-506 31/10/17 12:41 PM Page 498
498 PART IV ■ Service Delivery for the Aging Client
applied in New Zealand, Australia, Canada, the United
States, and several European countries. Day hospitals have
served several functions, including assessment, rehabilitation,
maintenance, provision of medical, nursing, and social
services, and respite care (Brocklehurst & Tucker, 1980);
however, rehabilitation and maintenance tend to be the main
focus of most day hospitals, and rehabilitation has been
regarded as the most important function (Brocklehurst, 1995).
Adult day care (U.S. term) programs offer an alternative to
institutionalization for newly or chronically disabled adults
who cannot stay alone during the day but who do not need
24-hour inpatient care. Designed to promote maximum in-
dependence, clients usually attend on a scheduled basis, and
services may include nursing, counseling, social services,
restorative services, medical and health-care monitoring,
medication administration, well-balanced meals, and trans-
portation to and from the facility, exercise programs, field
trips, recreational activities, in addition to occupational, phys-
ical, and speech therapy. In the United States, such programs
may serve individuals with physical limitations but in addi-
tion, many serve individuals with cognitive impairments
(London, Pike, Korte, & Goehrig, 2016). Day hospitals can
also provide respite services for family members and care-
givers. The Program of All-Inclusive Care for the Elderly
(PACE; Poku, 2015) is a U.S. federally supported project
designed to increase the availability of day care programs, as
an alternative to institutionalization. A variety of services are
provided, including distribution of prescription drugs, physi-
cian services, rehabilitation services, personal care, socializa-
tion and leisure activities, hospitalization, and nursing home
care. Additionally, case management, extended home care,
and respite care may be provided. Day services have been
found to decrease primary-caregiver stress and improve psy-
chological function (Fields, Anderson, & Dabelko-Schoeny,
2014; Zarit, Stephens, Townsend, & Greene, 1998), and
evidence suggests that day hospital care appears to be an
effective outpatient service for older people, but no more
effective and possibly more expensive than other forms of
comprehensive care for older adults (Forster, Langhorn, &
Young, 1999; L. Brown et al., 2015).
Home Health and Domiciliary Care
Home health care is provided in the client’s residence and is
recognized as an increasingly important alternative to hospi-
talization or care in a nursing home for older adults who do
not need 24-hour professional supervision. Home health
care is described in detail in Chapter 31. A variety of health
services can be provided in a home health-care program, and
it has been found that older adults receiving rehabilitation
in their home (compared with hospital) took more initiative
in expressing and determining their own goals (von Koch,
Wottrich, & Holmvist, 1998), had equal or higher in func-
tion, cognition, and quality of life (Stolee, Lim, Wilson, &
Glenny, 2012), and reported higher satisfaction (Stolee et al.,
2012).
Outpatient and Ambulatory Care
Outpatient rehabilitation can be provided in various settings,
including hospitals, free-standing clinics, private practices,
and in comprehensive outpatient rehabilitation facilities
(CORFs). CORFs offer a more comprehensive array of
services than typical outpatient rehabilitation settings and
utilize interdisciplinary team goals (Capilouto, 2000). Use of
interdisciplinary teams in outpatient settings has been shown
to improve functional outcomes and increase patient satis-
faction with care. Toseland and colleagues (1996) compared
frail older patients assigned to outpatient geriatric assessment
and management with patients receiving usual outpatient
primary care. The patients receiving team assessment and
management reported higher satisfaction with the services.
Outpatient rehabilitation requires that evaluation effectively
select those individuals who have potential for improvement
(Rodriguez & Goldberg, 1993), and a description of various
community agencies can be found in Chapter 29.
Evaluation
Chapter 27 provides extensive detail regarding the purposes
of assessing older adults, a philosophy of client-centered and
contextually based assessment, issues specific to older adults
when considering assessment, and different methods used
to assess older adults. Within a rehabilitation context, a
standardized and comprehensive assessment is important to
ensure the systematic evaluation of the older adult, the iden-
tification of relevant problems requiring further investigation
and treatment, the facilitation of care planning, and collec-
tion of data to allow quality improvement and research
to be conducted (Royal College of Physicians and British
Geriatrics Society, 1992). Although a systematic screening
assessment is useful to identify potential problems that may
be modified, findings of screening assessments indicate the
need for further evaluation and assist in directing a more
comprehensive assessment. In rehabilitation settings, a com-
prehensive geriatric assessment (CGA) tends to be the norm
and is often viewed as an approach designed to improve
the health of the older adult and defines care for this client
population (Rubenstein, 2004). Identifying the factors that
influence function and occupational performance problems
and developing an individualized management plan can be
challenging. Since its development in the United Kingdom,
CGA has been introduced and adopted in many other
countries and is conducted in a variety of settings, such as
hospital, home, and nursing homes, and with varying pro-
gram types and levels of intensity, such as hospital geriatric
evaluation units (GEUs), geriatric assessment units (GAUs)
or geriatric evaluation and management services (GEMs),
acute care for the elderly units, hospital consultation teams,
such as Inpatient Geriatric Consultation Service (IGCS)
team, a multidisciplinary team that assesses, discusses, and
recommends a plan of treatment for frail older adults in
hospital, outpatient brief screening assessment programs, or
4605_Ch32_489-506 31/10/17 12:42 PM Page 499
intensive in-home assessment and case management programs
(Rubenstein, 2004).
Comprehensive geriatric assessment is a multidimen-
sional, interdisciplinary process that is used to determine an
older adult’s medical, psychosocial, functional, and environ-
mental needs resources and problems and is linked to an
overall plan for management and follow-up. CGA helps
health-care professionals determine and prioritize problems,
develop long- and short-term plans of care, and implement
rehabilitation strategies that optimize management, improve
function and outcomes, prevent further deterioration, optimize
living location, decrease unnecessary health-care resources
and service use, arrange long-term case management, and
prolong survival of older adults. CGA has several major
measurable dimensions, usually grouped into the domains
of (a) physical health (e.g., traditional history and physical
examination, medical assessment, nutritional assessment,
medication review, laboratory data, disease-specific severity
indicators, and preventive health practices); (b) functional
status (e.g., ADL, IADL, and other functional status as
mobility and quality of life); (c) psychological health (mainly
cognitive and affective status); and (d) socioenvironmental
parameters (e.g., social networks and supports, economics,
and environmental safety, adequacy, and needs) (Rubenstein,
2004).
✺
PROMOTING BEST PRACTICE
Comprehensive Geriatric Assessment
A systematic review of hospital-based Comprehensive Geriatric
Assessment (CGA) examined data from 22 randomized controlled
trials with more than 10,000 participants from six countries. Older
adults who received CGA compared with general medical
care were more likely to be alive and in their own homes after
12 months and have improved cognition and were less likely
to be institutionalized after acute hospital care, deteriorate, or
die (Ellis et al., 2011).
Assessment Instruments
Rehabilitation outcomes for older adults not only should
measure individuals’ performance in functioning domains but
should also evaluate the extent to which older adults partici-
pate in valued life activities. There are numerous widely known
and widely used standardized tools that can be used to assess
the older adult in a rehabilitation setting. In the United States,
some assessments are mandatory, such as the Long-Term
Care Minimum Data Set, for clients admitted to certain set-
tings (see Chapter 31). ADL and IADL are carefully docu-
mented in a CGA and in the older adult rehabilitation setting.
As well, tests of specific physical and psychosocial function
are also commonly used (e.g., gait and balance, cognitive
status, depression, quality of life) and are essential assessments
as part of a CGA. Commonly used assessment instruments
are found throughout this text and via the online ancillary
materials.
CHAPTER 32 ■ Rehabilitation 499
Personal and Environmental Factors
to Consider
Assisting older adult clients in reaching their goals and opti-
mizing service delivery within the current constraints of the
health-care system requires an understanding of the factors
that facilitate or impede the rehabilitation process. Most
rehabilitation studies have focused on demographic vari-
ables, mental status, mood, and functional status on admis-
sion as predictors of rehabilitation outcomes. Age (Mossey,
Mutran, Knott, & Craik, 1989), evidence of social support
(Cummings et al., 1988; Magaziner, Simonsick, Kashner,
Hebel, & Kenzora, 1990), admission function (Cameron,
Schaafsma, Wilson, Baker, & Buckley, 2012; Resnick &
Daly, 1998), and interruptions in the rehabilitation process
(Heinemann, Linacre, Wright, Hamilton, & Granger, 1994)
have been found to be statistically significant predictors of
function following rehabilitation. Specifically, those who are
younger; have better function on admission; are able to com-
plete their rehabilitation course without interruptions due to
acute illness, surgery, or financial problems; and are more
likely to have higher function at discharge from a rehabilita-
tion program. In addition, cognitive status and depression
have been found to be significantly correlated with lower
levels of functional ability at the time of discharge from
rehabilitation (Cameron et al., 2012; R. E. Harris, O’Hara,
& Harper, 1995; Resnick & Daly, 1998). It is important to
note that most study findings are mixed and jointly the pre-
ceding predictor variables only account for a small portion of
the variance (Patrick, Knoefel, Gaskowski, & Rexroth, 2001).
Personal Factors That May Influence
Rehabilitation
Frailty
An important factor that may determine rehabilitation out-
comes is frailty. Frailty has been discussed in Chapter 17. A
key factor associated with rehabilitation is that frailty implies
a diminished capacity to perform ADL (I. Brown, Renwick,
& Raphael, 1995). It encompasses deterioration in multiple
organ systems, including musculoskeletal, cardiovascular,
metabolic, and immunologic systems, which results from and
contributes to declining physical function (Bortz, 2002).
Motivation
Poor rehabilitation outcomes are often attributed to the lack
of motivation on the part of the client (Stoedefalke, 1985).
“When people say that someone is not motivated, they usu-
ally mean that they do not understand why that person is
acting a certain way, that they do not condone his or her
actions, or that his or her actions go against sociocultural
norms” (Kemp, 1988, p. 42). Motivation has been found to
be important in older adults’ recovery from disabling events
(Popović, Kostić, Rodić, & Konstantinović, 2014) and in
older adults’ continued performance of functional activities
4605_Ch32_489-506 31/10/17 12:42 PM Page 500
500 PART IV ■ Service Delivery for the Aging Client
(Resnick, 1998, 1999). There are numerous theories of
motivation that try to explain why people behave as they do,
what sustains and directs a person’s attention, and what
arouses and instigates behavior, gives direction or purposes
to behavior, continues to allow behavior to persist, or leads
one to choose or prefer a particular behavior. Motivation
should not be confused with adherence, the extent to
which a client follows a health-care professional’s advice or
recommendations.
One theory used to explain why people behave the way
they do is the theory of self-efficacy (Bandura, 1977, 1986).
Self-efficacy refers to the state of belief of one’s ability
(abilities), which in turn will affect one’s belief about future
accomplishments. In other words, personal evaluations of
one’s own performance capabilities on a particular task or
activity will affect one’s motivation to perform that task and
will influence the outcome expectations related to the task
or activity. A very interesting qualitative study used semi-
structured interviews to examine how self-efficacy and
outcome expectations are strengthened and how these expec-
tations influenced motivation and behavior in 77 older adults
(55 females, 22 males) in a rehabilitation program (Resnick,
2002). Some of the key findings of this study and sample
strategies for addressing key areas are summarized in the
online ancillary materials.
Depression
Depression in older adults is common, is associated with
functional disability, tends to be undertreated, and can be a
significant barrier to rehabilitation (Fauth Gerstorf, Ram, &
Malmberg, 2014). Depression is associated with diminished
coping mechanisms that can negatively affect outcomes of
rehabilitation (cf. Stoilkova, Wouters, Spruit, Franssen, &
Janssen, 2013). The therapist must not ignore the possibility
of undiagnosed depression being present before or during the
rehabilitation experience.
Cognitive Status
Older adults with cognitive impairments often have problems
with being admitted to or reimbursed for rehabilitation
services (Department of Health & Human Services, 2001;
Lenze et al., 2007), most likely related to evidence that
suggests the odds of successful rehabilitation outcomes in
those with cognitive impairments to be lower than those
without dementia (Cameron et al., 2012). As described in
Chapter 12, people with dementia are capable of learning,
and rehabilitation should certainly be considered for those in
the early stages of a disorder causing cognitive impairment.
Strategies for supporting function in individuals with cogni-
tive impairment are discussed in Chapter 12. Although sever-
ity of cognitive impairment has been found to be related to
higher mortality and less successful return to independent
living, the evidence related to cognitive impairment and pos-
itive rehabilitation outcomes is equivocal. For example, some
studies have found cognitive impairment not to be associated
with rehabilitation efficiency or daily functional gains (Gillen,
Tennen, McKee, Gernert-Dott, & Affleck, 2001; Paker,
Buğdayci, Tekdös, Kaya, & Dere, 2010), and others have found
cognitive impairment to be associated with worse rehabilita-
tion efficiency (Benedetti et al., 2015; Heruti, Lusky, Barell,
Ohry, & Adunsky, 1999; Zwecker et al., 2002).
Comorbidities
As discussed previously, many older adults have one or more
chronic conditions. Physical and psychologic comorbidities
are weakly associated with outcomes such as rehospitalization
following rehabilitation, and more predictive when functional
status is also considered (Kumar et al., 2017). Primary reha-
bilitation diagnoses tend to influence the effects of medical
comorbidities on rehabilitation outcomes (Patrick et al.,
2001).
Environmental Factors That May Influence
Rehabilitation
Family Members and Caregivers
Family members and caregivers are an integral part of the
care team. They know the older adult and can often provide
additional information about the older person’s perspectives,
habits, behaviors, and needs; can provide emotional and
instrumental support; and can facilitate adherence to treat-
ment recommendations. Conflicts may arise if the goals of
the older adult and family and caregivers differ. Chapter 24
discusses strategies for working with families. Full-time care
of an aging spouse or relative by a spouse who may also have
a chronic illness or disability can be stressful and may increase
if caregiving is required over a long period of time (Chen,
Chen, & Chu, 2015). Other caregivers are part of the sand-
wich generation, a generation of people who are caring for
their aging parents while supporting their own children. For
example, in the United States, almost 50 percent of persons
in their 40s and 50s have parents over age 65 and are also
raising children or supporting grown children financially
(Parker & Patton, 2013). Williams (2004) noted that these
individuals are often dealing with the conflicting demands
of raising children and caring for aging parents or other
relatives.
If the family member is the older person’s chief caregiver,
he or she may be depressed, anxious, and need support serv-
ices as well. Psychological and physical health problems are
common in caregivers (Longacre, Wong, & Fang, 2014),
caregiver burden can be high, and burnout can and does
occur. Thus, in addition to the older client’s needs, caregivers’
needs require special attention and assessment, and it is
important to provide caregivers the resources they need.
Living Arrangements
Whether an activity limitation becomes a participation restric-
tion or not depends on the physical and social environments
a person inhabits. For some older adults, there is an increased
4605_Ch32_489-506 31/10/17 12:42 PM Page 501
likelihood of living alone, with limited support systems. The
effects of living arrangement on rehabilitation outcomes have
not been sufficiently researched and the evidence is unclear.
Assessment and adaptation of the home environment are
essential components of overall rehabilitation management
and may allow the older adult to age in place.
Therapist–Client Interaction
Young (1996) describes rehabilitation management as being
hard or soft (Figure 32-4). Hard interventions are those that
are more observable, objective, and for which costs can be
estimated, such as hands-on treatment or direct management
of client problems. Soft interventions are those that are not
always easily evident or recognizable, but are equally, if not
more, important and involve great skill. These skills are the
therapeutic skills related to interpersonal communication and
encompass the development of a relationship and trust, all of
which embody the therapist–client interaction. The therapist
acts as a facilitator, assisting the older client to make the most
appropriate decisions regarding care. Effective communica-
tion skills, a nonjudgmental attitude, respect for the client’s
wishes and priorities, allowing time for the client to express
his or her fears and concerns, and being supportive and encour-
aging are key aspects of being able to establish an effective
therapeutic relationship.
Rehabilitation for Older Adults—The
Evidence
There is general consensus regarding the benefits of rehabil-
itation, including preventative rehabilitation for older adults.
Although the cost-effectiveness of some kinds of interven-
tions has yet to be determined and continues to be debated,
studies dating back over the past 4 decades have found that
rehabilitation for older adults is associated with improved
functional abilities and decreased nursing home placement,
even for individuals with severe disability or advanced age
(Ellis et al., 2011; Evans, Connis, Hendricks, & Haselkorn,
1995; R. E. Harris et al., 1995; Liem, Chernoff, & Carter,
Advice
Education/information Encouragement
Counseling Negotiation
Soft
Support
rehabilitation
Listening
Hard
Pharmacotherapy rehabilitation Assistive
devices
Therapy (e.g., Adaptive
physiotherapy, equipment
occupational therapy,
speech)
FIGURE 324 Hard and soft rehabilitation. (Adapted from Young, J.
[1996]. Rehabilitation and older people. British Medical Journal, 313,
677–681.)
CHAPTER 32 ■ Rehabilitation 501
1986; Penington, 1992; Reutter-Bernays & Rentsch, 1993).
As discussed in Chapters 9 and 13, among other chapters,
research has determined that exercise and other specific occu-
pational and physical therapy interventions are important for
maximizing physical function and for reducing falls. Reha-
bilitation has been found to positively affect physical impair-
ments and functional abilities, although age affects the extent
of recovery. For example, Street, Wong, Rotondi, and Gage
(2013) found that younger individuals have better outcomes
from joint replacement than older adults. Meiner and col-
leagues (2015) noted that younger individuals have better
functional outcomes from stroke than those who are older.
However, Meiner and colleagues emphasize that many older
individuals often regain sufficient function to return to inde-
pendent living. Even individuals with cognitive impairments
benefit from rehabilitation through improved functional
performance and an increase in discharge rates to home
(Goldstein, Strasser, Woodard, & Roberts, 1997; Hamman,
1997). More recent systematic and meta-analysis reviews
of rehabilitation research have confirmed the benefits of
comprehensive multidisciplinary assessment and rehabilita-
tion for older adults.
✺
PROMOTING BEST PRACTICE
Impact of Multifactorial Care
Older adults who received multifactorial care and rehabilitation
compared with those who did not were found to have decreased
nursing home admissions, number of falls, and acute hospital
admissions. Death rates were not found to be reduced (Beswick
et al., 2008).
A comprehensive overview of the evidence is beyond the
scope of this chapter, and thus the authors strongly recom-
mend that readers refer to other chapters and explore the
literature related to rehabilitation of older adults with health
conditions, impairments, activity limitations, and participa-
tion restrictions of particular interest or related to specific
settings of interest.
SUMMARY
This chapter has reviewed a broad range of issues essential to
the rehabilitation of older adults. Understanding the demo-
graphics of older adult disability and the unique aspects of
rehabilitation for this population group sets the scene for
practice in this area. Rehabilitation to improve or maintain
functional and occupational performance can be effective for
many older adults. Effective management and care begin with
evaluation that includes screening, comprehensive assess-
ment, and careful selection of assessment instruments, regard-
less of setting. To assist clients, continuity of care can be
better facilitated if therapists have a practical understanding
of rehabilitation delivery systems, reimbursement issues,
practice management concerns, and the unique aspects of
rehabilitation in older adults. Personal and environmental
4605_Ch32_489-506 31/10/17 12:42 PM Page 502
502 PART IV ■ Service Delivery for the Aging Client
factors should not necessarily rule out whether an older per-
son can participate in rehabilitation but need to be carefully
considered during the evaluation process and when planning
interventions and deciding on the appropriate rehabilitation
setting. The evidence strongly suggests that rehabilitation is
beneficial for a variety of diagnostic conditions that affect
older persons.
CASE STUDY
Albert King is a 68-year-old man with a grade 4 glioblas-
toma. He has a rapid-onset dense left hemiplegia and is
being seen by home care nursing, physical therapy, and
occupational therapy under the palliative care program. In
June, a craniotomy was done to debulk the tumor. After
surgery he discharged himself, against medical recommen-
dations that he stay for inpatient rehabilitation. On his
arrival home, an urgent request was sent to home services
to clarify his new mobility/transfer status for the home
support workers (HSW). The family members were
hoping for intensive in-home rehabilitation and in fact ex-
pected Mr. King to walk again. Examination revealed
grade 1 to 2 strength in scattered leg muscles and a flaccid
left arm. Mr. King was unable to sit unsupported. Stand-
ing pivot transfers were maximum lift × 2, so use of the
mechanical lift was recommended. These findings were
essentially unchanged from Mr. King’s preoperative status.
Intensive rehabilitation is not feasible, but the therapist
agreed to teach the HSW range of motion and facilitation
exercises and see him weekly for ongoing reevaluation.
Over the succeeding 3 months, Mr. King has been seen
eight times, and there has been no motor or sensory recov-
ery. There have been very small functional gains: Mr. King
is now able to roll to his weak side in bed using the
bedrail. Mr. King has variable wheelchair sitting tolerance
(10–60 minutes). Last week, Mrs. King asked about admis-
sion to a rehabilitation facility to capitalize on these gains.
Questions
1. Tell this story from the person’s perspective—the
therapist, the client, and the wife/family member.
Give each story a title.
2. What else do you need to know?
3. What advice would you like to give this circle
of care?
4. Is the scenario describing rehabilitation? If yes, why?
If not, why not?
Critical Thinking Questions
1. In your own words, describe rehabilitation.
2. What are the unique features of rehabilitation for
older adults?
3. What are the differences among a multidisciplinary
team, an interdisciplinary team, and a transdiscipli-
nary team?
4. What are the benefits of using a team approach in
older adult rehabilitation?
5. Why is it important to use a comprehensive
approach when assessing an older adult?
6. Discuss at least five strategies that may be beneficial
in motivating an older adult.
7. Compare and contrast the various rehabilitation
settings.
8. Consider the following two client cases and answer
the following questions:
a. What personal and environmental factors may
influence rehabilitation for Mr. Williams and
Mrs. Peters?
b. Describe the potential continuum of rehabilita-
tion settings for Mr. Williams and Mrs. Peters.
Client 1: Mr. Williams
Mr. Williams is a 77-year-old man who retired
from teaching at age 65. He remains active in an
informal group of retired teachers who meet weekly
for breakfast. This group also organizes a monthly
dinner or special event to which spouses and guests
are invited. He has been an avid reader and sports fan
throughout his life and maintains participation in
retirement. His wife is also a retired teacher and par-
ticipates in some of these activities. They own their
own home and continue to manicure the landscaped
yard they developed over 30 years in this location.
Their three children are all self-supporting and live
out of state. Mr. Williams had been in relatively
good health during retirement. He has experienced
an intermittent need for medication adjustments for
his hypertension. Over the past 1 to 2 years, he has
rested a bit more often, but generally has maintained
participation in his activities. Two days ago he was
admitted to the hospital via the emergency depart-
ment. He was diagnosed with a stroke affecting
his left side.
Client 2: Mrs. Peters
Mrs. Peters is a 63-year-old woman who had total hip
replacement surgery because of progressively increasing
pain, ADL restrictions, and functional mobility prob-
lems resulting from osteoarthritis. She deliberated for
several months before deciding to have the surgery.
Mrs. Peters is a financial planner and has a busy practice
with several clients who depend on her service. She is
active in gardening and enjoys attending the activities
of her grandchildren with her husband. The surgery
was routine.
4605_Ch32_489-506 31/10/17 12:42 PM Page 503
Acknowledgment
“My Uncle Alphonse” is based on the experiences of a family
member of the second author. The scenario of Mr. King is based
on an actual real-life patient scenario, and was originally developed
from the clinical experience of a learner in the post-professional
MSc (Rehabilitation Science) program at McMaster University.
It has been modified and used with permission.
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“If athelifetime…follows a path, there is a need for a leader. In the progressive phase where
path leads upward to greater skill, the leader is a teacher; in the regressive phase
when tasks need simplifying the leader is a caregiver or therapist.
LEARNING OUTCOMES
By the end of this chapter, readers will be able to:
1. Name and describe critical legislation that created the
modern nursing home.
2. Describe the types of residents typically found in
long-term care settings today.
3. Describe the occupational needs of residents in
long-term care.
4. Explain principles of occupational therapy as they
relate to occupational performance in long-term care
settings.
5. Discuss principles of physical therapy in long-term care
settings.
6. Discuss interdisciplinary care in nursing home settings.
7. Discuss reimbursement and regulatory issues involved
with delivering occupational therapy and activities services
to residents in long-term care.
8. Describe the application of strength-based approaches in
long-term care.
Clinical Vignette
Arthur Rogers is a 73-year-old former machine worker who
retired at age 60. He had lived with his wife of 51 years in a
small two-story bungalow until 3 weeks ago, when he expe-
rienced a cerebrovascular accident that left him with right
hemiplegia and expressive aphasia. He spent a week in an
acute care facility and then was transferred to a rehabilitation
center. He made little progress and has now been moved to
a long-term care facility.
1. What are some possible reasons Mr. Rogers might not
have been discharged to his home?
2. Are any of those reasons factors that might be modifi-
able to enable him to return home?
3. What issues would be most critical in helping Mr. Rogers
adjust to his new circumstances?
CHAPTER 33
Long-Term Care
Joshua Greene
—Barbara B. Dreher, 1997
”
T his chapter considers occupational performance in
long-term-care settings. It describes how the nursing
home industry has been changed by federal regulations in the
past 30 years and provides a description of typical nursing
home residents. This is followed by a discussion of the role
of occupational performance in the nursing home setting.
In particular, it emphasizes the ways in which interventions
to enhance performance skills are implemented, regulated,
and reimbursed. The chapter uses the term “occupational
performance,” which is consistent with occupational therapy
(OT) usage. It is important to keep in mind that physical
therapy (PT) is equally important to quality of life, and
the chapter considers the ways in which PT conceptualizes
resident needs, evaluates skills, abilities, and deficits, and
provides interventions to enhance quality of life.
The next section of the chapter specifies some recent
innovative trends in activities implemented in long-term care,
including a discussion of how to use activities as interventions
and mechanisms for rehabilitation in long-term care. The
chapter concludes with a summary and a depiction of chal-
lenges still facing implementation of PT and OT as well as
occupation-based programming in long-term care.
The chapter focuses primarily on long-term care in the
United States. Because of the wide range of types of long-term
care and the centrality of specific government and third-party
payer regulations, it is beyond the scope of a single chapter to
cover long-term care around the globe. In some countries,
long-term care facilities are rare either because economic
circumstances make it impossible to afford such care or because
families feel strongly about providing care themselves. In other
countries, an array of long-term care options may provide
alternative models worthy of consideration for implementation
in the United States. Certainly, as the population ages world-
wide, options for ensuring adequate care for elders at the end
of their lives will become increasingly important.
Long-term care has come to mean much more than just
nursing home care (R. A. Kane & Cutler, 2015). There is
507
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508 PART IV ■ Service Delivery for the Aging Client
increasing emphasis on consumer choice and preference, so
that an array of community, assisted-living, and home health
programs have emerged to address the needs of individuals
who need ongoing relatively intensive support as their
abilities wane. Many of these kinds of programs have been
described in previous chapters. The emphasis here is on long-
term care as provided in nursing home settings.
In general, nursing home care can be thought of as falling
into three main categories: skilled, which provides high-level
medical care immediately after a hospitalization (this includes
subacute and some ventilator care); rehabilitative, which
includes stays of several weeks to several months during
which time the individual is expected to improve and, prob-
ably, to return to a less-restrictive environment; and custodial
care, in which the home aspect of nursing home care is
most prominent (note that “custodial care” is the accepted
Medicare term for long-term residential care; medicare.gov,
n.d.). There are also residential alternatives such as assisted
living and community resources such as adult day centers that
provide less-restrictive care.
Evolution of the Nursing Home
The nursing home industry in the United States has been in
a state of change since 1965, when the health entitlement
programs Medicare and Medicaid were created. These pro-
grams provided financial resources for nursing home care and
served as the impetus for tremendous growth in the nursing
home industry. The population of elderly adults in nursing
homes in the United States increased by 55 percent from
1970 to 1980, and by another 29 percent from 1980 to 1990
(Aronson, 1999). In 2005, approximately 1.5 million persons
over age 65 lived in nursing homes (National Center for
Health Statistics, 2005). In 2012, there were approximately
8 million Americans receiving long-term care services either
in institutional or community settings (Harris-Kojetin,
Sengupta, Park-Lee, & Valverde, 2013). Of these, about
1.4 million were residents of nursing homes and another
700,000 in residential care communities (Harris-Kojetin et al.,
2013; State Health Facts, 2012).
Fifteen years after Medicare and Medicaid were enacted,
Unloving care was published (Vladeck, 1980). This was the
first systematic evaluation of nursing homes and nursing
home policy. Its findings revealed that nursing homes were
places where nurses spent little time in direct patient care and
physicians seldom visited, and residents were physically and
chemically restrained. Residents’ rights were limited, the
environment often smelled of urine or disinfectant, and there
were few if any meaningful activities available to residents.
The Institute of Medicine’s 1986 report, Improving Quality
of Care in Nursing Homes, and the Omnibus Budget Recon-
ciliation Act (OBRA) of 1987 began a process of change in
nursing home culture and expectations (Institute of Medi-
cine, 1986; OBRA, 1991). This occurred through creation
and enforcement of regulations emphasizing consistent
quality of care, quality of life, residents’ rights, and develop-
ment of a standardized assessment tool, called the Resident
Assessment Instrument (RAI), which included the minimum
data set (MDS; Hawes, Morris, et al., 1997; Hawes, Phillips,
et al., 1997; Mor et al., 1997; Phillips et al., 1997). Nursing
homes were now being held accountable for adhering to
national standards of care. This trend has continued with
the enactment of the Affordable Care Act (Henshaw &
Richards, n.d.). The ACA emphasizes nursing home quality,
with provisions for additional, more transparent, reporting
of quality measures, including requirements to enhance
nursing home websites.
Legislation and Regulation
Medicare and Medicaid
The majority of nursing home care in the United States is
paid for through Medicare and Medicaid (CMS, n.d.).
Medicare covers up to 100 days of skilled nursing care and
requires that the nursing home placement be preceded by a
hospitalization. Medicaid is the primary source of longer
term coverage, particularly when there is no immediate
precipitating medical trigger and the care is deemed “custo-
dial.” For example, Medicaid would be more likely to pay for
long-term care for an individual who has a cognitive impair-
ment that is likely to worsen over time. Some individuals
can manage to pay privately or through personal long-term
care insurance. But the cost for nursing home care averaged
$220 per day for a semiprivate room in 2015 (Genworth,
2015), making it difficult for most individuals and families
to cover the cost of care.
As you’ve seen in Chapters 3, 31, and 32, both Medicare
and Medicaid come with significant regulations. We focus
here on some specific regulations that address long-term
residential care.
MDS 3.0
An important starting point for understanding how Medicare
and Medicaid regulate nursing home care is to review the
assessment and reporting requirements. The MDS is com-
pleted for each resident upon admission to a facility. It is also
administered when there is a change in a resident’s status
(e.g., when a resident must be hospitalized). Even without a
change in status, the MDS is completed on a quarterly basis
for all residents of skilled nursing facilities (SNFs). The most
current version is MDS 3.0, which became effective in the
fall of 2010. MDS 3.0 requires use of assessments and inter-
views to develop comprehensive care plans (support) and
accurate coding, as the MDS directly impacts reimbursement
for residents whose care is being covered by Medicare Part A.
The MDS is a survey, with most items rated on a “present
or absent” or on a Likert scale. However, CMS reminds those
administering the instrument that probes may be appropriate
as the goal is to fully understand the individual’s status and
4605_Ch33_507-520 31/10/17 12:41 PM Page 509
needs. Section O of the MDS involves “Therapy Supplement
for Medicare PPS.” Items assess the amount of recreational
therapy provided over the past 7 days, as well as the amount
of physician-ordered therapies such as OT, PT, or speech
pathology services. Specific details of the MDS can be found
at the Centers for Medicare and Medicaid Services (CMS)
website (2014).
The MDS was designed to screen for residents’ problems
and also for abilities and preferences. When particular patterns
of MDS item scores are obtained, this sets off a triggering
mechanism that should lead to additional information gather-
ing. The MDS 3.0 has replaced the previous resident assessment
protocols (RAPs) with care area assessments (CAAs). It also
encourages the use of validated discipline-specific assess-
ments, rather than one developed for the MDS (Berger,
2014). After examining what items triggered a CAA for
a resident, an interdisciplinary team develops a care plan.
Note that some triggers focus on rehabilitation potential,
for example, if a resident expressed an interest in increased
independence. All CAA potentially could benefit from
interventions with input from rehabilitation staff. However,
areas such as activities of daily living (ADL) functional/
rehabilitation potential, activities, cognitive loss, communica-
tion, and behavioral symptoms are especially salient areas
where rehabilitation professionals could provide meaning-
ful input in care plan development, implementation, and
evaluation.
MDS 3.0 also requires interviews promoting a client-
centered approach by having the resident directly involved
in the assessment process (Berger, 2010). Residents are
interviewed to obtain information about cognitive patterns
(Section C), mood (Section D), preferences for customary
routines and activities (Section F), and pain (Section J). Data
from the MDS define what are called Resource Utilization
Groups (RUGs; Bowblis & Brunt, 2014). These groups
reflect the intensity of service needed and thus the amount
of payment that will be provided. The current system is the
RUG-IV. It defines three types of treatment minutes: individ-
ual, concurrent, and group, each with its own criteria. The
criteria require identification of clinical complexity, behavioral
factors, and physical factors and define the complexity of care
required. Medicare rules require more frequent administra-
tion of the MDS for residents whose care it is covering
compared with those whose care is paid by other sources.
A new classification system, called the Resident Classifi-
cation System (RCS-1) is currently under consideration
(cms.gov, 2017). This system, if adopted, would create a
payment structure based on residents’ clinical presentation,
without consideration of therapy minutes. As is typical of
such reviews and potential revisions, it is likely that the guide-
lines will change based on input.
The Omnibus Budget Reconciliation Act of 1987
In addition to Medicare and Medicaid, other legislative ini-
tiatives, most notably the Omnibus Budget Reconciliation
CHAPTER 33 ■ Long-Term Care 509
Act of 1987 (OBRA), focused on changing society’s perception
of the aging process and stereotypes regarding older adults.
In the nursing home industry, a change began occurring in
the basic philosophy regarding the type of care to be deliv-
ered. It is no longer deemed acceptable to house older adults
in settings where care is limited to sheltering and feeding
them. Instead, there has been growing concern about ensur-
ing good quality of life through environmental interventions,
a philosophy of control and choice, and both specialized and
routine service capacity (R. A. Kane & Cutler, 2015).
OBRA introduced a wellness philosophy embracing the
concept that the older adult possesses numerous capabilities
or abilities and should be treated with dignity and respect.
OBRA developed new standards of care as well as new survey
and enforcement procedures. The Quality Indicators Survey
was created in 2007 (Lin & Kramer, 2013). It was necessary
to develop objective standards to ensure consistent delivery
of adequate care. The survey process became oriented toward
functional outcomes, objectively assessing issues such as
the prevalence of weight loss, staff training standards, and
competency of staff, while subjectively assessing quality-
of-life issues such as privacy and resident satisfaction. Lack
of adherence to the legislated standards created immediate
sanctions, such as fines, for facilities that were out of com-
pliance. The new standards of care challenged nursing home
administrators and caregivers to change their paradigm for
care delivery and begin redefining the concept of long-term
care and its organizational structure.
Nursing home care improved after the inception of OBRA.
For example, use of physical restraints decreased from
21 percent in 1991 to less than 5 percent in 2007 according
to data collected by the CMS (2008). There was also a decrease
in chemical restraints. Restraint reduction is effective when
undertaken in a multidisciplinary fashion and has multiple
benefits for long-term care residents (Köpke, et al., 2012).
The OBRA ’87 legislation provides owners and operators
of long-term care facilities latitude in the implementation
of the regulations. For example, the federal OBRA laws
mandate that for ongoing activities, “The facility must pro-
vide for an ongoing program of activities designed to meet,
in accordance with the comprehensive assessment, the inter-
ests and the physical, mental and psychosocial well-being of
each resident” (OBRA, 1991, Tag number F248).
F-Tag 248—Activities was updated in 2006 to refine
the definition of activities by including “any endeavor, other
than routine ADLs in which a resident participates that is
intended to enhance his sense of well-being and to promote
or enhance physical, cognitive and emotional health” (n.p.).
Opportunity now exists for multiple organization depart-
ments to be a part of the individualized programs. So a nurse
might read to a resident, certified nursing assistants (CNAs)
may help residents with jigsaw puzzles, or a member of the
maintenance staff might take a restless resident with them on
night rounds. Finally the term “age appropriate” was replaced
with person appropriate. SNFs have altered their traditional
models, including enhancing environments and providing
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510 PART IV ■ Service Delivery for the Aging Client
increased personal attention, food choice, and opportunity
for engagement (Shippee, Henning-Smith, Kane, & Lewis,
2013).
According to the federal regulations that have remained
unchanged since 1991 (Legal Information Institute, n.d.),
the activities program must be directed by a qualified profes-
sional who meets the following criteria:
1. is a qualified therapeutic recreation specialist or an
activities professional who—
a. is licensed or registered, if applicable, by the state
in which practicing; and
b. is eligible for certification as a therapeutic recre-
ation specialist or as an activities professional by a
recognized accrediting body on or after October 1,
1990; or
2. has 2 years of experience in a social or recreational
program within the past 5 years, one of which was full
time in a patient activities program in a health-care
setting; or
3. is a qualified occupational therapist or occupational
therapist assistant; or
a. has completed a training course approved by the
state (OBRA, 1991).
State Regulations
In addition to the numerous federal guidelines regulating
nursing homes, individual states have established their own
policies (University of Minnesota, 2009–2011). Among the
areas that are often governed by state law are qualifications
for nursing home administrators, licensing and inspection of
facilities, admission rules, resident rights, programming, and
a host of other factors. So, for example, in North Dakota,
nursing home administrators are required to have 20 contin-
uing education credits each year, whereas in Washington, the
requirement is 36 hours every 2 years. Similar differences can
be found in every aspect of nursing home management and
programming, extending to building codes, furnishings,
staffing, and programming.
Despite the numerous regulations in place, or perhaps
because of them, care can be fragmented, and important
elements of quality care may be overlooked. As R. L. Kane
(2015) noted, “the [long-term care] system is not what any-
one would have designed. It has grown in fits and starts with
one eye on efforts toward improving clients’ function and the
other on market opportunities, all done in the context of
heavy regulation” (p. 297). Thus, quality care is dependent
on careful planning by staff to maximize quality of life for
residents.
Models of Care
In the context of the complex regulations already described,
it is important to keep in mind that the goal of care, and of
the regulations, is to enhance the well-being of nursing home
residents. An effective model for conceptualizing care empha-
sizes the environment, philosophy, and service capacity of
the long-term services (R. A. Kane & Cutler, 2015). The
environment, in this conceptualization, includes both private
space and public and shared space. Availability of single
rooms that include familiar resident furnishings and a
welcoming and supportive public environment have an impor-
tant role in quality of life. As R. A. Kane and Cutler noted,
a wealth of research supports the importance of a philosophy
that allows residents control and choice in their daily lives
and care. Service capacity must encompass both routine care
and specialized services.
These characteristics are evident in new and emerging
models of care, including those being integrated into existing
nursing home facilities, as well as stand-alone models of care
such as the Wellspring Program and the Eden Alternative
(Junxin & Porock, 2014). These models focus on using
24 hours a day as potential time for engagement in the
various areas of occupation such as social participation or
instrumental ADL (IADL). The Wellspring Program,
developed for residents with memory loss, is designed to
foster a self-regulating series of behavior-based feedback
loops among the resident, staff, and family members. This
approach fosters independence and spontaneity creating
activities for the moment. The Eden Alternative attempts
to redesign the experience of aging and limitations by using
animals, plants, and children to transform the nursing
home environment into habitats where individuals enjoy
living. Staff, including everyone in contact with residents,
continually ask, “What is best for the resident?” The resi-
dent remains the central focus at all times, ensuring that
each day reflects the natural rhythms of life and freedom
of choice.
✺
PROMOTING BEST PRACTICE
Improving the Dining Experience
Providing maximal levels of independent choice in dining
options can enhance quality of life for nursing home residents
(Quiring, 2012). Food carts that allow the individual to select
type and amount of food also provide opportunities for staff
to notice nutrition, as well as cognitive change and social
interaction of residents.
Several factors affect the current models of nursing
homes. First, the introduction of long-term care insurance
dictates the amount of money that will be paid for care.
Although there are typically copays required from resi-
dents, the total amount of funding available is often less
than optimal care might require, so that interventions are
not necessarily based on the client’s needs. Shortened length
of stay in acute-care settings mean that nursing home res-
idents are likely to have numerous acute medical needs that
require a shift to more medical interventions and away
from those emphasizing quality of life (R. L. Kane, 2015).
The nursing home of tomorrow will be challenged to create
4605_Ch33_507-520 31/10/17 12:41 PM Page 511
a niche within the continuum of care, perhaps creating
specialized services, or forming alliances with other spe-
cialty providers and developing strategies about how to
successfully operate within a restricted reimbursement
environment (R. L. Kane, 2014). The Affordable Care Act
(ACA) also has implications for long-term care, with its
goal of reducing rehospitalization of Medicare recipients
within 30 days of acute discharge. This goal has the potential
to shift emphasis from functional to medical intervention
(Fisher & Friesema, 2013); however, as noted throughout
this text, the future of the ACA is not known at this time;
many of its standards may be revised or revoked as the law
is modified.
Profile of Nursing Home Residents
“A relatively small number (1.5 million) and percentage
(3.5%) of the 65+ population in 2012 lived in institutional
settings such as nursing homes (1.2 million). However, the
percentage increases dramatically with age, ranging (in
2012) from 1% for persons 65–74 years to 3% for persons
75–84 years and 10% for persons 85+. In addition, in 2009,
approximately 2.7% of the elderly lived in senior housing
with at least one supportive service available” (Administra-
tion on Aging, 2013).
The majority of nursing home residents are female
(66.8 percent) and have no spouse (60 percent are widowed;
CMS, 2013). Because women generally outlive men and
have marital partners their own age or older, they are less
likely than men to have a caregiver at home should they
become disabled. Therefore, men are less likely to enter nursing
homes than women. Additional risk factors for nursing home
placement include low income, low levels of social activity,
functional or mental difficulties, and poor family support
(especially if there is a lack of a spouse and children). There
are significant racial disparities in nursing home admission,
with particularly low rates among Hispanic populations
(Thomeer, Mudrazija, & Angel, 2014). It is not clear whether
this is due to limited access or to preference for family care
and support in the home. At least one-third of the residents
in long-term care are experiencing some form of dementia
(CMS, 2013).
Among the common reasons for nursing home admission
are as follows (Centers for Disease Control and Prevention,
2001):
1. short-term need for skilled nursing care or rehabilitation,
2. long-term care for cognitive disorder, or
3. long-term care for chronic disabling health condition.
The growth of assisted care facilities has minimized the
last of these, while the greatly reduced length of stay in acute
care hospitals has increased the first. Informal caregivers
report reasons that include the need for skilled care; dementia-
related behavior; need for supportive care; and caregiver health
(Buhr, Kuchibhatla, & Clipp, 2006).
CHAPTER 33 ■ Long-Term Care 511
AROUND THE GLOBE: Nursing Home Placement in Spain
In a qualitative study of nursing home residents and informal
caregivers in Spain, Rodriguez and colleagues (2014) found that
the primary reason for the choice depended to some extent on
the resident’s needs. For those with cognitive impairments, the
primary reason was the inability of the informal caregivers to
provide needed care. For those without cognitive impairment,
the main reasons were social isolation and limitations in physical
functioning.
Because disabilities increase in frequency with age, most
nursing home residents are disabled. Of those residents
aged 65 and older, when admitted to a nursing home, 75 per-
cent need assistance with three or more ADL such as bathing
(96 percent), dressing (88 percent), and toileting (82 percent).
A majority of these residents (55 percent) are bladder inconti-
nent, and 45 percent are bowel incontinent (CMS, 2013). More
than a third have difficulty with hearing or seeing (American
Geriatric Society Foundation, 2005). Although the vast
majority of nursing home residents aged 65 and older receive
various forms of medical care, only 19 percent receive rehabil-
itation. With regard to pharmacology, 64 percent receive
psychoactive medication, compared to 24.5 percent receiving
pain medication and 8 percent receiving antibiotics (American
Health Care Association, 2005). As the population continues
to age, it is projected that the nursing home of tomorrow
will focus increasingly on chronic illness, not age-specific
dysfunction.
Therapy in Nursing Home Settings
As described earlier, therapy services are governed by a wide
array of federal and state regulations. It is essential that ther-
apists regularly review new guidelines to ensure that their
intervention is acceptable. However, it is also important that
therapists keep in mind the core values and emphases of their
disciplines. Both OT and PT focus on function and quality
of life. This focus can make a tremendous contribution to the
well-being of older adults in nursing home settings and their
families. Fortunately, guidelines have begun to shift in this
direction for nursing home care overall. Chapters 3 and 31
described the Jimmo v. Sebelius court case that allowed ther-
apists to intervene not just to improve functional status but
also to maintain function and delay of functional loss.
The Occupational Therapy Practice Framework, Third
Edition (OTPF; American Occupational Therapy Associ-
ation [AOTA], 2014) provides an outline for OT practi-
tioners to develop programs to promote the health and
wellness of the residents of their SNF. Focusing on partic-
ipation and engagement in occupation translates to the
SNF resident having the opportunity for a more satisfying
quality of life compared with the perceived nursing home
of the past. Similarly, physical therapists look to the Inter-
national Classification of Function (ICF; World Health
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512 PART IV ■ Service Delivery for the Aging Client
Organization, 2001) to guide intervention, emphasizing
participation as an important goal.
Research supports the involvement of OT in facilitating
self-care and PT in addressing falls prevention and increase
or maintenance of physical capacity in nursing home residents
(Grönstedt et al., 2013). An approach combining the two
disciplines led to improved physical capacity and function.
Occupational Therapy
OT services, along with the other rehabilitative services, focus
on functional problems as their primary concern (Washkowiak
et al., n.d.). This emphasis is important in addressing many of
the common issues among nursing residents, having a posi-
tive impact on dementia-related symptoms (Galik, Resnick,
Hammersla, & Brightwater, 2013) and depression (Meeks,
Van Haitsman, Schoenbachler, & Looney, 2015).
Consistent with the OTPF-3 (AOTA, 2014), OT in
long-term care addresses the individual’s ability to accomplish
needed and desired activities. Because nursing home residents
tend to have significant cognitive or physical limitations,
strengths must be carefully identified, deficits noted, personal
goals identified, and a series of strategies developed to facil-
itate those goals. Specific intervention depends on the nature
of the condition and expectations about whether the person
will return to the community. So, for example, for residents
who have experienced CVA, maintaining participation in
ADL may require a focus on posture and positioning, along
with training in new strategies for accomplishing activities
(Fletcher-Smith, Drummond, Saddey, Moody, & Walker,
2014). Self-care for individuals with dementia can be en-
hanced through music that seems to reduce resistance to care
(Konno, Kang, & Makimoto, 2014). In the former case,
there is the possibility that the person may be able to return
home; for the latter, the most likely scenario is that the
nursing home will be home.
As noted earlier, some nursing home residents expect their
stays to be rehabilitative in nature. So, for example, individ-
uals with hip fractures may well recover sufficiently to regain
normal or near-normal function. For these individuals, the
focus of care in OT is on finding ways to structure their home
environments to maximize performance and manage energy
expenditure (Buddingh et al., 2013). The important role
of physical therapy in working with individuals after a hip
fracture is described in the Interprofessional Practice box.
INTERPROFESSIONAL PRACTICE
Rehabilitation After Hip Fracture
A common cause of nursing home placement is hip fracture.
Postfracture, an intensive course of rehabilitation can minimize
long-term functional deficits. The most effective strategies
involve rehabilitation teams with physical therapists focused
on regaining range of motion and strength in the affected
extremity to support functional mobility. OT emphasizes self-care,
including personal care and home care (Buddingh et al., 2013).
For all nursing home residents, social activities have partic-
ular salience (Adams, Roberts, & Cole, 2011). Among the
many benefits of such activities is avoidance of depression. If
activities also have an altruistic element, this benefit is even
more pronounced (Cipriani, Haley, Moravec, & Young, 2010).
All too often, individuals residing in nursing homes feel some-
what useless; the ability to do for others can enhance meaning.
Of particular note is the fact that nursing homes can be-
come home to individuals with long-standing challenges,
including older adults with developmental disabilities
(Cronin, 2013). Such individuals may have managed in the
community when informal care from parents was available
but be unable to live independently when parents either
die or become too infirm to care for them. As is true for
individuals with dementia, for these individuals the nursing
home is home, and interventions to structure a homelike
feel can be important. This might include such simple
measures as giving residents choices about when to go
to bed and wake up and providing access to snacks and to
choice about meals.
Occupation in Long-Term Care
Although progress has been made in improving program-
ming in long-term care, much remains to be done (Leedahl,
Chapin, & Little, 2015). Residents still spend a good bit of
their time in passive activities despite evidence that social
relationships and meaningful leisure occupations can improve
quality of life.
Whether treatment planning for specific medical deficits
or for occupational engagement, all facets of an individual
must be considered (AOTA, 2014). The OTPF-3 notes that
people are occupational beings, a concept important for the
entire life span. A comprehensive occupational profile, com-
pleted by an occupational therapist, will describe a person’s
routine, habits, values, and interests. The connectedness
elders have with their rich lifetime experiences and past
relationships, as well as their physical, emotional, social, and
cognitive abilities, should be taken into account. The goal
of an effective activities program, under the direction of an
occupational therapist, is to focus on goal- and process-directed,
purposeful tasks that capitalize on a person’s abilities and
growth potential. A nonreimbursable occupation-based
program can be viewed as an ongoing, long-term approach
to the maintenance and enhancement of functional abilities,
and thus a preventative health program rather than a short-
term solution to a specific deficit.
INTERPROFESSIONAL PRACTICE
Addressing Oral Hygiene
Oral hygiene is an often-overlooked element of nursing home
care, but it has significant implications for the well-being of the
residents. Good dental health is vital to adequate nutrition and
to ability to communicate effectively. Absence of good dental
health can also increase pain and discomfort, making
engagement with activities difficult.
4605_Ch33_507-520 31/10/17 12:41 PM Page 513
Team intervention can enhance dental health (Bonwell,
Parsons, Best, & Hise, 2014). Nutritionists can focus on appropriate
diet and adequate hydration. Physical therapists can emphasize
strength of oral and throat muscles. Occupational therapists can
address social aspects of eating, as well as managing flossing and
brushing of teeth.
As appropriate interventions are identified for older adults
who are institutionalized, one must consider various deficits
that an older adult may present, including those who are
aging with a preexisting disability such as developmental
or intellectual disabilities as described earlier. Deficits may
include physical, cognitive, and social changes, redefined
relationships, sensory impairments, changes in life roles and
self-esteem, among others. Attention must be given to the
individual’s health needs and health improvements without
sacrificing the residential, social environment.
Goals for occupation-related programs in long-term care
can focus on a wide variety of target areas, including promoting
change in intrapersonal skills (appropriately tolerating frus-
tration, developing realistic expectations of self); promoting
change in communication skills; demonstrating appropriate
impulse control; actively listening; promoting change with
cognitive and task performance skills (organizing own tasks,
self-correcting task errors); promoting change in independent
living skills (effectively managing time, using appropriate
safety judgment, and developing a sense of emotional well-
being); and promoting maintenance or improvement of
physical skills (dexterity for self-care independence, ability
to produce a legal signature). Occupational performance pro-
grams have as many diverse goals as the therapists possess
creativity.
Stav et al. (2012) conducted a systematic review discussing
occupational engagement among community dwelling older
adults. The goal of their research was to investigate the
health benefits of participation in daily activities of older
adults. OT practitioners can use health-promoting activities
in the community and also translate the same concepts to
long-term care.
Steultjens et al. (2004) reviewed research on the use of OT
with older adults living independently in the community.
They concluded that there was strong evidence for the efficacy
of advising on assistive devices, some evidence for the training
of skills in decreasing incidence of falls in at-risk elderly
clients, and some evidence for the efficacy of OT on func-
tional ability, social participation, and quality of life. These
areas should become commonly targeted for persons with
dementia living in skilled nursing facilities, as well.
To accommodate cognitive loss that accompanies dementia,
therapists rely more heavily on the use of external cues. Mem-
ory books and other cuing systems can be helpful in assisting
persons with dementia to reach therapeutic goals (Bourgeois,
2007). This is especially true when combined with other pro-
cedures such as errorless learning (Camp, 2006a), teaching
task-specific routines or self-monitoring related to executive
dysfunction (Sohlberg & Mateer, 2001), or spaced-retrieval,
CHAPTER 33 ■ Long-Term Care 513
which is described in more detail in Chapter 10 and in the
following paragraphs.
A consistent finding is that social interaction and social
supports are of vital importance in nursing home settings
(Leedahl et al., 2015; Van Haitsma et al., 2015). Organizing
systems in which staff interact regularly among themselves and
with clients can enhance a variety of outcomes. Van Haitsma
and colleagues note that individualized psychosocial inter-
ventions can minimize behavioral problems for individuals
with dementia.
A dilemma in inferring from this research what will be
effective in nursing home settings is a relative dearth of
research specifically focused on OT and PT interventions
(Fletcher-Smith, Walker, Cobley, Steultjeans, & Sackley,
2013).
As of June 2006, CMS guidelines and regulations regard-
ing activities provided to residents of skilled nursing facilities
emphasize the need to ensure that activities match the indi-
vidual resident’s personal interests, age, gender, and level of
cognitive functioning. One target area for surveyors following
these guidelines is to determine whether facility staff mem-
bers other than those in activity departments are involved
with activity programming. Camp, Breedlove, Malone,
Skrajner, and McGowan (2007) described areas being tar-
geted for more intense scrutiny by surveyors and provided an
extensive list of recommendations on how to address these
issues using Montessori-based activities, which are described
in more detail later in this chapter and in Chapter 12.
Physical Therapy
While OT focuses on accomplishing desired occupations, PT
emphasizes the physical capacity required to enable those
occupations. So for an individual who has post-CVA limita-
tions, for example, maintaining range of motion in affected
limbs, strengthening, and balance may be essential emphases.
Regaining mobility and strength following hip fracture can
make the difference between temporary and permanent func-
tional limitations (Buddingh et al., 2013). Physical therapy
makes a substantial contribution in care after joint replace-
ment. In one study, physical therapy was associated with
superior outcomes for individuals who received initial reha-
bilitation in a long-term care setting (Malinson et al., 2011).
Some of those same interventions might reduce falls and
thus fractures in long-term residents (Silva, Eslick, &
Duque, 2013). Falls are a particular risk for individuals
with dementia, and rehabilitation after a fall is particularly
challenging for these individuals, so prevention becomes
essential (McGough, Logsdon, Kelly, & Teri, 2013). Fur-
thermore, physical therapy intervention can prevent func-
tional, relational, and physical losses (Castilho-Weinert
et al., 2014).
There is a significant interaction between the goals asso-
ciated with OT intervention emphasizing ability to partici-
pate in occupations like self-care and leisure, and the goals
associated with PT emphasizing physical performance and
4605_Ch33_507-520 31/10/17 12:41 PM Page 514
514 PART IV ■ Service Delivery for the Aging Client
physical activity (Grönstedt et al., 2013). Participation in
occupations requires sufficient performance skills, including
motor ability. Furthermore, motivation for undertaking
physical exercise is often based on the desire to participate in
meaningful occupations. For this reason, team-based inter-
vention is critical in long-term care facilities. Box 33-1 shows
what an OT and a PT treatment plan might look like in a SNF.
BOX 331 Sample OT and PT Treatment Plans
Sample PT Treatment Plan
Assessment: Client is a 92-year-old female post right CVA affecting
L side with resulting L sided weakness. Client lives with sisters in
2 story home and was previously independent for mobility and
did not use assistive device for mobility. Client currently presents
with L sided weakness with L UE flaccid, pain, L shoulder sublux-
ation, and impaired sequencing. Client presents with impaired
transfer ability, safety awareness, and functional activity tolerance.
Client would benefit from skilled PT services to address these
deficits and promote safe return home at highest level of func-
tional ability.
Physical capacity deficits: Decreased UE passive/active assist/
active ROM; decreased UE strength; decreased gross motor skills;
decreased fine motor skills; decreased standing balance/tolerance;
decreased activity tolerance; decreased sequencing; decreased
safety wheelchair positioning; decreased safety awareness.
PT Long-Term Goal 1: Client will have 1/5 or trace muscle strength
in L UE to incorporate L UE into ADL tasks
PT Long-Term Goal 2: Client will ambulate safely with assistive
device (cane) both indoors and outdoors for distances required for
ADL, IADL, and other functional activities.
PT Short-Term Goal 1: Client will tolerate 8–10 minutes of static/
dynamic functional standing tolerance during therapeutic activities
PT Short-Term Goal 2: client will engage in 15–20 minutes of light
to moderate levels of functional activities including UE exercise with
1–2 rest breaks for increased strength and functional activity toler-
ance required for long-term goals.
Intervention Plan: therapeutic exercise, activity tolerance, seating/
positioning, transfer training, family/resident education.
Sample OT Treatment Plan
Assessment: Client is a 92-year-old female post right CVA affect-
ing L side with resulting L sided weakness. Client lives with sisters
in 2 story home and was previously independent for ADL/
IADL including driving and did not use assistive device for
mobility. Client currently presents with l sided weakness with
L UE flaccid, pain, L shoulder subluxation, and impaired sequenc-
ing. Client presents with impaired ADL/IADL, and functional
Interdisciplinary Teams in Long-Term Care
Given the wide variety of needs of long-term care residents,
a variety of professionals are required to meet these needs.
As a result, professionals creating occupational performance
programs for long-term-care residents must work as part of
an interdisciplinary team. Members of the interdisciplinary
transfer ability, safety awareness, and functional activity tolerance.
Client would benefit from skilled OT services to address these
deficits and promote safe return home at highest level of func-
tional ability.
Learning barriers: none
Rehab potential: good
Performance deficits: Decreased independence/safety with activi-
ties of daily living; decreased independence/safety with IADL;
decreased UE passive/active assist/active ROM; decreased UE
strength; decreased gross motor skills; decreased fine motor skills;
decreased standing balance/tolerance; decreased activity toler-
ance; decreased cognitive functioning; decreased sensory/motor
skills; decreased sequencing; decreased safety wheelchair position-
ing; decreased safety awareness.
OT Long-Term Goal 1: Client will be Mod I for feeding, grooming,
UE dressing/bathing, and supervision for LE dressing/bathing, and
toileting using DME as needed to return to baseline functional
abilities and prevent the need for 24-hour care.
OT Long-Term Goal 2: Client will be supervision for toilet and
shower transfers using DME as needed to return to baseline func-
tional abilities and prevent the need for 24-hour care.
OT Long-Term Goal 3: Client will be supervision for simple meal
prep, light cleaning tasks, and Mod I for medication and money
management using DME as needed to return to baseline functional
abilities and prevent need for 24-hour care.
OT Short-Term Goal 1: Client will complete cognitive tasks graded
in levels of complexity with good accuracy and 1–2 verbal cues for
increased attention, awareness, and problem solving required to
safely complete self-care tasks.
OT Short-Term Goal 2: Client will be Min A for LE dressing with
efficient use of DME as needed while demonstrating good safety
techniques.
Intervention Plan: ADL education/training; IADL education/training;
therapeutic activities; sensory/motor intervention; cognitive training;
resident/family education
4605_Ch33_507-520 31/10/17 12:41 PM Page 515
team must work in collaboration and partnership with one
another, advocating for the rights of the resident and never
losing sight of the resident’s needs. The composition of the
long-term care interdisciplinary team is dependent on the size
of the organization, its staffing patterns (e.g., whether most
staff are contractual vs. employees), and the needs of the
residents. Long-term care residents and organizations benefit
from having a comprehensive team of skilled health-care
professionals holistically evaluating and treating residents
based on their physical, cognitive, and psychosocial needs.
Members of the team will bring their unique specialties and
perspectives to the decision-making process. The interdisci-
plinary team is typically composed of a variety of specialists
such as nurses, nurse assistants, physicians, social workers,
and therapists from various disciplines—art therapy, audiol-
ogy, music therapy, OT, PT, speech/language pathology,
nutritionists, and recreational specialists.
It is important to include the contributions of CNAs
(Morley, 2014). These individuals provide the majority of di-
rect care to residents, and are “key to resident quality of life”
(p. 610). They can provide input about residents’ behavior
and needs on the basis of consistent observation, and can
implement a variety of aspects of care identified by other dis-
ciplines. For example, the physical therapist and nurse may
develop a plan for maintaining skin integrity for a bed-bound
resident; the CNA will be the individual actually implement-
ing many aspects of that plan.
INTERPROFESSIONAL PRACTICE
The Value of Restorative Care
On occasion, individual OT and PT interventions are suspended
when residents have received full benefit (Talley et al., 2015). In
such cases, restorative care offered by designated staff members
trained by OT and PT have positive impact in avoiding physical,
cognitive, and functional decline. Training focused on identifying
activities perceived as valuable and interesting enhanced
participation. Minimizing decline contributes to both resident
well-being and reduced care cost.
Of course, the most important members of the team are
the resident and family members or significant others, who
should be involved whenever possible to assist in establishing
goals and making informed decisions. Family members are
vital to effective care, while also reducing staffing and other
care costs (Roth, Fredman, & Haley, 2015). Such caregiving
is stressful for families but also provides benefits. Roth and
colleagues note that some studies have shown that caregiving
may be associated with improved health and lower mortality,
a finding that contradicts conventional wisdom. Regardless,
acknowledging the contributions of family, providing them
with training, involving them in decision-making, and address-
ing their stress can have positive benefits for residents as well
as the caregivers themselves.
On the basis of the assessments of all the team members, a
comprehensive, personalized plan of care is developed, outlining
CHAPTER 33 ■ Long-Term Care 515
all aspects of care delivery for a resident. The plan of care
should reflect individualized cognitive and physical problems,
goals, interests, and intervention strategies (Figure 33-1) and
identify which disciplines will be responsible for providing
the intervention.
Interdisciplinary meetings for each resident are held at least
quarterly or more frequently if and when there is a change in
medical status, whether it is improvement or decline. The
team is charged with the responsibility to creatively develop a
plan of intervention that will maximize an individual’s abilities
and focus on successful interactions while maintaining the
resident’s dignity and feelings of self-worth. Effective docu-
mentation of observed behavior, response to intervention, and
changes in health or function can ensure that team members
are well informed. Box 33-2 shows a typical clinical note.
Staff attitudes and communication are the most significant
determinants of whether an interdisciplinary team will be
FIGURE 331 Chess, checkers, and other board games emphasize
focused concentration, fine motor skills, and social interaction.
Stockbyte/Stockbyte/Thinkstock
BOX 332 Sample Clinical Note (OT)
Total Individual Time (Min): 75. Subjective: “I told myself I was
going to work hard on the weekends” PAIN: No complaint of pain
OBJECTIVE: client seen for morning ADL session SELF CARE:
GROOMING: Modified independent seated in w/c at sink to
wash/rinse/dry face, apply deodorant and complete oral care
including mouthwash, brushing teeth. Increased time to com-
plete. Moving at a slow pace, completed mouthwash × 2. Large
amount of time spent on thoroughly brushing teeth. Client
completed own setup at w/c level, no assist required to open
containers on this date. BATHING: Modified independent to
wash/rinse/dry upper body while seated in w/c at sink. Increased
time spent on thoroughness. UE DRESSING: modified independ-
ent seated to doff pullover shirt over head. MOD I to don pullover
shirt/CGA to don open front jacket while seated in w/c. ASSESS-
MENT: increased time to complete full ADL session due to slow
pace. Significant progress demonstrated during ADL session.
INTERVENTION PLAN: continue to work toward goals
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516 PART IV ■ Service Delivery for the Aging Client

successful or not. Staff members must focus on the needs of
the client and set aside individual differences and potential
competitiveness among disciplines. This may be especially
challenging in this era of managed care and changes within
the government entitlement programs. Considering staffing
patterns for long-term care, it will be critical for all care
providers to work cooperatively to create and maintain envi-
ronments that support and maintain optimal programming
for residents. Professionals must view themselves as having
the potential and responsibility of maintaining interventions
initiated by persons outside their own discipline.
It is quite possible for an interdisciplinary rehabilitation
team to be very successful at creating an occupation-based
project while maintaining the integrity of their individual dis-
ciplines. For example, at Menorah Park Center for Senior
Living in Beachwood, Ohio, an interdisciplinary team was
developed to create a quilt describing significant personal life
events of several residents in the long-term care facility. This
was a collaborative effort of staff from art therapy, music ther-
apy, OT, and speech/language pathology. The goals of the
task included providing an avenue for reminiscing; increasing
feelings of accomplishment; enhancing clients’ satisfaction
and reaffirming their value in society; enabling individuals to
make a unique contribution to a whole that was far more than
the sum of its parts; providing a way for residents to be as
independent as possible during a creative process; and finally,
providing a forum to connect with families, careers, hobbies,
and past life experiences. In this case, the occupational
therapist was an equal member of the interdisciplinary team,
and each discipline focused on its area of expertise with the
resident.
modules; vehicles for exploring and integrating into the
community at large; a specific place for worship and meditation;
a resident bank and beauty shop, exterior garden spaces with
putting greens, and raised flower beds (Figure 33-2); an ice
cream parlor; an auditorium used for entertainment, evenings
of formal dining with visiting family members; dances, and so
on. Development of an engaging and homelike environment
such as this one requires input from a variety of team members,
as the quilt project described earlier demonstrates.
Evidence-Based Approaches to Care
for Patients With Dementia
Innovation and creativity are required to ensure that the prin-
ciples and philosophy of OT will be part of engagement for
long-term care residents. For example, a memory interven-
tion for persons with dementia called spaced retrieval (SR)
has been the focus of investigation to address cognitive loss.
SR involves giving persons with memory deficits practice at
successfully remembering information over increasingly long
periods of time, and it has been shown to enable persons with
a variety of dementing conditions to retain new information
across clinically meaningful (i.e., days, weeks, or months)
periods of time (e.g., Camp, 2006a; Camp, Bird, & Cherry,
2000).

Therapies and the Total Environment

Along with the expertise and attitude of the staff, the general
environment of an organization can and should support the
delivery of a quality occupational performance program, and
the environment must be supportive of a variety of activities
(Kane & Cutler, 2015). Each of the residents has an array of
previous life skills that can be incorporated into program-
ming. It is a mistake to believe that rehabilitation can occur
only within a traditional clinic setting focusing on tabletop
tasks and therapy materials. Therapists must look beyond the
obvious and utilize the total living environment as an element
in treatment planning.

✺ PROMOTING BEST PRACTICE

Therapeutic Environment
At Menorah Park, in Beachwood, Ohio, the treatment
environment includes a horticulture area; an in-house nature
center; in-house pets; therapeutic and recreational swimming
facilities; work trial areas in a snack shop, gift shop, or reception
area; an on-site child care facility for volunteer experiences; FIGURE 332 Wheelchair gardening. The use of assistive devices and
available technology such as environmental controls, aids for prepared environments makes outdoor gardening accessible to
the visually impaired, Internet access, and computer learning residents. sorcerer44/iStock/Thinkstock
4605_Ch33_507-520 31/10/17 12:41 PM Page 517
SR has been developed into an intervention for persons
with dementia that can be implemented by therapists from
various disciplines, including OT, PT, music and art therapy,
and speech-language pathology, within the contexts of reg-
ular therapy sessions (Bourgeois et al., 2003). Thus, SR can
enable clients in long-term care to accomplish additional
therapy goals within the same time frame as regular therapy
sessions, enabling therapists to accomplish more within the
context of the number of therapy sessions imposed by
Prospective Payment Systems (PPS) described in Chapter 31.
Recall that PPS provides fixed reimbursement based on spe-
cific diagnoses and the expected needs associated with them.
Although neurological impairment cannot be reversed, it
is useful to focus on abilities that are spared or less impaired
over the course of dementia as the basis for improving the
social psychological environment within long-term care. For
example, Squire (1992, 1994) described several abilities, such
as priming, classical conditioning, and skills and habits,
which might serve as the basis for interventions for persons
with dementia (Camp, 2006b; Camp & Nasser, 2003). Camp
and his colleagues used this approach to create an intergen-
erational program in which individuals with dementia living
on an Alzheimer’s Disease Special Care Unit served as teach-
ers and mentors for preschool children using Montessori
teaching materials and lessons as the basis for the program
(Camp, 2006b), as well as in an adult day health center (Camp,
Orsulic-Jeras, Lee, & Judge, 2004). Such intergenerational
programs can be of great benefit to many nursing home
residents (Figure 33-3).
Montessori-based activities have been provided directly to
persons with moderate to advanced dementia (Volland &
Fisher, 2015). Using this approach is based on the idea that
there may be a developmental progression to the loss of
abilities in dementia, roughly following a “first-in, last-out”
model of cognitive deterioration labeled by Reisberg (Reisberg,
Franssen, Souren, Auer, & Akram, 2002) as “retrogenesis.”
FIGURE 333 Intergenerational programming can enhance quality of
life and promote a sense of meaning for nursing home residents.
monkeybusinessimages/iStock/Thinkstock
CHAPTER 33 ■ Long-Term Care 517
The Myers-Menorah Park/Montessori-based Assess-
ment System (MMP/MAS) is composed of a set of seven
Montessori-based activities. It is designed to be administered
by an occupational or recreational therapist charged with
creating activities programming for persons with dementia
and yields information more relevant to this purpose than
more standard assessments of cognitive assessment in late-
stage dementia. As described in Chapter 12, these Montessori
programs are one type of strength-based programming. The
emphasis in therapeutic intervention not only on minimizing
dysfunction but also capitalizing on strengths can enhance
quality of life (Judge, Yarry, & Orsulic-Jeras, 2010; Volland
& Fisher, 2015). These approaches have been found particu-
larly beneficial for clients with significant and deteriorating
cognitive impairments, but the general principles are relevant
for all long-term care clients.
In structuring these kinds of interventions, awareness of
clients’ cultural backgrounds can enhance effectiveness. En-
gagement in familiar cultural activities can be meaningful and
can stir memories that promote engagement both with the ac-
tivity and with others. So, for example, a group activity empha-
sizing familiar foods might stimulate pleasant recollections of
childhood and family. Such activities can readily be graded for
the level of ability of the participants—from actual food prepa-
ration to simply eating a traditional meal together.
SUMMARY
Therapists must objectively prove to regulators and reim-
bursement sources that activities-based programs designed
and implemented by their disciplines, as opposed to general-
ists, provide positive, objective, and sustained functional and
quality of life outcomes. Positive clinical outcomes will be the
most important factor in determining the future of activity-
based programming. In the future, the long-term care indus-
try is expecting to admit more frail older adults with multiple
medical diagnoses. Many long-term care facilities may maintain
their focus on provision of health-care needs from the med-
ical model, but truly progressive organizations will attempt
to meet these needs whenever possible without sacrificing the
psychosocial needs of the resident.
The resident of the future will present with chronic disease
and pose conflicting goals for the organization. The resident
will desire safety, autonomy, and excellent medical services
but may be unwilling or unable to pay for the services. To
meet the needs of residents and deliver services within long-
term care settings, therapists must be creative and innovative
when approaching the subject of activities programming and
be able to demonstrate tangible benefits of such program-
ming for both residents and staff.
An individual’s age should not be the determinant of
whether a person should or should not participate and benefit
from a therapeutic activities program, but will third-party
payers understand the significance of quality-based activities
programs for the frail older adult and be willing to reimburse
4605_Ch33_507-520 31/10/17 12:41 PM Page 518
518 PART IV ■ Service Delivery for the Aging Client
therapists for their skills? It is clear that nursing home guide-
lines are increasingly focused on function and quality of life
(R. A. Kane & Cutler, 2015; R. L. Kane, 2015). This may
well portend a renewed interest in providing truly therapeutic
activities for long-term care residents. If so, the skills and
knowledge of occupational and physical therapists may become
more salient to facilities seeking to comply with regulatory
imperatives.
CASE STUDY
Mrs. Johnson is a 94-year-old African American widow,
currently residing in a nursing home. She lived alone in
her own home until 2 years ago, when her five adult chil-
dren became concerned about her memory and her ability
to manage ADL and IADL tasks. Mrs. Johnson has had
arthritis for at least the past 10 years; it causes her mod-
erate pain most days. She also has diabetes, which she
developed at age 50. She requires both diet management
and medication to control this condition. The family has
used visiting nurse services to assist them to put systems
in place for Mrs. Johnson to remain home.
The main concern about her condition is her rapidly
developing dementia. Her children noticed about 4 years
ago that her recent memory was deteriorating. They decided
that she needed nursing home care after an incident in
which one of the children came for a visit and found an
empty pot sitting on the stove over an open flame.
The children and grandchildren remain involved with
Mrs. Johnson and are frequent visitors. However, staff mem-
bers want to ensure that she remains as functional as possible
and have noted that recently she’s been relatively withdrawn
and less involved with activities. In addition, they are con-
cerned about her arthritis and the limitations it imposes on
her daily function. They have referred her to OT for an eval-
uation of her condition and suggestions about a care plan.
Questions
1. To adequately develop a treatment plan for
Mrs. Johnson, what additional information should
the OT seek?
2. Mrs. Johnson’s children report that she used to sing
in the church choir, and that before entering the
nursing home, she was very involved in the church
sisterhood. They also report that she used to be a very
good bridge player and had a regular game with three
longtime friends. How might this information be
helpful to the occupational therapist?
3. What aspects of a comprehensive occupational pro-
file are missing? What other activities might help
maintain Mrs. Johnson’s quality of life?
4. What are areas of emphasis for PT assessment and
intervention?
Critical Thinking Questions
1. Discuss the implications of OBRA ’87 legislation on
activities programming in long-term care facilities.
2. What kinds of interventions are most central
to promoting quality of life for nursing home
residents? Why is quality of life an important
outcome of care?
3. What factors influence the role of occupational ther-
apists in long-term-care settings?
4. What factors influence the role of physical therapists
in long-term care?
5. Describe the different kinds of goals that might be
set for occupation-related programming.
6. Discuss the use of interdisciplinary teams for creating
occupational-performance-based plans of care for
persons with dementia.
7. How are Montessori-based activities helpful in
working with SNF residents?
Acknowledgment
The author thanks Ruth Plautz, OTR/L, and Cameron Camp,
PhD, for previous development of this chapter.
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Karen la Cour
“We exploit the uncertainty about the end of our existence to live as if we are—K.E.
LEARNING OUTCOMES
By the end of this chapter, readers will be able to:
1. Argue for occupational and physiotherapy services as a part
of end-of-life and palliative care services.
2. Describe and discuss contemporary definitions and under-
standings of end-of-life and palliative care and hospice
philosophy.
3. Have knowledge about contemporary criteria for the “good”
death and cultural implications.
4. Describe the end-of-life challenge as it relates to older
people, human existence, and functioning (life span
development/aging).
5. Describe the consequences of how end-of-life circumstances
of an older person may affect close family and relatives.
6. Understand the palliative care needs related to occupational
therapy and physiotherapy, including activity and participa-
tion (functioning) of older people facing end of life.
7. Understand international health policy and political-societal/
environmental factors as they relate to palliative care services
for older people.
8. Identify and discuss roles for occupational therapists and
physiotherapists in palliative care as an interdisciplinary
service including interventions and implications for collabo-
ration and clinical practice.
9. Identify and critically reflect on appropriate outcomes in
palliative care as well as ethical dilemmas.
Clinical Vignette
Sarah Winford is a 75-year-old woman with lung cancer that
has metastasized to liver and brain. No treatment is available.
She lives in a house in the countryside with her partner Jim.
Sarah has two sons, Peter and Poul. Peter is married and
has a daughter. Poul lives by himself and has had difficulties
establishing a life on his own. Sarah has always been active
and has many interests; however, she is increasingly burdened
by breathlessness and side effects from chemotherapy, which
cause pain in her fingers and toes. Sarah worries about decline,
and how her sons and Jim will manage when she is no longer
there. The symptoms of fatigue and pain especially impinge
CHAPTER 34
End of Life
■ Line Lindahl-Jacobsen
not going to die.
Løgstrup
”
on her daily activities, keeping her from doing even the
smallest tasks and forcing her into passivity and dependency.
1. In addition to her concerns about her husband and
sons, what might be significant issues for Sarah at this
point in her care?
2. How might her resources to engage in occupations best
be assessed and prioritized?
T he end-of-life phase is significant because it potentially
will touch every family and individual in some way as
they strive to deal with closure, transition, grief, mourning,
and life itself.
As people grow old, their awareness of the end of life is
accentuated, due to aging, including decreasing abilities and
deterioration, and possibly to illness. As the population of
older people continues to grow, so does the need for health-
care services, including attention to health policies and ethical
responsibility.
In working with people facing the end-of-life and termi-
nal illness, occupational therapists and physiotherapists can
serve a significant role by addressing issues related to physical
and psychosocial functioning as well as existential challenges
(Cooper 2006; K. Taylor, Simader, & Nieland, 2013).
Old age is commonly accompanied by bodily and psy-
chosocial decline, including increased risk for various diseases.
These factors together often reduce the older people’s ability
to carry out and manage basic activities of daily living (ADL)
and limit the possibility of enjoying a degree of autonomy
in the given sociocultural context and circumstances under
which life is lived (Sviden et al., 2009). Becoming aware of
imminent end of life may lead to existential considerations,
often related to the losses involved such as decreased func-
tioning, as well as loneliness and having to leave beloved
others such as children and important family members, which
in turn may cause additional emotional distress. Furthermore,
older people and people living with life-threatening illnesses
are often prone to marginalization and stigma (Davies, 2004).
The end-of-life phase thus often requires older people to
rework their prior understandings of self and their abilities
and to develop ways of being, to cope with functional
521
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522 PART IV ■ Service Delivery for the Aging Client

decline, and to create meaning in the life remaining to them

in given circumstances.
Research shows that care of older dying persons and their
significant others has improved slowly. One of the reasons
for the slow progress is the lack of palliative care education
as an integral part of health professional education, and death
and dying have not, until recently, been part of a public
discourse or included in health-care education (Kastenbaum,
2011; Socialstyrelsen, 2006). Education of occupational ther-
apists and physiotherapists preparing for work in palliative
care is limited. In a study of preparedness for palliative care
among six occupational therapy schools from Australia and
New Zealand and 24 occupational therapists found that
the schools reported 2 to 10 hours of palliative care–specific
education and that less than 50 percent of clinicians recalled
undergraduate education in palliative care (Meredith, 2010).
Furthermore, little attention has been paid to death and
dying in old age possibly because life-threatening illnesses
such as cancer attract more economic and societal support
when the individual is a younger person. Evidence shows that
older people who are dying suffer unnecessarily, in part due
FIGURE 341 Occupations that promote meaning can be particularly
to insufficient assessment and undertreatment of their prob-
important at the end of life. danr13/iStock/Thinkstock
lems including lack of access to home care, palliative care,
and other specialist services (Davies & Higginson, 2004). In
response to these problems, the World Health Organization health-care policies and relevant roles for occupational and
(WHO) has emphasized the care of older people facing end physiotherapists in palliative care with implications for prac-
of life through two evidence-based reports to guide policies tice, outcomes, and research.
and palliative health care for older people (Davies, 2004;
Davies & Higginson, 2004).
Supporting older people with terminal illnesses at the end End of Life, Palliative Care, and Hospice
of life calls for a holistic understanding of the cycle of human Philosophy
life. Therapists need this kind of understanding to address
and embrace both functional problems and significant life- The end of life describes the total circumstances of a person
course issues pertaining not only to the specific life situation with a life-threatening illness. The end-of-life phase may last
of the individual who is dying, as well as to his or her family. for days, weeks, months, or years and hence does not only
Thus, end of life is a highly complex situation for occupa- equate to dying.
tional therapists and physiotherapists; it requires great respect End-of-life care is by the National Council of Palliative
when entering into people’s lives while they are dealing with Care (2011) defined as care that helps those with advanced,
some of the greatest challenges in human existence. To serve progressive, incurable illness to live as well as possible until
people who are dying, therapists must possess competencies they die. End-of-life care enables the supportive and pallia-
to enable and support clients to manage daily occupations tive care needs of both patient/client and family to be iden-
and preserve integrity while coping with unavoidable physical tified and met throughout the last phase of life and into
insults and losses. bereavement. It includes the management of pain and other
This chapter explores the concepts and conditions related symptoms and the provision of psychological, social, spiritual,
to end of life of older people with life-threatening illnesses. and practical support. The term “end-of-life care” has replaced
It addresses the roles of occupational therapists and physio- the term “terminal care” and encompasses both hospice and
therapists providing palliative therapy to elderly clients and palliative care, which can be provided during the final stages
their families when life is moving toward its end. of life (Burkhardt et al., 2011).
The chapter introduces contemporary definitions of end- Supportive care is defined as care that helps patients and
of-life and palliative care conceptualizations as well as possi- their families cope with their condition and its treatment, from
ble implications for the provision of therapy. It describes the prediagnosis, through the process of diagnosis and treatment,
end-of-life challenge as related to human existence, activity, to cure, continuing illness, or death and into bereavement.
participation and functioning, including the challenges older Palliative care is the active total care of patients whose
people encounter in regard to meaning-making and sustain- disease is unresponsive to curative treatment. Control of
ing life roles important to retain self-respect and integrity pain and other symptoms and support to manage physical,
until the end of life (Figure 34-1). Finally, it discusses relevant psychological, social, and other problems are paramount. The
4605_Ch34_521-538 31/10/17 12:40 PM Page 523
goal of palliative care is achievement of the best quality of life
for patients and their families.
According to the WHO, all patients with a life-threatening
illness are potential recipients of palliative care (Sepulveda,
Marlin, Yoshida, & Ullrich, 2002). A person may receive
supportive care for a variable amount of time even when
death is not anticipated, as in the case of someone who has
had treatment for cancer and is now considered cured, or
someone with chronic obstructive pulmonary disease whose
condition is not terminal.
Palliative care becomes particularly relevant when the
person’s condition deteriorates, active treatment does not
control the disease, and cure is no longer expected. Here
progressive deterioration and death is anticipated and the
emphasis of care moves from active treatment of the disease
to comfort and control of symptoms, such as pain. In such
circumstances, treatment that is usually used to actively treat
disease may be helpful for symptom control as part of pallia-
tive care. An example is radiotherapy, which is often used to
treat certain types of cancer (active treatment of the disease),
can be used to help with pain control (palliative treatment).
End-of-life care encompasses supportive and palliative
care and is most commonly provided through hospice and
palliative care services. Hospice as a concept derives from the
Latin word hospitum and means a guesthouse of rest for weary
BOX 341 Definition, Aims, and Principles of Palliative Care
Definition: World Health Organization (www.who.int)
Palliative care is an approach that seeks to improve the quality of
life of patients and their families who face problems associated with
life-threatening illness, through the prevention and relief of suffering
by means of early identification and impeccable assessment and
treatment of pain and other problems, physical, psychosocial, and
spiritual.
Palliative care:
■ Provides relief from pain and other distressing symptoms
■ Affirms life and regards dying as a normal process
■ Intends neither to hasten or postpone death
■ Integrates the psychological and spiritual aspects of patient care
■ Offers a support system to help patients live as actively as
possible until death
■ Offers a support system to help the family cope during the
patient’s illness and in their own bereavement
■ Uses a team approach to address the needs of patients and
their families, including bereavement counseling, if indicated
■ Will enhance quality of life, and may also positively influence
the course of illness
■ Is applicable early in the course of illness, in conjunction
with other therapies that are intended to prolong life, such
as chemotherapy or radiation therapy, and includes those
CHAPTER 34 ■ End of Life 523
travelers (MedicineNet.com 2008). The hospice movement
was founded by Dame Cicely Saunders in the early 1960s
in Great Britain (Abel, 1986; Saunders, 1983) where she
established the St. Christopher’s Hospice near London and
provided palliative care for dying patients. The hospice move-
ment constitutes the foundation for today’s end-of-life care,
based on the central idea that death is part of life and that
the experience of dying should be meaningful. Emphasis
is placed, for example, on the idea that patients should be
supported in opportunities for physical as well as mental
activity to preserve self-control and independence as much as
possible (Saunders, 1983). Thus hospice is perceived as a care
system provided in residential facilities such as nursing
homes, private and public residences or inpatient hospice
settings. Hospice care is the most comprehensive interdisci-
plinary care system available to patients, families, and caregivers
of persons living with a terminal illness. On the basis of this
definition, palliative care applies not only to people in the later
stages of illness but also to people throughout their disease
trajectory (Worldwide Palliative Care Alliance [WPCA],
2014).
The European Association for Palliative Care (EAPC) has
proposed a definition of palliative care that complements that
of the WHO and extends to the understanding of palliative
care (see Box 34-1). The EAPC definition specifies that
investigations needed to better understand and manage
distressing clinical complications
The European Association for Palliative Care (EAPC) has extended
the understanding of palliative care by stating that:
Palliative care is the active, total care of the patients whose disease
is not responsive to curative treatment. Control of pain, of other
symptoms, and of social, psychological and spiritual problems is
paramount. Palliative care is interdisciplinary in its approach and
encompasses the patient, the family and the community in its scope.
In a sense, palliative care is to offer the most basic concept of care –
that of providing for the needs of the patient wherever he or she is
cared for, either at home or in the hospital. Palliative care affirms life
and regards dying as a normal process; it neither hastens nor post-
pones death. It sets out to preserve the best possible quality of life
until death. (www.eapcnet.eu)
The EAPC definition specifies that palliative care is called for when
curative treatment is no longer possible. Furthermore EAPC empha-
size an interdisciplinary approach in the definition.
Until recently, researchers often used the terms “palliative” and
“terminal” interchangeably and made fairly strict distinctions
between the curative and the palliative phase. Today the pallia-
tive phase is rather considered as a continuum starting from the
time of diagnosis (Radbruch & Payne 2009).
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524 PART IV ■ Service Delivery for the Aging Client
palliative care is called for when curative treatment is no
longer possible.
The terms “palliative” and “terminal” have been used inter-
changeably, and today the palliative phase is rather considered
as a continuum starting from the time of diagnosis (Radbruch,
& Payne, 2009). According to the WHO approximately
3 million patients around the world received palliative care
in 2011. Only 20 countries worldwide have palliative care
well integrated into their health-care systems (WHO, 2013;
WPCA, 2014), and outside Europe, North America, and
Australia access to palliative care is rare (WPCA, 2014).
AROUND THE GLOBE: Provision of Palliative Care Around
the World
Most palliative care is provided in high-income countries, while
almost 80 percent of the global need for palliative care is in the
low- and middle-income countries (WHO, 2013; WPCA, 2014).
Outside Europe, North America, and Australia access to palliative
care is rare (WPCA, 2014). A significant number of older people do
not die in their preferred place (Ahearn, Nidh, Kallat, Adenwala, &
Varman, 2013).
Palliative care for people with life-threatening diseases is
organized and provided in a variety of ways. In some coun-
tries, palliative care is divided into a basic and a specialized
level. Basic-level palliative effort concerns services provided
in general hospital wards performed by hospital staff and in
patients’ homes provided by the general practitioner and
community-based home-care services. Specialized-level
palliative care is provided to patients with complex sympto-
matology demanding specialized efforts and usually provided
by a specialist palliative care team (Neergaard, 2009; Social-
styrelsen, 2006; Sundhedsstyrelsen, 2005). However, very few
studies have identified who receives and who misses out on
specialist palliative care. Most studies are conducted in regard
to cancer patients, and little is known of the extent to which
noncancer patients receive specialized palliative care and in
particular if and how occupational therapy and physiotherapy
are part of such services (Rosenwax & McNamara, 2006).
Palliative home care includes all palliative care services
provided in the patients’ homes. For older people living in
nursing homes, the facilities are considered their homes
(Neergaard, 2009). Over the past century, the location of
deaths has increasingly become hospitals, nursing homes,
and, less often, people’s “own” homes (Teno et al., 2004).
Prior to that time, death almost always occurred in the per-
son’s primary residence. Yet we have not been able to identify
studies comparing the quality in end-of-life care between
death in the hospital setting and at home, whether nursing
home or one’s own home. A study of older patients’ preferred
place to die showed that older people in the United Kingdom
typically do not die in their preferred place; they are aware of
the type of care offered by hospices, which might facilitate
dying in the site they would prefer (Ahearn et al., 2013).
Palliative care and hospice services are characterized by
their emphasis on interdisciplinary approaches, which should
include occupational therapy and physiotherapy. Occupa-
tional therapy and physiotherapy are included in palliative
and hospice care to varying degrees in different countries
around the world.
AROUND THE GLOBE: Occupational and Physiotherapy
in Palliative Care
Occupational therapists and physiotherapists are included
in palliative and hospice care to a varying degree in different
countries around the world. Physiotherapy is more commonly
part of palliative and hospice care (J. Taylor et al., 2013).
In Canada less than 1 percent of therapists work in palliative
and hospice settings (Lala & Kinsella, 2011), whereas palliative
occupational therapy and physiotherapy is more commonly
provided as palliative care services in countries like the United
Kingdom (Cooper, 2006) and, to a lesser extent, in the United
States (Pizzi & Briggs, 2004). In Scandinavia, occupational therapy is
rarely a natural part of specialized palliative care services through,
for example, hospices and palliative care teams. Physiotherapy
is more often an integrated part of the palliative care team. In
nursing homes such as in Sweden, it is likely that occupational
therapy is provides support to those who are facing end of life
(Sviden et al., 2009). In Denmark, occupational therapy is not yet an
integrated part of palliative care, despite the fact that occupational
therapists provide services directed to end-of-life support
(Hjelmroth, 2007; la Cour, Johannessen, & Josephsson, 2009).
Living in Old Age With a Life-Threatening
Illness
Living in old age with a life-threatening illness is characterized
by ongoing losses and changes that affect not only the indi-
vidual but also his or her family and other people close to the
patient (Breitbart, 2002; Emami & Tishelman, 2004). The
losses are closely related to the deterioration and fragility that
accompanies aging, concurrent with other health conditions,
comorbidity and symptoms, side effects of treatment, and
problems related to body function, activity, and participation
in life situations (Kopp, 1997; Zachariae, 2004). Cheville
(2001) highlights the fact that fear of impending death is
often eclipsed by concern over functional decline and uncon-
trolled symptoms. Furthermore, Lindqvist, Widmark, &
Rasmussen (2006) identified that, for those living with con-
ditions such as incurable cancer, bodily problems such as
deterioration and impaired functionality were given meaning
by patients’ perceptions of living in a cyclic movement of
losing and reclaiming wellness. In addition to the decline in
body systems and body function described in other chapters,
typical physical problems for people with life-threatening
illnesses are pain, fatigue, and side effects of medical treat-
ment such as nausea and confusion along with psychological
problems such as anxiety and depression (Zachariae, 2004).
4605_Ch34_521-538 31/10/17 12:40 PM Page 525
Elders are prone to experience losses that affect their capacity
to carry out and engage in basic ADL, social roles, and valued
relationships (Cheville, 2001; Jacobsen, Jørgensen, Dalgaard,
& Jørgensen, 1998). Regarding the latter, it is well known
that social relations are of essential importance for well-
being in end of life (Koffman, Morgan, Edmonds, Speck, &
Higginson, 2012) (Figure 34-2).
Changes in the way families live and work can leave older
people increasingly isolated and vulnerable which in turn
affect their sense of belonging within society (Davies, 2004).
In addition, the older person faces existential concerns in that
life is moving toward its end (Davidsen-Nielsen, 1995; Hansen,
2003; Kübler-Ross, 1995). Thus old age and a life-threatening
illness can elicit strong emotional reactions, exacerbated
by a discourse of death associated with fear and uncertainty
(McKechnie, MacLeod, & Keeling, 2007; Sonntag, 1991;
Tritter & Calnan, 2002).
A model commonly used (Hagelin, 2008; Hansen, 2003)
for comprehending the experiences of dying was proposed by
Kübler-Ross (1995), who identified five stages that may be
experienced in the dying process. The first stage is denial and
isolation, which is common among almost all patients not
only at the beginning of disease but also later on. The second
and third stages involve anger and bargaining as the individ-
ual wishes to live longer. The fourth stage is dominated by
depression, often seen when the person can no longer deny
the conditions and anger is replaced by feelings of loss. The
final stage is acceptance, when the patient has sufficient time
and is no longer depressed or angry about “destiny” (Kübler-
Ross, 1995). However, Levine (1982) has argued that there
are no stages but only the “incessant changes of the mind.”
Levine suggested that the stages of dying are constantly
changing in the process of an ordinary day and in the face of
reality. With Levine’s arguments in mind, the stages may not
only be seen as distinct entities but also as ongoing processes
of dying.
Hansen (2003) suggested a typology of the suffering
experienced by people with incurable cancer. Living with
FIGURE 342 Having loved ones present at the time of death can
be comforting both to the person who is dying and the family
members. CandyBoxImages/iStock/Thinkstock
CHAPTER 34 ■ End of Life 525
the awareness of being incurably ill, which includes losing the
hope for cure, and being dependent on professionals are
among the main features of suffering that Hansen identifies.
Others are fighting for acknowledgment, protecting oneself
from realities, and experiencing powerlessness. In addition,
the individual has to adjust to the unpredictability of illness
and fear of the future, exacerbated by increasing pain, while
simultaneously struggling to maintain or regain physical
strength, independence, and possibilities for meaningful
activities in the face of increasing limitations.
Rasmussen and Elverdam (2007) highlighted that the con-
frontation with death made many participants reorganize their
lives and prioritize how they would spend the time remaining
to them. In another study, Rasmussen and Elverdam (2008)
suggested that the natural structure and order of daily living,
which had always been taken for granted disappeared in
contexts of palliative and hospice care. Vrkljan and Miller-
Polgar (2001) suggested that life-threatening illness challenges
the individual’s ability to engage in meaningful occupation as
a consequence of decreasing choice and control in everyday
occupations.
As another dimension to end of life, philosophers such as
Søren Kierkegaard (1969) and Paul Ricœur (Ricœur, 2007;
Ricœur, 2009) suggest that life in the face of death and being
confronted with one’s mortality may retain potentials for a
more intense existence and awareness of the present (Ricœur,
1984). Studies of older cancer patients, for example, suggest
that advanced cancer can bring about an increased apprecia-
tion of the small things in daily living (Henriksen, Tjornhoj-
Thomsen, & Hansen, 2011; la Cour & Hansen, 2012).
A Good Death and Different Cultures
Research has shown that the ways in which people cope with
the dying are individually shaped, often mirroring strategies
developed over the life course. Providing effective and high-
quality therapy for older people at the end of life requires an
understanding of the nature and course of dying as well as what
constitutes a good death in different cultures and contexts.
In Time for Dying, Glaser and Strauss (2007) discussed
the question of when and how fast a dying person will die.
Certainty and time are the two key factors they use to describe
types of “death expectations”: (a) certain death at a known time,
(b) certain death at an unknown time, (c) uncertain death but
at a known time when certainty will be established, and (d) un-
certain death and an unknown time when the question will be
resolved. The different time expectations for death influence
the dying process for the dying person as well as the family
and health-care staff and therapists (Glaser & Strauss, 2007).
There is no consensus about a single definition of what
constitutes a good death. According to the U.S. Institute of
Medicine (IOM; 1998), the good death is “free from avoid-
able distress and suffering for patients, families and care-
givers; in general accord with patients and families wishes;
and reasonable consistent with clinical, cultural and ethical
standards” (p. 4). Central to the understanding of the good
4605_Ch34_521-538 31/10/17 12:40 PM Page 526

526 PART IV ■ Service Delivery for the Aging Client

death is that the person is allowed or enabled to die on his or

her terms relatively pain free and with dignity. BOX 342 Factors Important for a Good Death
Accommodating a good death requires attention to cul-
An awareness of dying by the individual and significant others
tural aspects in end of life. Different countries have different
Social adjustment and personal preparations as more time with
cultures, with distinct values, beliefs, morals, and customs
loved ones
for death and dying (Pahor &Rasmussen, 2009). In Western
Delegation of care, comfort, and responsibilities
cultures, the hospice movement and specialist palliative care
Control of symptoms
have set the frame for health-care services in end-of-life and
Preparation for death
the discourses shaping understandings of the dying trajectory,
Opportunity for closure or a sense of completion
which may not be equally appropriate in other cultures. Pahor
Good relationships with family and health-care professionals,
and Rasmussen (2009) identified two predominant schools
farewells
of thought informing ethical beliefs about death and dying.
Access to spiritual and/or religious support
The first is represented by the northern European and the
Public preparation
Anglo-Saxon world, including North America, where codes
of ethics are informed by American utilitarian philosophy. From Institue of Medicien, 1997; Kellehar, 1990.
The central principles are patients’ autonomy, beneficence,
nonmaleficence, and justice. The second school of thought
reflects southern Europe with traditions rooted in the Aris-
totelian philosophy based on values that community is greater
than the individual (Pahor & Rasmussen, 2009). This is seen,
for example, in cultures where the role of the terminally ill
person’s family is more important than independence and
autonomy. Also in countries where the Catholic Church
prevails, different views of life and death influence preferences
for support at end of life. For example, in some countries,
people may not value the need to openly acknowledge dying
or may reject disclosing a terminal diagnosis to the individual
who is dying (Fainsinger et al., 2010).
Because of such differences worldwide and within nations,
cross-cultural considerations must be incorporated in pallia-
tive services. Moreover, cultural differences and ethical beliefs
shaped by the ways people live their lives with family cultures
and societal circumstances in time and place must be carefully
considered with respect to both individual as well as collective FIGURE 343 Family support means a great deal to the dying and can
differences to ensure ethical palliative care at end of life. form warm memories for younger individuals. Photo courtesy of Karen
Kellehar (1990) and the IOM (1998) emphasize certain la Cour. Reprinted with permission.
common features for a good death, as shown in Box 34-2
When providing therapy services for an older person at the
end of life, occupational therapists can significantly improve consequences for these individuals (Ledderer, la Cour, &
quality of life by creating meaning and maintaining integrity Hansen, 2014). In Western countries, women are likely to
through occupational engagement and experiences that help live, on average, 6 years longer than men; this means that
the client achieve a good death (Figure 34-3; Burkhardt et al., when an older person loses a spouse or partner, more often
2011). the woman is the one left to live on (Davies & Higginson,
Physiotherapists can facilitate mobility and transfers, as 2004). Toward the end of life, people who are dying progres-
well as maintain a minimum of physical functioning. Work- sively deteriorate in regard to their functional independence
ing with the dying person’s goals and needs with a palliative and ability to participate in life, often requiring increasing
care approach to everyday living whether at home or in more amounts of help and care from others in the period leading
supportive environments is one way to ensure therapists fulfill up to death (Murray, Kendall, Boyd, & Sheikh, 2005).
this role in an effective manner (Frost, 2001). Hence, for the family, the decline of the person dying can
have consequences for practical matters like having to take
over roles and obligations and provide more extensive support
The Influence of End of Life on Close Family
in daily activities, in addition to the emotional implications
and Relatives
including coping with concerns, fears, and mourning for the
End of life also affects the immediate family, significant dying process and the future. Furthermore, the disease tra-
others, and relatives (Milberg, Strang, & Jakobsson, 2004). jectory may affect socioeconomic status, social networks, and
However, researchers have only recently focused on the personal resources, including quality of life (Hellbom,
4605_Ch34_521-538 31/10/17 12:40 PM Page 527
Bergelt, Bergenmar, & Johansen, 2011; Steinvall, Johansson,
& Berterö, 2011). Challenges can include communication
and interpersonal problems in the family, which in turn may
complicate the dying trajectory (Fletcher, Lewis, & Haberman,
2010; Morgan, Small, Donovan, & McMillan, 2011; Song
et al., 2011). The emotional strain caused by concerns for
a partner or relative can lead to stress, depression, and psy-
chosomatic reactions, especially when the relative is the
primary support and caregiver (Ezer, Chachamovich, &
Chachamovich, 2011; Steinvall et al., 2011). Hence, the end-
of-life phases may be a challenging time for the significant
other and close relatives.
The emotional strain of living in proximity to a dying
person can continue for extended periods of time, even after
the loved one’s death (Arnaert et al., 2010). Although pallia-
tive care services aim to meet the needs of family and rela-
tives, many issues can influence the dying process and affect
patients and their relatives (Arnaert et al., 2010; Ezer et al.,
2011). A study by Teno et al. (2004) found that family
members of decedents who received hospice services at
home were most likely to report a favorable dying experience.
Along with the growing awareness of the relational con-
sequences of end-of-life circumstances, there is an increasing
need to develop ways in which occupational therapists and
physiotherapists can address relational issues when working
in palliative care to support the persons closely affected
(Jacques & Hasselkus, 2004). For the family, lack of appro-
priate palliative care can be an additional burden.
Needs for Palliative Occupational
Therapy and Physiotherapy
Identified needs form the basis for initiating, developing, and
evaluating health-care services—in this case palliative occu-
pational therapy and physiotherapy for older people in the
end of their lives (K. Taylor & Currow, 2003). To understand
the palliative needs for occupational therapy and physiother-
apy, therapists must first understand the general palliative care
needs of older people in the last stages of life. A report made
by the Health Evidence Network for the WHO (Davies,
2004) identified unmet needs that included pain, issues for
noncancer illnesses (such as heart conditions and dementia),
multiple problems of aging, concerns about communication
and preferences for place of care and place of death.
According to Strang, Koop, and Peden (2002) and sys-
tematic reviews (Albinsson & Strang, 2002; Bee, Barnes, &
Luker, 2009), palliative care problems and needs in end-of-
life stages pertain to four dimensions covering physical,
psychological, social, and existential areas. Physical dimensions
typically include control of symptoms such as pain, fatigue,
and sensibility problems as well as problems due to functional
decrease including mobility, endurance, and body mechanics
and loss of daily routines and activities including ADL
ability, self-care, home management, and leisure. The most
common psychological dimensions are issues of fear and worry,
CHAPTER 34 ■ End of Life 527
anxiety, and increased risk of depression and loss of identity
and self-worth. Social dimensions pertain to, for example, loss
of prior social roles and network, communication, and inter-
action with family members and caregivers, dealing with
marginalization and issues related to where the client can
live (home/home care, hospital, nursing home, hospice, or
other). The existential dimension involves life crisis and the
awareness of end of life (Davies, 2004; Frost, 2001; Harding
& Higginson, 2003; Strang et al., 2002; K. Taylor & Currow,
2003). Problems and needs deriving from these dimensions
affect quality of life in the end-of-life phase in many ways,
for example, by interfering with sleep, ADL, and social in-
teraction (Allard, Maunsell, Labbé, & Dorval, 2001).
Palliative care needs in relation to occupational therapy
and physiotherapy especially concern levels of body function,
activity, and participation in relation to given environments:
■ problems and needs related to physical functioning such as
pain, depression, fatigue, worry/anxiety, physical weakness,
and physical inactivity (Santiago-Palma & Payne, 2001); and
■ ability to perform and engage in needed and desired occu-
pations contributing to quality of life on a daily basis, such
as maintaining occupations, preserving physical and mental
functions, and maintaining a sense of well-being (Lyons,
Orozovic, Davis, & Newman 2002).
The needs vary widely within clients and different cultures.
Clients may wish to spend time and energy with family and
friends, for example, visiting old friends or sharing memories
with relatives. Some wish to prepare for death while making
memory items for their loved ones, telling their personal
history, or writing farewell letters.
A prospective study of patient-identified unmet needs
among cancer patients, for example, showed that 30.8 percent
of 104 participants reported unmet ADL needs. A larger
number of females than males reported unmet needs, and
older patients reported higher levels of needs (K. Taylor &
Currow, 2003). Recent research reported major problems and
needs in relation to ADL among 118 clients with advanced
cancer. The majority of problems were within self-care and
leisure (Lindahl-Jacobsen, 2014). A cross-sectional study of
the needs related to daily activities in the home environment
with 164 clients with advanced cancer showed that the prob-
lems identified primarily were within recreational activities,
social activities, mobility, and domestic activities (Brandt, la
Cour, & Waehrens, 2014).
Older people facing imminent death prioritize maintain-
ing a sense of control, integrity, and being connected with
important others (Lala & Kinsella, 2011). In old age, as
people may lose hope for cure and prolonged life, their need
and desire for meaningfulness, integrity, and dignity at the
very end of life may be more important than problems related
to function. For older people in the final stages of life, there is
a significant focus to connect to past, present, and future lives,
not only of the life the person has been part of themselves but
also the life ahead of their descendants (la Cour, Josephsson,
& Luborsky, 2005).
4605_Ch34_521-538 31/10/17 12:40 PM Page 528
528 PART IV ■ Service Delivery for the Aging Client
Identification of needs from the perspective of the older
person and the immediate relatives in an ongoing dialogue
with the therapists (health professionals, occupational ther-
apists and physiotherapists) is essential, as therapists must
integrate functional dimensions of illness and functioning
along with the older person’s personal meanings, coping strate-
gies, preferences, values, motivation, and resources.
Health Policy and Related Factors
Affecting End-of-Life and Palliative Care
Because of the differences in health-care systems around the
world, the provision of hospice and palliative care varies
among countries and within regions of each country. In many
countries, for example, there is limited or no government
support for palliative care. In others, however, charitable pal-
liative care has developed and operates under permission
(Ferris et al., 2002).
Health policy is fundamental to develop and secure con-
ditions of palliative care services including support of families
and caregivers (Higginson, 1997; WPCA, 2014). Despite
the growing population of older people and the awareness
of end-of-life challenge, studies in different countries have
shown that care for dying patients is far from optimal due
to lack of communication, unmitigated symptoms, inade-
quate pain control, unaddressed fear and spiritual needs, and
patients being isolated or even left to die alone (Ellershaw &
Ward, 2003; Pahor & Rasmussen, 2009; Teno et al., 2004).
Although occupational therapy and physiotherapy always
have been provided to the elderly population, care focused on
death and dying has been given little attention.
Integrated care pathways, which include structured mul-
tidisciplinary care plans that detail essential steps in caring
for patients with specific clinical problems, have been devel-
oped to improve care of patients who are in the last days of
life. These care pathways aim to ensure that the most appro-
priate management occurs at the most appropriate time and
that it is provided by the most appropriate health profes-
sional. They can also be used to introduce clinical guidelines
and systematic audits of clinical practice (Hockley, Dewar,
& Watson, 2005).
The Liverpool Care Pathway is an example of an inte-
grated care pathway specifically for the dying phase of palli-
ation (Chan & Webster, 2013); it was developed in late
1990s to disseminate the high standard of care provided at
the Marie Curie Hospice. This pathway includes descriptions
of targets for care for dying clients and caregivers in relation
to physical, psychological, social, and spiritual aspects; exam-
ples of such targets include suggestions for what palliative
care options to consider and whether nonessential treatments
should be discontinued. This care pathway is used interna-
tionally, and in the United Kingdom it is approved as Best
Practice by the National Health Service (2012).
Another kind of policy document to ensure optimal pal-
liative care for older people facing end of life can be enabled
through advance care planning (ACP), increasing the likeli-
hood that patient and family preferences are respected (Brown
et al., 2005; Tan, Digby, Bloomer, Wang, & O’Connor,
2013). However, the implementation of directives for ACP
varies across nations and within countries (Brown et al., 2005;
Malpas, 2011; Tan et al., 2013).
Profession-specific policies and clinical guidelines advising
palliative occupational therapy and physiotherapy are being
developed worldwide. In the United States, for example, the
American Occupational Therapy Association has published
a statement with directions for occupational therapy in
end-of-life care to inform therapists as well as relevant stake-
holders (Burkhardt et al., 2011). In Canada, the Canadian
Association of Occupational Therapists (2011) has stated
its recommendations for actions in regard to occupational
therapy interventions in end-of-life care. The EAPC (2010a,
2010b) has defined the roles of occupational therapists and
physiotherapists, the British Pain Society has made clinical
guidelines for cancer pain management supported by the
Association for Palliative Medicine and the Royal College
of General Practitioners (Raphael, 2010), and in Denmark
clinical guidelines for physiotherapy within palliative care has
been developed (Dansk Multidisciplinær Cancer Gruppe
for Palliative Indsats, 2013). The guidelines typically consist
of clinical recommendations for practice based on recent
research, such as concrete competences, tasks, and education.
Clinical guidelines can ensure the implementation of best
practices but may also increase the risk of missing specific
individual needs.
End-of-Life Palliative Occupational
Therapy and Physiotherapy
Interventions
End-of-life support is a special area of intervention for occu-
pational therapists and physiotherapists. It calls for a holistic
approach, which can be seen as a unique opportunity for
therapists to integrate the knowledge they have from differ-
ent areas of therapy. That is, in palliative intervention, the
knowledge base from physical dysfunctions and psychiatry
and social functioning must be synthesized to effectively serve
palliative patients and their families. These ideas are in line
with contemporary approaches to life at the end-of-life
according to Carpenter (2014), who pointed to a holistic,
bio-psycho-social-spiritual approach serving what he called
“scrupulous attention” to the full spectrum of needs as death
draws near.
Palliative occupational therapy and physiotherapy com-
plement other palliative care services through a focus on
different aspects of activity which for occupational therapy
includes enabling individuals to engage in meaningful every-
day activities and maintain occupational roles of daily living
that are perceived by the individual to be important given the
limitations of time and of physical ability (Kealey & McIntyre,
2005; Lloyd, 1989) and for physiotherapy to maintain physical
4605_Ch34_521-538 31/10/17 12:40 PM Page 529
functioning (J. Taylor et al., 2013). Although occupational
therapy at end of life is not uncommon, evidence that
supports palliative occupational therapy is in its early devel-
opment with an increasing need to evidence base its potential
effectiveness (la Cour et al., 2005; Lindahl-Jacobsen, 2014;
Sviden et al., 2009). Palliative occupational therapy requires
a constant iteration of assessment and reassessment of the
needs of the individual client and his or her caregivers to
adjust and modulate intervention and support (Cooper,
2006).
When working with an older person in the end-of-life
phase, the role of the occupational therapist is to value the
person’s remaining life, to support the person in living in the
present by optimizing possibilities for activity and engage-
ment that enhance integrity and quality of life according to
the person’s and the family’s needs and wishes, and to assist
in the preparation for approaching death within the ethical
guidelines and the professional code of conduct (Cooper,
2006; Penfold, 1996; Trump, Zahoransky, & Siebert, 2005).
Occupational therapy interventions accommodate the expe-
rienced problems and needs by providing varied interven-
tions, including teaching energy conservation techniques;
educating clients in how to manage symptoms such as pain,
dyspnea, and anxiety; and providing activity management
strategies to decrease the detrimental impact of symptoms
such as fatigue (Burkhardt et al., 2011; Lemoignan, Chasen,
& Bhargava, 2010). Studies on the use of creative activities
in palliative occupational therapy have shown to be effective
in easing life in proximity to death (la Cour et al., 2005;
la Cour, Josephsson, Tishelman, & Nygård, 2007; Sviden
et al., 2009).
✺ PROMOTING BEST PRACTICE
Effects of Using Creative Activities With Clients Who
Have Life-Threatening Illnesses
Participation in creative activities allowed clients to cope
with declining abilities and to create connections to life. In
addition, clients reported an improved existential awareness
of their past, their present, and possible future (la Cour et al.,
2007).
The role of the physiotherapist in palliative care is to im-
prove functional independence, provide meaningful physical
activity (Mackey & Sparling, 2000; Jensen et al., 2014),
and minimize pain and symptoms of the disease while main-
taining body functions (J. Taylor et al., 2013). In addition,
physical exercise has shown significant positive effects on
cancer-related fatigue (Andersen et al., 2013), vitality, mus-
cular strength, physical and functional activity and emotional
wellbeing (Adamsen et al., 2009) in patients undergoing
chemotherapy, even in people with advanced disease (Adamsen
et al., 2006). Exercise programs must be tailored to the indi-
vidual needs of the client and should start cautiously, build
gradually, and be within the client’s tolerance levels (Douglas,
2005).
CHAPTER 34 ■ End of Life 529
✺ PROMOTING BEST PRACTICE
Living With Cancer-Related Fatigue
A 4-week fatigue management program was carried out by
a physiotherapist and an occupational therapist specializing
in palliative care. The program was delivered in a hospice
day care program with patients with cancer. Clients who
completed the program reported decreased fatigue levels,
overall improved functioning, and enhanced ability to cope
(Saarik & Hartley, 2010).
Therapy will differ significantly depending on whether the
client is in an early, late, or terminal stage. The client’s context
also influences how and what therapy should and can encom-
pass. Context is the place where the older person is living—
at home, in a nursing home, or in a hospice. For example,
therapy for clients living at home may focus on establishing
a safe environment, whereas the focus of therapy for clients
living in nursing homes may be optimizing the use of struc-
tural supports in the residence. For clients in hospice, inter-
ventions may be aimed at preparing for imminent death
through saying goodbye, for example, or focusing on sup-
portive and spiritual needs that may be more relevant. In ad-
dition, the social network surrounding the person should be
considered at each stage of the intervention and problem-
solving process. Hence, the therapy trajectory as a whole
ranges from early planning and decision-making throughout
the intervention, support prior to and following bereavement,
as well as inclusion of family and the cooperation with other
caregivers.
Referral
A client may be referred to occupational therapy or phys-
iotherapy at any point during the end-of-life process.
Referrals often come from the client’s doctor or other
health professional depending on the care pathways in
the given country (Currow et al., 2012). Therapists may
actively inform clients, caregivers, and staff about their
services, given that clients may not be well informed about
how they can help. Being visible in hospital wards and the
use of booklets are ways of advertising which kinds of serv-
ices are available on a hospital unit, in the community, in
a day-care setting, in hospice or at a residential facility
(la Cour & Cutchin, 2013). This can help ensure that appro-
priate referrals occur and unmet needs related to functioning,
activity, and participation are met. Occupational therapists
and physiotherapists can also identify when symptoms
call for referral to other specialized evaluation and treat-
ments such as need for psychologist or social worker.
Hence close attention to changes in the client’s condition
and knowledge of when to refer to other professionals and
how to facilitate such referrals are valuable competencies
to ensure clients receive the appropriate therapy (Carpenter,
2014).
4605_Ch34_521-538 31/10/17 12:40 PM Page 530
530 PART IV ■ Service Delivery for the Aging Client
Assessment
A client-centered approach enables the therapist to establish
a relationship that facilitates dialogue and appropriate inter-
vention priorities of occupational and functional areas. For
example, the client with a terminal illness may prefer to be
washed by a caregiver to save energy to play cards with his or
her grandchild. On the basis of the client’s priorities and
needs, the therapist should assess and analyze the client
and/or caregiver’s performance skills in the desired activities.
Potential tools include the Assessment of Motor and Process
Skills (AMPS; Fisher, 2010), The Canadian Occupational
Performance Measure (COPM; Law et al., 1990; Law,
Carswell, McColl, Polatajko, & Pollock, 2005), Individual
Prioritized Problems Assessment (IPPA; Socialstyrelsen,
2014), the Activities of Daily Living Interview (ADL-I;
Wæhrens, 2010), time-use-diary, and qualitative interview.
Because the ultimate outcome of end-of-life care is support-
ing or improving the client’s and family’s quality of life
(Burkhardt et al., 2011), using “quality of life” tools may also
be appropriate. Within cancer care and palliative care, the
European Organization for Research and Treatment of
Cancer (EORCT) has developed a set of questionnaires
regarding quality of life (http://groups.eortc.be/qol/eortc-
qlq-c30). Because clients receiving palliative care services may
have declining abilities, the therapist needs to take care to
preserve the client’s dignity and minimize the risk of a client
feeling defeated (la Cour, 2008). The therapist assesses
strengths and capacities that support continued engagement
in and performance of desired occupations or functions,
analyzes the supports and barriers of the physical context
and social environment, and identifies the adaptive or com-
pensatory strategies needed to carry out task performance,
keeping in mind that performance will change over time.
Another dimension of the clients’ environment includes
the family members, other caregivers and professional team
members who may provide essential information to complete
the assessment. In some countries, it is standard practice in
palliative care for therapists to include family members as part
of the unit of care; therefore, they need to be integrated in
the assessment process. Identification of the client’s needs,
combined with analysis of the client and caregiver’s perform-
ance skills, allows the therapist to initiate the goal setting
process and identify effective and client-centered interven-
tions to be incorporated into the interdisciplinary plan of care.
Goal Setting
Goal setting with older clients in end-of-life stages requires
attention to individual problems, needs, and wishes (Lemoignan
et al., 2010). The goals of palliative occupational therapy and
physiotherapy are distinct from almost any other life phase
because clients are confronted with myriad unsettling concerns.
For example, they may have to decide whether to preserve
life-sustaining treatment, determine how to communicate a
terminal prognosis to family, adapt to rapid deterioration and
altered capacities, and solidify wishes for the future. In light of
such weighty and compelling issues, setting appropriate goals
for therapy is a great challenge. Older persons differ profoundly
in their level of disease, acceptance, and expectations for the
end-of-life period.
The transition from rehabilitation-oriented goals to pal-
liative is most often gradual (Meredith, 2010). Life continues
to happen right up until the time of death; therefore, the
goals identified by people at end of life often focus on quality
of life; it is thus crucial that the goals are client-centered and
reflect the client’s actual needs along with their individual
needs for independence and autonomy (Carpenter, 2014).
Engagement in personally meaningful activities, relation-
ships, and life roles are viewed as extremely important to
individuals, helping them to maintain a sense of normality
and achieve a sense of occupational identity (Keesing &
Rosenwax, 2011). Every desired activity can contribute toward
giving the client a peaceful end of life.
Intervention
Occupational therapists and physiotherapists play key roles
in assisting each client to attain the occupational roles and
activities that are perceived as being important by the client
or the caregivers, given the limitations of time and physical
ability (Lemoignan et al., 2010; Pizzi & Briggs, 2004).
Occupational therapy staff could support both the client
and their families in this difficult process as they are trained
in enhancing participation in meaningful activities, sensory
stimulation, family and staff education, positioning, and
emotional and spiritual needs (Trump et al., 2005).
Occupational therapy interventions in palliative care include
the following:
■ Prioritizing resources and energy related to daily activities
(Cooper, 2006; Lindahl-Jacobsen, 2014)
■ Teaching compensatory strategies (including home modi-
fications and assistive technologies) (Cooper, 2006; Lindahl-
Jacobsen 2014)
■ Educating clients, caregivers, and health professionals
(transfer, relaxation techniques, ergonomics, and lifestyle)
(Cooper, 2006)
■ Training to accomplish daily activities (Cooper, 2006;
Frost, 2001)
■ Managing fatigue (Cooper, 2006; Crompton, 2004; Saarik
& Hartley 2010)
■ Providing opportunity for enjoyment (la Cour et al., 2005,
2009)
■ Providing creative and symbolic outlets through engage-
ment in meaningful activities (la Cour 2008; la Cour et al.,
2007)
■ Guiding establishment of routines through daily activity
patterns to facilitate a sense of continuity (Cooper, 2006;
Frost, 2001; la Cour et al., 2009).
In addition, calming sensory output, such as the client’s
favorite music, audio books, family pictures, scents or video,
4605_Ch34_521-538 31/10/17 12:40 PM Page 531
may serve to improve quality of life. Support for commu-
nication needs and positioning to secure maximum comfort
as well as the occupation of dying are also considered as a
part of the occupational therapy practice (Pizzi & Briggs,
2004).
Physiotherapy interventions in palliative care include the
following:
■ Pain relief (transcutaneous electrical nerve stimulation
[TENS], heat, massage, lymphedema treatment, acupunc-
ture) (Frost, 2001; Frymark, Hallgren, & Reisberg, 2009)
■ Physical activity (Frost, 2001; Frymark et al., 2009)
■ Therapeutic massage (Frost, 2001; Frymark et al. 2009)
■ Fatigue management (Frymark et al., 2009, Saarik &
Hartley, 2010)
■ Passive movements (Frost, 2001; Frymark et al., 2009)
■ Relaxation exercise (Frymark et al., 2009)
■ Positioning (rest/comfort) (Frost, 2001; Frymark et al.,
2009)
■ Advising (family/relations) (Frost, 2001; Frymark et al.,
2009)
Physiotherapy interventions also include massage, manual
lymphatic drainage, mobilization, and manipulation (Frost
2001), which are primarily passive treatments. Occupational
therapy calls for a more active approach with focus on assess-
ing mobility, transfers, and self-care activities with a view to
teaching alternative techniques of coping and prescribing
equipment to aid independence (Cooper, 2006). Treatment
of lymphedema secondary to conditions such as AIDS,
cancer, and infections is most effective when provided by an
interprofessional team.
In conjunction with the palliative care team, occupational
therapists and physiotherapists can address emotional pain
and feelings of hopelessness and helplessness by approaching
crucial aspects such as the psychological pain of isolation and
loss of roles (Marcil, 2006).
The therapists formulate an intervention plan in collabo-
ration with the client, the caregivers, and the rest of the team.
The intervention plan identifies the outcomes of intervention,
the approaches to be used, and the mechanism for service
delivery (Trump et al., 2005). The processes of assessment
and goal setting allow therapists to formulate intervention
plans that will address identified problems and achieve
desired goals (Burkhardt et al. 2011).
Analysis of activity tolerance levels and education in
skills can enable functional restoration without provoking
painful episodes. Techniques such as pacing, planning,
prioritizing, energy management, activity analysis, work
simplification, time management, compensatory techniques,
ergonomic principles, and the reorganization of routines
can be taught to provide clients with the skills necessary to
restructure their lifestyle, thus minimizing painful episodes.
Analyzing, grading, and adapting activities allow clients
to continue managing themselves within their ability, tol-
erance level and pain parameters (Crompton, 2004; Strong
& Bennet, 2002).
CHAPTER 34 ■ End of Life 531
Engaging in meaningful occupations not only improves
quality of life but can also serve as an important tool for
symptom management because focusing on meaningful
occupation can make clients pay less attention to physical
symptoms (Burkhardt et al., 2011). Appropriately prescribed
and graded activities can be used to increase activity tolerance,
autonomy, social integration, self-esteem, and competency,
and can also decrease pain behaviors (Șahin, Akel, & Zarif,
2017).
Considering that the majority of terminally ill clients wish
to die at home (Griffin, 1991; McClement, 2001; Tang &
McCorkle, 2003; Townsend et al., 1990), adequate provision
of home nursing along with support services and equipment
are key issues in achieving a home death (Addington-Hall,
Altmann, & McCarthy, 1998; Addington-Hall, Fakhoury,
& Mc Carthy, 1998). Typically the occupational therapist
addresses aspects of lifestyle management and adapts the
home environment to accommodate the client’s needs and
wishes for the last days, while the physiotherapist can also be
involved in some aspects (e.g., positioning and prescription
of walking aids if necessary); such interventions are vital to
achieving the best outcomes (Kealey & McIntyre, 2005).
Bereavement for Older Persons in End
of Life and for Family Members
Engagement in creative and aesthetic activities serves a func-
tional purpose, as well as providing foundations for connect-
ing, disconnecting, and rearranging connections to life; for
confronting and working through psychosocial developmen-
tal issues at the end of life, and for working through grief and
mourning over the life that is moving toward an end (la Cour,
et al. 2005; Luzzatto, Sereno, & Capps, 2003). Research
shows that families of clients who are dying and who are
receiving care from specialists in palliative care experience fewer
psychological symptoms compared with families of clients
receiving standard care (Gysels & Higginson, 2003).
Family Involvement and Support
Studies involving both clients and their close family members
in end-of-life care demonstrate that joint involvement in
intervention services can strengthen patients and their rela-
tives in their quest to better understand themselves and each
other, for example, to develop skills for communication and
mutual care and find inspiration for alternative ways for living
during phases with terminal illness (Ledderer et al., 2014).
Occupational therapists and physiotherapists working in
palliative care can draw on this knowledge by providing clients
and relatives opportunities for exchange with others in similar
circumstances. Attention to support of relatives can be increased
not only in formal palliative care programs but also in other
kinds of more informal peer support networks established for
example in local networks in communities. A study of patients
and relatives involved in cancer rehabilitation demonstrates
4605_Ch34_521-538 31/10/17 12:40 PM Page 532
532 PART IV ■ Service Delivery for the Aging Client
that engagement in valued activities can direct their attention
on other aspects of their life besides disease-related fear and
worry (Ledderer, la Cour, & Hansen, 2014). Similar princi-
ples apply for palliative care.
Families involved in end-of-life caregiving face multiple
roles and responsibilities added to their everyday roles and
chores presenting secondary stressors, which may result in
role overload (Pickens, O’Reilly, & Sharp 2009). Role over-
load may lead to occupational imbalance and dissatisfaction
in everyday life, in turn affecting health and family dynamics.
In such circumstances, therapists must explore factors
involved in the caregiving role and provide support to family
caregivers in decision-making for their loved ones and in
balancing role and responsibilities with careful attention to
their own needs, grief, and mourning (Dumont, Fillion,
Gagnon, & Bernier, 2008; Pickens et al., 2009). In a study
of family caregiving in end-of-life, Pickens et al. (2009)
found that holding on to normalcy was a key strategy for
family members and hence a significant aspect for occupa-
tional therapists to support through daily activity patterns
and traditions.
Palliative Care: A Team-Based
Approach
As described in the beginning of this chapter, hospice phi-
losophy builds on holistic approaches requiring team coop-
eration and integration of therapies to secure coherence and
coordination of care and support. Optimally, this requires
INTERPROFESSIONAL PRACTICE
Roles of Occupational Therapy and Physiotherapy
Physiotherapy
Focus ■ Improve functional ability
■ Maintain or regain physical independence
■ Provide meaningful physical activity
Assessments ■ Balance and walking tests
■ Patient-Specific Functional Scale (PSFS)
■ VAS Borg-RPE scale
■ Borg-CR10 scale
Interventions ■ Pain relief (TENS, heat, massage,
lymphedema treatment, acupuncture)
■ Physical activity
■ Therapeutic massage
■ Passive movements
that occupational therapy and physiotherapy are part of pal-
liative care, or at minimum that these services are delivered
in close collaboration and coordination with other services.
Several studies have shown that quality of life of both client
and caregivers can be improved by coordinated support
(Gysels & Higginson, 2003).
Some of the challenges for optimal interdisciplinary
collaboration pertain to cultural barriers within systems and
among health-care professionals. Communication and coor-
dination between providers can make cultural barriers visible
and raise awareness of existing and tacit knowledge support-
ing possibilities for collaboration. A shared mutual language
among different health-care providers can facilitate inter-
disciplinary collaboration and coordination. The ICF has
received much attention in Scandinavia as a common concep-
tual classification system useful for rehabilitation and inter-
disciplinary collaboration. Drawbacks of the ICF that may
be evident in palliative care include unqualified differentiation
of main terms such as activity and participation, and insuffi-
cient inclusion of clients’ subjective experiences (Borell,
Asaba, Rosenberg, Shult, & Townsend, 2006; Bromann
Bukhave, la Cour, & Huniche, 2014; Hemmingsson &
Jonsson, 2005).
Collaboration in palliative care does not only pertain to
the health professions involved but equally to collaboration
with clients and families. There is a general growing interest
among health-care providers in involving clients in the design
and planning of services to ensure specialists provide more
client-centered care. Evidence is lacking, but involved clients
reported positive outcomes (Crawford et al., 2002).
Occupational therapy
■ Improve functional ability
■ Support clients in living in the present by optimizing
possibilities for activity and engagement that enhance
integrity and quality of life according to the client’s and
the family’s needs and wishes
■ Adaptive approaches insofar as possible or desired,
maintain self-care and other occupations
■ Assist in the preparation for approaching death within
the ethical guidelines and the professional code of
conduct
■ Individual Prioritized Problems Assessment (IPPA)
■ ADL (I)
■ Canadian Occupational Performance Measure (COPM)
■ Assessment of Motor and Processing Skills (AMPS)
■ Time-use diary
■ Qualitative interviews
■ Prioritizing resources and energy related to daily
activities
■ Care of lymphedema in collaboration with physical therapy
■ Compensatory strategies (including home modifications
and assistive technologies)
4605_Ch34_521-538 31/10/17 12:41 PM Page 533
■ Fatigue management
■ Relaxation exercise
■ Positioning (rest/comfort)
■ Advice (family/relations)
Outcome ■ Motor control
examples ■ Physical ability
■ Symptom management
Appropriate Outcomes for
Palliative Occupational Therapy
and Physiotherapy and Implications
for Practice
Research in many areas of palliative care services has been
difficult because palliative care outcomes, whether related to
quality of care, effectiveness, or cost-effectiveness, are noto-
riously difficult to define and measure, especially given clients’
declining and deteriorating conditions (Barraclough, 2001).
To ensure that dying older people receive the best possible
palliative therapy in the last stages of life, it is important to
evaluate the services therapists provide and to demonstrate
that clients’ needs are being met. By evaluating and docu-
menting palliative occupational therapy and physiotherapy
services, the interventions can be developed and refined,
clients and families can follow support and “progress” even
when it is progress toward farewells, and the effects can sup-
port changes in practice (Cooper, 2006).
Therapists should evaluate whether clients’ goals were
achieved. For example, did the therapist help the client reduce
pain during particular activities? Did the therapist’s educa-
tional intervention help the caregiver to assist the client in
transfer without pain in the home environment? Did the
team manage to arrange for the client to come home to die?
These considerations are crucial to evaluate the success of the
therapy provided. A client’s condition can worsen rapidly,
and therefore goals often have to be short term so that they
can be achieved (Bye, 1998).
Furthermore, outcomes should be evaluated in relation to
the assessments conducted as a basis for intervention to test
for effectiveness of therapy. Such outcome measures typically
pertain to functioning, task performance, processing, and
quality of life. Diaries, for example, can help therapists obtain
information about daily routines, which are useful, both for
intervention as well as outcomes, related to changes in occu-
pational patterns and balance.
The ultimate outcome of end-of-life care is supporting or
improving the client and family’s quality of life. Therefore
quality-of-life measures are commonly employed as primary
CHAPTER 34 ■ End of Life 533
■ Education of client, caregivers and health professionals
(transfer, relaxation techniques, ergonomics and lifestyle)
■ Training daily activities
■ Providing opportunity for enjoyment
■ Fatigue management
■ Creative and symbolic outlets through engagement in
meaningful activities
■ Guide establishment of routines through daily activity
patterns to facilitate a sense of continuity
■ ADL ability
■ Well-being
■ Maintaining roles
■ Social functioning
outcome when testing the effectiveness of end-of-life inter-
ventions, such as palliative occupational therapy and physio-
therapy. To properly measure effects, it is pertinent to use
outcome measures proximal to the given intervention—for
example, ADL and motor and processing skills. Yet, although
difficult to measure, attention to well-being and quality of
life should not be ignored.
SUMMARY
Despite existing programs, the real needs related to everyday
end-of-life circumstances of older people—for pain relief, to
feel involved and listened to, and to enjoy a certain degree of
autonomy—are often not addressed. Pain, physical suffering,
helplessness, loneliness, and marginalization can too often
become part of daily experience in the final phase of life.
Clearly, with the growing population of elderly people and
numbers of people who live for extended periods of time with
life-threatening illnesses, all requiring support when facing
the later stages of life and palliative care, it is necessary to
optimize and strengthen possibilities for occupational therapy
and physiotherapy. To do so, several actions are needed. First
of all, information and knowledge about potential contribu-
tions by occupational therapy and physiotherapy to both
clients in end-of-life stages and caregivers is essential for
appropriate referral to take place.
Second, more research is required to document and specify
the most pertinent needs and to develop palliative occupa-
tional therapy and physiotherapy interventions and evaluate
for their relevance and effectiveness.
Third, ensuring that therapists have been educated to
undertake appropriate and highest-standard interventions is
important. Although the role of occupational therapists and
physiotherapists, in regard to end-of-life services such as
palliative care, has been addressed in the literature (Cooper
2006) and including existing research studies (Meredith,
2010; Chiarelli, Johnston, & Osmotherly, 2014).
In sum, the combined consequences of aging and life-
threatening illness can profoundly affect the life situation of
the individual, including the ability to engage and manage
4605_Ch34_521-538 31/10/17 12:41 PM Page 534
534 PART IV ■ Service Delivery for the Aging Client
necessary and valued occupations. This is where both phys-
iotherapy and occupational therapy may play a significant
role in supporting people to maintain functional capacities,
prioritize limited resources, and find ways to create meaning
in the last period of life. Therapists may help such clients
find relief from pain and worries, adjust activity to their
current abilities and live with an increased appreciation of the
moment, and grapple with understandings of life through,
for example, cultural and creative outlets and affirm life
(la Cour et al. 2005).
CASE STUDY
Catherine Benson is a 68-year-old woman who has
amyotropic lateral sclerosis. She lives alone in an apart-
ment in a large city. Her husband died of a heart attack
when she was 62 years old. She has two adult children
and four grandchildren. She used to work as a teacher.
Catherine has a good social network with family and
friends and plays cards with a group of friends regularly.
Catherine is referred to therapy while she is in hospital to
get a gastrostomy tube placed. She has severe difficulties
with both sensory and motor functions in her right upper
extremity.
The physiotherapist meets with Catherine to discuss
problems and needs and to assess whether there are phys-
ical interventions to be initiated. They agree that there is
no need for physiotherapy at present. The occupational
therapist receives a referral with a prescription for a home
visit because Catherine feels uncertain whether she can
manage her daily activities in the home environment.
When the occupational therapist first visits Catherine
at the hospital unit, the therapist asks Catherine about her
condition and her activities, her family and her interests,
needs and wishes. Catherine talks about her home and
shares that she has a passion for playing cards. She is very
sad that she cannot play cards with her friends because of
mobility limitations in her right arm. The occupational
therapist offers a cardholder for her to try.
Later that week the occupational therapist conducts a
home visit and assesses the various activities that Cather-
ine needs to do on a daily basis. Together they set goals
for the intervention. Making dinner for friends and family
is important to Catherine because this activity connects to
her role as a woman and host preparing meals and inviting
friends and family to her home. The therapist evaluates
accessibility of the environment, and she and Catherine
arrange a training session in the occupational therapy
department where Catherine will make dinner and the
therapist can observe and introduce her to assistive devices.
In the training session, Catherine manages to make the
entire meal using the assistive devices and without assis-
tance from the occupational therapist. The occupational
therapist makes necessary arrangements and coordinates
with an occupational therapist in the community so
Catherine can be discharged to her home.
After 3 months, Catherine’s condition worsens, and
she is readmitted to the hospital. The physiotherapist and
the occupational therapist provide ongoing intervention,
as Catherine’s needs change. In the terminal phase,
Catherine is affected by increased physical limitations and
pain. Still, when the therapists ask her about her needs,
she is determined to make scrapbooks for her grandchildren
to provide them with information on her own childhood.
The therapists arrange for Catherine to get the necessary
materials to make the scrapbooks. Catherine dies in hospital
on Christmas Eve after finishing the scrapbooks for her
four grandchildren.
Questions
1. Which assessment tools could be appropriate to use
in this case?
2. How could Catherine’s fear be handled?
3. How would you work with short-term goals in
regard to Catherine’s situation?
4. How would you consider your responsibilities in
regard to Catherine’s family after she died?
Critical Thinking Questions
1. What are the key factors related to occupations for
older persons facing end of life?
2. What kind of challenges may older persons experi-
ence in regard to death and dying?
3. Discuss the ethical dilemmas that may arise when
providing palliative therapy?
4. What do you think are the most important contribu-
tions occupational therapy and physiotherapy can
provide for people in the late stages of life?
5. How can therapists work together with the family of
a person at end of life?
6. How can therapists use past and future elements in
their therapy with people at end of life?
7. Discuss how and when to step back when a person
should no longer receive intervention from occupa-
tional therapist or physiotherapist.
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Bette Bonder
“ Do not deprive me of my age. I have earned it.
—May Sarton, The Poet and the Donkey: A Novel
LEARNING OUTCOMES
By the end of this chapter, readers will be able to:
1. Identify demographic developments that will affect aging in
the future.
2. Describe trends in social, cultural, and personal characteris-
tics that describe expectations for aging in the coming
decades.
3. Discuss emerging trends in creating meaning in later life.
4. Describe ways in which changing social and physical envi-
ronments may change the experience of later life.
5. Discuss emerging factors in health care that will alter strate-
gies for working with older adults in the future.
6. Identify the ways in which these various trends interact to
affect older adults.
7. Describe the implications of these trends for delivery of
physical therapy and occupational therapy services.
Clinical Vignette
Harriet Smythe is a 78-year-old widow who lives in a
small Iowa town. Her husband, who had been a farmer, died
12 years ago, at which point Mrs. Smythe moved from the
farm into the nearby town. She was increasingly uncomfort-
able with driving and felt she would be closer to help if she
lived in town.
Mrs. Smythe retired 2 years ago from her position as
bookkeeper for a local business, a job she held for 30 years.
She has no pension and a very modest income from social
security. She also has a small income from investments made
after the sale of the farm. She now lives in a compact two-
story cottage that has not been updated recently. The town is
rapidly losing population as young people move to urban
areas. In addition, only one of five health clinics remains
open; the three physicians there are all over age 70 and talk-
ing about retiring. A hospital 100 miles away offers weekly
telehealth appointments.
Before her bookkeeping job, she was a stay-at-home
mother for her two daughters. One daughter has moved to a
city in the same state, at a distance of 300 miles from her
mother. She and her husband and three children visit twice
CHAPTER 35
The Future of Aging
■ Vanina Dal Bello-Haas
”
a year. Mrs. Smythe used to visit them but no longer feels
comfortable making the drive. The other daughter lives in
New York City where she manages a dance troupe. This
daughter never married.
Mrs. Smythe has lost muscle mass, which makes it diffi-
cult for her to carry groceries and other moderately heavy
items. She has slightly elevated blood pressure but is otherwise
healthy. She is an active and enthusiastic gardener, although
joint pain has begun to limit her ability to work in the garden
for sustained periods. She belongs to four book clubs (three
of them online) and stays in close touch with her former
coworkers. She indicates that she worries about her daughter
in New York and that she wishes she saw her grandchildren
more often. She does communicate regularly with them using
Skype and Facebook and has a long list of other Facebook
friends. She describes herself as being, on the whole, satisfied
with her life, although she has concerns about the potential
for worsening health in the future and about the services that
are available in her town.
1. What are some factors that contribute, either positively
or negatively, to Mrs. Smythe’s ability to age positively?
2. What factors in her situation do you think reflect
emerging trends in aging?
T his text has discussed many complex and interacting
factors that affect the experience of aging for individuals
and populations. The unfolding of this stage of life has changed
over the decades, and compelling evidence suggests that
such change will continue. This chapter reflects on potential
futures, based on currently available evidence. It is important
to do so because the education of health-care providers,
and the kinds of services they offer to elders, depend on the
societal changes that affect later life.
Demographic and Societal Trends
The number and proportion of older individuals around the
world is predicted to increase (Vincent & Velkoff, 2010; World
Population Prospects, 2012). The only possible exceptions are
539
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540 PART IV ■ Service Delivery for the Aging Client

parts of Africa and Asia (notably India) where fertility rates by care in institutions, although the supply of such facilities has
remain high (“Age Invaders,” 2014) and, particularly in the not nearly kept pace with demand.
case of some African countries, diseases like HIV and Ebola
have taken a significant toll on life expectancy (Nabalamba
Of course, other information needs to be factored into an
& Chikoko, 2011). In the United States, the population of
understanding of the impact of an aging population. Recent
individuals over age 65 was roughly 40.2 million in 2010; by
data suggest that incidence is declining for many serious
2050, the number is projected to be 88.5 million, roughly
diseases of later life throughout developed countries (Kolata,
20 percent of the total population (Vincent & Velkoff, 2010).
2016). Colon cancer, dementia, and heart disease are all
The implications of such change can be seen in Japan, a
showing significant decreases; researchers have no explana-
country where those over age 65 already represent 23 percent
tion for these findings. Such unexpected changes make
of the total population (Muramatsu & Akiyama, 2011). The
predicting the future difficult and suggest that to some extent,
expectation is that by 2050, elders will be roughly 30 percent
planning for the future requires expecting the unexpected.
of the total population. “Japan’s experience could provide
Three potential scenarios describe the impact of the world-
lessons from which other countries might learn” (p. 431). For
wide population shift in population age (“Age Invaders,”
example, the current generation of young adults has come of
2014). The first scenario suggests that the increasing propor-
age during a significant economic recession in Japan. As a
tion of older adults will be a drag on societies as these elders
result, they have fewer resources, are marrying later, and are
become ill and disabled, thus requiring resources that might
having fewer children. The impact on the availability of a
otherwise be directed toward economic growth. The second
skilled workforce has been profound, and Japan is focused on
scenario suggests that changes in the expectations and behav-
finding ways to retain older adults in the workforce to make
iors of older adults will mitigate such economic and social
up for the resulting labor shortages. Another concern is the
shifts as elders work longer and remain healthier. The third
availability of care, especially as provided by informal care-
scenario suggests stagnation will occur as companies cut back,
givers but also due to the shortage of younger workers. Not
workforces shrink, and medical needs increase.
only are there fewer young people but many more women are
It is hard to predict which of these scenarios will domi-
in the workforce and so are not available for their traditional
nate because factors such as economic growth or recession,
caregiving roles. Social isolation is a significant problem for
immigration/emigration, and other societal variables cannot
older adults, one that is expected to increase as younger
always be foreseen. For example, the level of skill of older
people move to urban areas, leaving their parents living in
adults will affect their ability to remain in the workforce. “It
rural communities. To address these concerns, Japan has
will be a world in which ageing reinforces the changes in
implemented policies that include preventive services as
income distribution that new technology has brought with
part of long-term care benefits and encouraging experiments
it: the skilled old earn more, the less-skilled of all ages are
to identify strategies for helping elders maintain function.
squeezed” (“Age Invaders,” 2014, p. 25). Likewise, an increas-
Japan has also focused on creating supportive environments
ing focus on healthful behaviors seen among better educated
(Muramatsu & Akiyama, 2011).
older adults is counterbalanced by increasing obesity and
On the other side of the coin, some countries like China,
associated diseases like diabetes that disproportionately affect
which have not anticipated the rapid aging of their popula-
older adults in socioeconomically disadvantaged groups. It
tions that they are now experiencing, are struggling to adapt
seems probable that aging will differ significantly based on
(Frazier, 2013). A recent change in the “one-child” policy
the kinds of sociocultural determinants discussed throughout
enacted in the 1970s now allows families to have a second
this text.
child; this is a reaction to the recognition that there are now
too few young people to take care of their elders (Feng, Liu,
Guan, & Mor, 2012). However, it will be years before this Cohort Effects
new policy makes a difference, and in the interim, China is In the United States and in Europe, one immediate aftermath
struggling to serve the older population of World War II was an increase in fertility that led to a large
cohort of individuals now reaching old age (Ogg & Bonvalet,
2006). However, a cohort is marked not only by its size, but
AROUND THE GLOBE: Aging in China
also by shared experiences that frame the beliefs and values
Zhang, Guo, and Zheng (2012) identified low fertility accompanied of the group. As Ogg and Bonvalet (2006) asked, “Did
by high life expectancy, the impact of China’s “one-child” policy Europeans growing up immediately after the Second World
implemented in 1979, a dramatic demographic transition from War share the same formative experiences? As far as major
a relatively young to a rapidly aging population, and persistent social transformations that have affected all western societies
poverty among older adults. The one-child policy means fewer is concerned, the answer seems to be yes” (p. 3). The Baby
young adults to care for their aging parents at the same time Boom generation will continue to move into old age over the
that many of those young adults are leaving rural areas to seek next 15 years. Their predecessors lived through a World War
economic opportunity, while elders remain in the countryside. and the Great Depression. The Baby Boom generation expe-
The tradition of elder care provided by families is being replaced rienced Vietnam, Sputnik, and the fall of the Berlin Wall.
4605_Ch35_539-549 31/10/17 12:40 PM Page 541
The differences in the world during their lives will influence
their needs and expectations in old age. Some of these differ-
ences can be readily anticipated. For example, Baby Boomers
who lived through a period of relative economic ease are more
comfortable spending resources compared with their parents
who lived through the Great Depression. But some are
harder to predict. The institution of Medicare, an important
government policy, might lead to greater confidence in gov-
ernment policy, but reaction to the Vietnam War might cause
less trust in government. Although there have been grave
concerns about the burden the Baby Boom generation may
impose on societies globally and about the values that have
resulted from their shared experience, there are also those
who predict that “the aging Boomer population offers the
promise and the opportunity of rejuvenating both the econ-
omy and our communities” (Farrell, 2014a, para. 4). (See
Figure 35-1.)
AROUND THE GLOBE: Baby Boom in Europe
Although there are differences in birth rates and population
growth between the United States and Europe, several countries
experienced a similar fertility increase after World War II, between
1946 and 1964 (Ogg & Bonvalet, 2006). Sweden, Denmark, the
United Kingdom, the Netherlands, France, and Switzerland
showed growth similar to that of the United States. Germany,
however, experienced a population decrease during those years.
In the Mediterranean countries, there was a brief increase followed
by a decrease in birth rate. The countries that experienced
substantial population growth now have challenges in providing
for a large group of individuals retiring and needing support
services.
Culture and Aging
As discussed in Chapter 5, culture has a significant impact
on the experience of growing older. Culture also is not static.
Individuals move from one country to another. Acculturation
leads to generational shifts. Individuals from different cultures
FIGURE 351 Many individuals remain vigorous and engaged in later
life. TomWang112/iStock/Thinkstock
CHAPTER 35 ■ The Future of Aging 541
intermarry and create new customs and traditions. These
factors are becoming more evident as communication and
transportation bring people into closer contact.
Elders in many cultures value generative goals as a way to
find meaning in later life (Hofer et al., 2014). Generativity
has been defined as “the concern in establishing and guiding
the next generation” (Erikson, 1963, p. 276). Culture also
affects such characteristics as openness to change and con-
servation (valuing of tradition and conformity). These char-
acteristics affect the specific nature of the generative goals
chosen by elders from particular cultural groups. As cultures
increasingly mix and as new cohorts enter later life, physical
and occupational therapists must pay close attention to
changes in the generative goals that give life meaning. Ethno-
graphic strategies described earlier in this book (Chapter 5)
and elsewhere (Bonder & Martin, 2014) can be of great value
in understanding cultural mediators of meaning in life as
changes occur.
Meaning in Life
The ways in which older adults perceive meaning in their lives
is changing later life. Individuals at any age seek lives of
significance and, happily, many find it (Heintzelman & King,
2014). However, individuals differ about definitions of and
expectations about finding meaning late in life. Some believe
that aging will bring greater calm, less materialistic concerns,
and growing opportunities to contribute to societal well-
being late in life (Easterbrook, 2014). Others wish not to live
too long, fearing the inevitable losses more than valuing the
potential benefits of later life (Emanuel, 2014). Physical and
occupational therapists must recognize that productive pur-
suits are strongly associated with contentment in later life
(Versey & Newton, 2013).
✺ PROMOTING BEST PRACTICE
Activities and Happiness
To understand how activities contribute to happiness in later
life, Oerlemans, Bakker, and Veenhoven (2011) asked 438 older
adults to keep monthly electronic diaries of their activities
for 2 years. Those older adults who engaged in pursuits that
required them to exert effort in social, physical, cognitive, and
self-care—activities requiring physical and cognitive exertion—
reported greatest happiness as compared with individuals
whose activities were mostly passive, requiring no effort.
Combining those effortful occupations with restful activities
was most strongly associated with happiness.
Participating in Life and Community
What kinds of activities can reliably be projected to promote
positive aging in the future? Several kinds show particular
promise, but education is the most consistent and central
activity that helps older adults age well (Easterbrook, 2014).
Education, in and of itself, is meaningful and gratifying,
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542 PART IV ■ Service Delivery for the Aging Client
whether formal (classes, lectures) or informal (self-directed
exploration of new information through reading and conver-
sation). It is also a proxy for engaging in positive health habits
such as exercising and not smoking, as well as for having
social supports, particularly by marrying and remaining
married. Although some benefits of education accrue early in
life and cannot be changed, it is never too late to participate
in educational activities, a strategy that may help mediate
negative events in later life. For example, research shows that
enhanced personal meaning can reduce depression (Westerhof,
Bohlmeijer, van Belijouw, & Pot, 2010). Easterbrook suggests
that institutions of higher education are likely to continue
their evolution toward serving lifelong learners, potentially
improving health and quality of life for older adults, thereby
reducing need for health and other social services.
Work and Retirement
One area of activity that has generated particular interest is
that of work and retirement. To some extent, this attention
is the result of concerns about the workforce of the future
(Easterbrook, 2014). As a larger proportion of populations
are older, will there be enough workers to sustain economic
growth? And what are the consequences for societies as older
adults retire? Will there be adequate economic resources to
sustain them while also meeting the needs of younger individ-
uals? Easterbrook suggests that if social supports such as Social
Security in the United States are to be sufficient, “most indi-
viduals will likely need to take a new view of what retirement
should be: not a toggle switch—no work at all, after years of
full-time labor—but a continuum on which a person gradually
downshifts to half-time, then to working now and then” (n.p.).
Retirement, a new concept that emerged in the second
half of the 20th century, has already been reimagined as a
process rather than a point in time (Farrell, 2014b). This
trend is almost certain to continue both for financial reasons
(disappearing pensions, for example) and personal reasons
(the wish to remain engaged in meaningful work). For many,
retirement is financially out of reach. In the United States,
this last fact is expected to have a significant impact on
whether some older adults can ever retire (Walsh, 2014).
There are also concerns about the impact of retirement for
the individual (van der Heide, van Rijn, Robroek, Burdorf,
& Proper, 2013). Although in Western countries, retirement
is widely perceived as a desired and desirable state, some
individuals are dissatisfied and struggle to find meaning outside
of work, and some find that they are not financially secure
enough to retire (Walsh, 2014). For occupational and physical
therapists, this means many clients will need help maintaining
the skills and capacities needed to remain on the job.
There is tremendous potential for occupational therapy
(OT) and physical therapy (PT) to provide support for indi-
viduals and to advocate for policy with regard to work and
retirement. As described in Chapter 20, physical therapists
have a significant role in supporting physical capacity for
work, and, in collaboration with occupational therapists, job
redesign to facilitate continued employment. Occupational
therapists can assist with environmental modifications, task
modifications, and design of education and training to help
older workers adapt to changing job requirements. Both OT
and PT practitioners, in their role as advocates for clients,
can help educate policy makers about the needs of older
workers and the potential for economic growth offered by
their continued employment.
As older adults move toward retirement, OT offers vital
services focused on planning not just for financial security
but for ensuring continued meaning in later life. There are
numerous examples of the kind of programming that helps
older adults plan and implement meaningful occupational
profiles in retirement, including the classic study of a “well-
elderly” program (Clark et al., 1997).
One obvious growth industry is care for older adults.
Given the demographic shifts described in this chapter and
elsewhere in this text, many older adults have no children,
live at a distance from families, or otherwise find themselves
without the traditional source of instrumental and emotional
support. At present, however, many kinds of service positions
in gerontology (notably aides in long-term care and in home
health) do not receive the respect or remuneration that would
attract workers (Seavey, 2010). Seavey (2010) noted that
there are several strategies for making these jobs more
appealing. One entails improved pay and benefits. The other
involves making the content of the jobs more engaging. OT
and PT can play a role in providing the training and skill
development that would enhance the meaning of the work
while also improving care for older adults.
✺
PROMOTING BEST PRACTICE
Retirement and Health
A meta-analysis of 22 studies, 11 of which were assessed as
being strong research designs, found that retirement has a
beneficial impact on mental health as measured by self-rated
well-being, rates of depression, and use of antidepressant
medications (van der Heide et al., 2013). Findings were equivocal
for physical health and overall health, although there was
insufficient evidence to draw firm conclusions other than for
mental health.
Aging and Environment
This text has previously considered sociocultural determinants
of positive aging. These factors relate to both economic and
environmental issues, including the availability of financial
and social supports as well as characteristics of the physical
environment.
Financial Considerations
There is reason to be concerned about how older adults will
fare in the future in terms of basic financial resources. The
rapid decline of pension benefits has already resulted in a
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CHAPTER 35 ■ The Future of Aging 543

substantial increase in poverty among elders (Banerjee, 2013).
Older adults must now rely on their own savings (Rhee,
2013), but the ability to save is dependent on adequate
current income. The Great Recession during the first decade
of the 21st century significantly damaged the financial cir-
cumstances of many older adults. In the United States, the
expectation was that individual retirement accounts (IRAs)
or 401(k)-type investments would adequately replace pensions;
this has not proved to be the case. A second source of retire-
ment income in the United States is Social Security, but it
was never intended to provide primary support, and its finan-
cial stability is in question (Easterbrook, 2014). Some other
countries have more robust safety nets that ensure at least
modest comfort for older adults. In Sweden, for example,
older adults can retire between ages 61 and 67 with guaran-
teed pensions supported by the government (Elderly Care in
Sweden, 2014).
For some older adults, the absence of pension income and
savings will be ameliorated by their interest in and ability to
continue working. However, many elders will be physically
unable to work or may find the opportunities open to them
unacceptable. For these individuals, the financial picture will
be more dire (Rhee, 2013).
Financial issues can be addressed both by increasing income
and by managing resources more effectively. OT can play a
useful role in helping retirees improve their money manage-
ment skills and by helping them identify activities that are
low cost. Individuals with limited financial resources may
report quite positive subjective well-being because many
elements of meaningful life do not require substantial finan-
cial resources (Swift et al., 2014).
the residents themselves identify common issues (e.g., grocery
shopping, home maintenance) and secure common resources
to address them (e.g., scheduled shuttle service, handyman
services). As such buildings develop, communities sometimes
step in to provide services (transportation, on-site PT or OT,
housekeeping services) as well. Villages are grassroots,
membership-driven communities, not necessarily in the
same building but in close proximity. As is true for NORCs,
the members identify and arrange needed services.
✺ PROMOTING BEST PRACTICE
NORC and Village Programs
NORCs and villages are two models for supporting older adults’
wish to age in place (Greenfield, Scharlach, Lehning, Davitt, &
Graham, 2013). A survey of 69 village and 62 NORC program
leaders found that both kinds of programs had a role in serving
older adults. Village participants tended to be younger,
healthier, and more economically secure. NORC residents
offered more services but also relied more on government
supports.
Although these strategies may prove effective, it seems
likely that health disparities are likely to persist (Hudson &
Gonyea, 2012; Villa, Wallace, Bagdasaryan, & Aranda,
2012). Ethnic and socioeconomic disadvantage during earlier
life has cumulative and negative consequences for older adults,
and these consequences are projected to continue for the Baby
Boom generation (Shrira & Litwin, 2014) (Figure 35-2).

Living Arrangements
Living arrangements in later life may be affected by particular
social trends. For example, a larger number of Baby Boomers
are unmarried and childless compared with previous genera-
tions (I. Lin & Brown, 2012). Given that elders rely heavily
on family for instrumental and emotional support, this may
significantly affect elders’ ability to remain functional and in
the community (Ryan, Smith, Antonucci, & Jackson, 2012).
At the same time, many boomers are continuing to provide
care for their parents who are surviving into very old age. This
may further diminish the resources available to meet boomers’
needs.
Addressing these concerns will require thoughtful policy
and development. Efforts are already underway to experiment
with new multigenerational living arrangements (Kuraoka,
Hasebe, Nonaka, Yasunaga, & Fujiwara (2017). In addition,
a variety of environmental strategies are being explored as
well (Greenfield, 2012; Wahl, Iwarsson, & Oswald, 2012).
These include policies that provide support for services
needed by older adults in naturally occurring retirement com-
FIGURE 352 Availability of care providers may be an issue in the
munities (NORCs) and villages. NORCs develop organically future as the proportion of the population that is older continues
as existing apartment or condominium buildings come to have to increase. (Photo courtesy of Benjamin Rose Institute, reprinted with
residents who are primarily older adults. In some situations, permission.)
4605_Ch35_539-549 31/10/17 12:40 PM Page 544
544 PART IV ■ Service Delivery for the Aging Client
Individuals with limited education and financial means lack
the information to identify potential resources and the funds
to secure them. They are likely to be more dependent on family
caregivers, many of whom also lack personal and financial
resources to provide care.
Trends in Health Care
Current trends in health care related to systems of care,
evidence-based practice, technology, biomedical research,
and cost containment can be assumed to continue, although
some may experience significant modification.
Systems of Care—Facilitating Transitions
This text presented chapters from the perspective of different
kinds of institutions or settings for care—community based,
short-term rehabilitation, home health, long-term care facil-
ities, and so on—as they are structured in the United States.
It has also described systems in many other countries around
the world. Although many of those other countries have
some form of universal health-care payment, none has a
single, seamless system for providing care. In every country,
movement among institutions and into and out of the home
is typical in later life. Such fragmented care presents signifi-
cant difficulties ranging from poor care to inefficient use of
resources (Lynn & Montgomery, 2015).
Transitions from one facility to another are periods at
which clients are at particular risk (Cadogen, Phillips, &
Ziminski, 2016; Kane & Cutler, 2015). Cadogen and col-
leagues (2016) gave the example of the dangers inherent in
the period after discharge from the emergency department
for elders who are not admitted to the hospital. They note
that this is a point in care at which medical errors and adverse
effects are at heightened risk, and that the potential for sub-
sequent repetition of medical tests that generate added costs
affect availability of resources.
Although it is unlikely that there will be a single, coordi-
nated system of care in the near or intermediate future, it is
incumbent on care providers to recognize the challenges and
develop strategies such as education for care providers, tech-
nological coordination of referrals, and electronic follow-up
will be vital if outcomes are to be improved (Cadogen et al.,
2016; Kane & Cutler, 2015).
Evidence-Based Practice
One trend that all physical and occupational therapists rec-
ognize is the increasing emphasis on evidence in establishing
interventions. Clearly, evidence-based practice (EBP) helps
ensure that care provided is effective and efficient. However,
there is also growing awareness of the limits of EBP (Hinojosa,
2013). Much EBP is built on quantitative research, but such
studies focus on averages, and individuals are not averages. As
a way to address this, there is growing recognition that qual-
itative investigations can examine questions that may not lend
themselves to quantitative study. Physical and occupational
therapists have increasingly employed qualitative methods
(Schrieber, 2013; Su, Yong, & Price, 2014; Wimpenny,
Savin-Baden, & Cook, 2014). Such research provides deeper
explanation of phenomena, but because the number of
participants in a given study is often small, it is difficult to
generalize from the findings.
More recently, there is considerable emphasis on multi-
method research that incorporates a range of quantitative
and qualitative strategies, including those that are not struc-
tured in traditional controlled/comparative ways (Hansen &
Tjørnhøj-Thomsen, 2016). It is incumbent on health-care
providers, including PT and OT professionals, to understand
these strategies and to seek out research on specific concerns
that incorporate these emerging methods.
In some areas of exploration, there are significant philo-
sophical concerns that complicate the study of important
questions. As just one example, there have been calls for
improved education for health-care providers in developing
communication skills (Salmon & Young, 2013). One dilemma
is determining what constitutes skill; “it is rarely obvious in
practice whether any instance of communication was the
right thing to say” (Salmon & Young, 2013, p. 194). There
is also concern about defining communication as a “skill”
because this may oversimplify a complex phenomenon.
Salmon and Young recommended considering not only
EBP but also practice-based evidence—the systematic inclu-
sion of clinical observation as a mechanism for validating
intervention.
Because of increased emphasis on financial accountabil-
ity and positive outcomes, the trend to focus on EBP will
undoubtedly continue. As a counterbalance, in medical care
there is strong and growing interest in the concept of person-
alized medicine (Klose, 2010). With increasing understand-
ing of human genetics, biology, and physiology, it seems
probable that in the not-too-distant future it will be possible
to engineer drugs and their doses specific to each individual.
This is yet another form of EBP, one that deemphasizes
investigation of groups and populations and focuses instead
on understanding mechanisms unique to specific individuals
(Thornquist & Kirkengen, 2015). Investigation to understand
the benefits of these interventions will require careful thought
about research methods that can help practitioners make
accurate cost–benefit assessments.
The lessons for OT and PT are clear. Evidence is essential,
and so good basic and clinical research—qualitative, quanti-
tative, and mixed method—must continue to be a high priority.
At the same time, continued respect for the values of both
professions that emphasize the unique traits and needs of
individuals must be maintained—a dilemma OT and PT share
with researchers developing personalized medical interven-
tions. Caring for groups and caring for individuals are both
important, and ongoing research will be required to ensure
that both are done well.
Physical and occupational therapists must consider all
these complexities in determining what is best for a particular
4605_Ch35_539-549 31/10/17 12:40 PM Page 545
older adult, and what might be effective in a specific group
or community setting, because circumstances, wishes, and
needs vary so widely. They must also consider that some of
the most important factors in positive aging, including
attitudes and personal strengths, may require unique methods
of study. In the therapy literature, there is a relative lack of
research focused on mental health and quality of life (Lloyd
et al., 2010). Therapists should keep in mind that absence
of evidence does not mean that something is not true, but
it does make it harder to justify. A future endeavor for
which OT and PT are well suited is further development
of multiple, complementary methods of developing evidence
to validate outcomes and enhance practice.
Technology
Many new and developing technologies can support positive
aging. As you saw in Chapter 21, emerging and improving
technologies can support self-care (e.g., environmental
sensors, voice or motion-activated controls for appliances);
enhance safety (e.g., emergency call systems, motion-activated
lights); support medical needs (e.g., telemedicine, smartphone
apps for medication reminders); improve community mobil-
ity (e.g., Uber, Lyft driver services; self-driving cars); and
support socialization (e.g., Facebook, Twitter, Snapchat).
Research and development continue at a rapid pace, both
improving existing technologies and developing new ones.
Despite these benefits, there are also issues related to
acceptability, affordability, and effectiveness of emerging
technologies. As discussed in Chapter 21 older adults often
abandon assistive devices they do not perceive as helpful.
Some technologies raise ethical dilemmas. For example,
telemedicine has the potential to adversely affect privacy and
confidentiality of patient information and clinical encounters
(Nelson, 2010). With other technologies, safety may be
a concern. As an example, self-driving cars are far from
perfected and may well lack the ability (at least for now) of
making the kinds of rapid judgments required of drivers
(P. Lin, 2013). Thus, while technological advances may help
improve quality of life in later life, technology will not be able
to solve every problem.
The rapid growth of social media as a way to interact has
the potential to enhance socialization for older adults (Leist,
2013). Like other groups, older adults are increasingly using
electronic communication to maintain contact with friends
and to reach out for social support (Xie, Watkins, Golbeck,
& Huang, 2012). Direct conversation on Skype and “conver-
sations” on social media sites allow for personal interaction
at a distance. Individuals who are reaching later life now are
likely more technologically skilled than their predecessors,
a trend that will probably continue. Although affordability
is an issue for some, the cost of simple computers that allow
for such interaction has dropped considerably and will prob-
ably continue to decrease. Some individuals have abandoned
computers all together and use smartphones or tablets
instead. Although social media can be a tremendous resource,
CHAPTER 35 ■ The Future of Aging 545
particularly for individuals who have limited physical capacity
or constrained community mobility, it can also induce a
sense of loneliness. If the older adult does not feel his or her
“friends” list is adequate, if posts are not “liked,” if others are
perceived as having more interesting and exciting lives, an
older adult may feel diminished by online interaction rather
than supported. In addition, because of the absence of filters,
negative stereotypes of aging can creep into interaction,
leading to feelings of inadequacy or unworthiness (Levy,
Chung, Bedford, & Nvrazhina, 2014). Xie and colleagues
emphasize the importance of making the use of these tech-
nologies personally relevant to the individual by selecting
those that will help the individual achieve his or her goals.
An occupational therapist might help a client learn to use
Pinterest to identify a hobby group that can communicate
about a shared interest in needlepoint or woodworking, for
example.
Finally, the trend toward delivering care electronically
can help improve access to rehabilitation for individuals in
remote or rural settings (Charness, 2014). Videoconferenc-
ing might be used by a physical therapist to obtain infor-
mation about client exercise preferences, to teach the client
a set of physical activities, and to monitor performance and
outcomes.
Biomedical Research
Closely linked to technology are advances in biomedical
research. Some of these advances have the potential to
remediate some of the most challenging conditions found
in later life. For example, research on Parkinson’s disease
has increased understanding of underlying mechanisms and
identified potential treatments to minimize symptoms and,
perhaps someday soon, cure the disorder (Scripps Research
Institute, 2014). Increasingly effective treatments have made
some kinds of cancer survivable as chronic diseases, or even
curable.
At the same time, despite years of research, progress is
slow in some critical areas relevant to aging. For instance,
the mechanisms that cause Alzheimer’s disease are still not
well understood. Alzheimer’s disease seems to result from a
combination of environmental and genetic factors (Bicalho
et al., 2013), but the precise nature of the interaction that
leads to symptoms remains unclear. Likewise, efforts to slow
the rate of increase in diabetes, with its significant negative
long-term consequences, are stalled.
In the absence of effective medical treatments, OT and
PT remain essential as they provide interventions that can
maximize function and quality of life even in conditions
that may be progressive over time. Delaying functional loss
and identifying coping strategies will continue to be vital
interventions until medical breakthroughs are found to
minimize symptoms or cure disease. Even then, the aging
process leads to changes that must be managed, and OT
and PT will therefore remain essential to ensuring positive
aging.
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546 PART IV ■ Service Delivery for the Aging Client
Paying for Care
It seems probable that Medicare in the United States is going
to persist into the future, and it has been a highly successful
mechanism for ensuring access to care for older adults (AARP,
2005). At the same time, health-care costs in the United
States continue to grow at a rate that is higher than most
other countries and may not be sustainable. Thus, strategies
for cost containment will be increasingly vital in the United
States. The Affordable Care Act emphasizes value-based
purchasing and other efficiency strategies that affect Medicare
and Medicaid as well as other payment options (Fisher &
Friesema, 2013). However, at the present time, future laws
governing access to and quality of health care are the subject
of considerable debate; it is difficult to predict the direction
these new efforts will take.
While the United States spends more than every country
but Switzerland and Norway (World Bank, 2015) on health
care, often with inferior outcomes (Commonwealth Fund,
2014), cost is a factor elsewhere as well. In Canada, many
individuals with serious illness face unanticipated expenses
despite the availability of strong universal plans (Maurino,
2013). Countries with universal coverage must also consider
what will and will not be included in that coverage and how
much the country can afford. In Great Britain, long waiting
lists and poor outcomes for some kinds of care have led to
criticism of the system (Dalrymple, 2012).
Payment affects systems of care as well. In the United
States, payment is fragmented, with different payers requiring
different eligibility criteria (Lynn & Montgomery, 2015).
Disciplines like OT that have already established a role in a
variety of settings and emphasize health promotion are well
positioned to play an important role in reducing care transi-
tions such as rehospitalization (Fisher & Friesema, 2013). As
the Affordable Care Act continues to be implemented, its
emphasis on value-based purchasing, which links payment
to improvement in provider performance, as well as its focus
on avoiding hospital-acquired conditions like falls that can
increase costs, both PT and OT have an important role in
enhanced care.
Implications for Physical
and Occupational Therapy
What do all of these trends mean for the future of PT and
OT? In some sense, the future is a bright one, give the disci-
plines’ emphasis on function, participation (ICF), and quality
of life and the growing recognition that enhanced quality
of life is an essential outcome of health care. In particular,
physical and occupational therapists know that meaningful
activities contribute to meaning in life and help meet impor-
tant psychological needs of older adults (Eakman, 2013).
Although there are opportunities, there are also challenges.
Growing requirements to demonstrate both efficiency and
effectiveness mean that it will be increasingly vital to pursue
the kinds of data-based studies that document effectiveness
(Fisher & Friesema, 2013). This has been a priority for both
OT and PT for some time; however, a great deal remains to
be done to understand what interventions are most helpful for
which elders, given the substantial variations among individuals
with regard to functional status, coping skills, environments,
and resources (I. Lin & Wu, 2014). For example, Fisher and
Friesema (2013) noted that OT can implement prehospital
discharge risk assessments and recommend environmental
modifications to the home to reduce those risks. Careful
validation of the positive impact of such programs will be
central to the profession’s ability to continue to offer them.
One health-care trend that is likely to persist into the
future is the emphasis on interdisciplinary care. For example,
reasonable evidence suggests that preventing falls requires
multidisciplinary intervention (Fisher & Friesema, 2013).
OT focuses on safety in the environment, while physical
therapy emphasizes building physical capacity and enhancing
balance. Working in concert with medical evaluation to
minimize the possibility of medication-related dizziness or
instability, occupational and physical therapists can help
to reduce fall risk. Because falls contribute significantly to
disability and mortality in older adults, any reduction in risk
can improve well-being while reducing health-care costs.
Another example of the need for interprofessional care
involves health promotion. Interventions to support wellness
into old age require multiple perspectives and strategies, from
environmental design to educational interventions to a focus
on occupational profiles that enhance meaning in life. Rigid
professional boundaries interfere with effective care, meaning
that there must be careful consideration of how professionals
can contribute their unique perspectives and skills without
creating barriers that harm their clients (Kane & Cutler, 2015).
Physical and occupational therapists must keep in mind
that at some point, the vast majority of people will require
interventions at the end of life. Health-care professionals
as well as lay individuals are increasingly discussing what
those interventions should look like. Ezekiel Emanuel’s
(2104) article in The Atlantic, “Why I Hope to Die at 75,”
generated huge controversy. The article was published shortly
before the well-publicized case of Brittany Maynard, a young
woman with brain cancer who moved to Oregon to take
advantage of its assisted suicide statute, which allowed her to
choose the time of her death (Horowitz, 2014). Both this case
and the article brought attention to important questions of the
value of life and the meaning of death. Emanuel’s stance seems
to overlook the possibility that later life can be productive and
valuable. It does, however, encourage people to think realisti-
cally about what they want from life and from its end.
AROUND THE GLOBE: Assisted Suicide in Canada
and Around the World
On February 6, 2015, the Supreme Court of Canada unanimously
ruled in a 9–0 decision that the Criminal Code laws prohibiting
physician-assisted death infringes Section 7 of the Charter, which
states that everyone has right to life, liberty, and security of the
4605_Ch35_539-549 31/10/17 12:40 PM Page 547
person. The court laid out several specific conditions for physician-
assisted death:
■ The person must be a competent adult who clearly consents to
the termination of life.
■ The person must have a “grievous and irremediable” medical
condition, which includes an illness, disease, or disability.
■ The medical condition must cause “endless suffering” that is
intolerable to the person, although that suffering can be
physical or psychological.
Canada joins a small number of countries (Switzerland, Germany,
Albania, Colombia, Japan) and U.S. states (Oregon, Washington,
Vermont, New Mexico, Montana, Colorado) that allow physician-
assisted suicide. The Netherlands, Belgium, and Luxembourg allow
doctors, under strict conditions, to euthanize patients whose
medical conditions have been judged hopeless and who are
in great pain.
Despite best efforts, unexpected changes will affect the
ways in which aging is understood, and the kinds of services
that older adults need. As one example, throughout this text,
there has been reference to epidemiological projections that
suggest that people everywhere will live longer and healthier
lives. Yet there is recent evidence that the projected compres-
sion of morbidity and mortality has not yet been realized
(Crimmins, 2015). In addition, in the recent past, a decline
in life expectancy for women was reported by the Centers
for Disease Control and Prevention (Achenbach, 2016).
Although this could be a statistical anomaly, changes in
disease frequency, loss of adequate treatments due to such
factors as antibiotic resistance may alter the life course in ways
that are currently unexpected. No one has a crystal ball, so
projections of all kinds must be revisited frequently.
Although it is challenging to do so, it is necessary to
extrapolate to the greatest extent possible from current circum-
stances to the trends that are likely to affect the experience
of aging. By extension, the needs of older adults for preven-
tive and rehabilitative services can be forecast with reasonable
accuracy. Physical and occupational therapists have the
opportunity to contribute to effective care for elders as the
focus of health care shifts from quantity to quality of life.
SUMMARY
As Yogi Berra said, “It’s tough to make predictions, especially
about the future.” And yet, to make progress, it is essential.
Knowing history certainly helps. Paying attention to what
is happening in the world also helps. Because OT and PT
both embrace philosophies emphasizing a holistic approach
to health and well-being, one that focuses on these two out-
comes equally, practitioners need to be cognizant of the many
forces that affect both individual and societal experiences
related to aging. Efforts to improve quality of life for clients
are dependent on evaluating changing circumstances and
incorporating new resources. OT and PT will undoubtedly
have a vital role in the focus on quality of life, emphasizing
CHAPTER 35 ■ The Future of Aging 547
wellness, supportive environments, and other factors crucial
to positive aging, regardless of medical advances that might
result in reduced or delayed illness and disability in later life.
Perceived well-being is multifaceted and reliant on per-
sonal and subjective factors as well as concrete instrumental
issues. Factors such as retirement, widowhood, and declining
health, all issues that can be addressed through therapy serv-
ices, play a role in subjective assessments of well-being (Jivraj,
Nazroo, Vanhoutte, & Chandola, 2014). Even when physical
capacity is declining, PT can help minimize or delay decline
and OT can offer interventions that enable individuals to ad-
just to retirement and loss of a spouse through exploration of
new activities and social networks. At the same time, under-
standing of the many societal forces that influence aging can
also be appropriate areas of emphasis for therapists. Advo-
cating for effective systems of payment, facilitating care tran-
sitions, evaluating emerging technologies are all relevant to
effective care. Maximizing effective response to change is
challenging, but has the potential to be rewarding to thera-
pists, their clients, and society as a whole.
CASE STUDY
The Greens of Omaha is an apartment complex that was
built in the 1980s. It initially attracted primarily middle-
class working couples, “empty-nesters” whose children had
gone off to college. Many of those residents chose to stay
in the complex and are now in their 80s and 90s. Over the
years, they formed friendships and have helped individuals
in the group who have needed physical and emotional
support. For example, when one resident was newly
widowed, other residents developed a rotation to have
dinner with him so he would not have to eat alone. As some
of them have had to stop driving, others have provided
transportation.
However, the residents are becoming increasingly
frail, and several have chronic disabling conditions like
Parkinson’s and congestive heart failure. At the same
time, the facility has not been updated since it first
opened, and there is only one small, slow elevator. A
recent power failure caused significant problems because
the building has no generator, and many of the residents
cannot manage stairs.
Questions
1. What trends are reflected in this case?
2. What strategies might be implemented to facilitate
the residents’ ability to remain in the apartment
complex?
Critical Thinking Questions
1. How might projected demographic changes alter
sociocultural values in Western societies?
4605_Ch35_539-549 31/10/17 12:40 PM Page 548
548 PART IV ■ Service Delivery for the Aging Client
2. How do those demographic factors affect the needs
of older adults? Are there mechanisms for solving
some of the associated problems?
3. Consider some of the advantages and disadvantages of
evidence-based practice. What are some approaches
for addressing the disadvantages?
4. Are there specific strategies that could be undertaken
now to minimize societal dislocation related to aging?
5. Are self-driving cars likely to help older adults main-
tain community mobility? What cautions do you see
in their implementation?
6. What do you see in your own experience that relates
to the trends discussed in this chapter?
7. What are some opportunities for OT and PT in the
projected trends related to an aging world?
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GLOSSARY
Accessible design. Defined as design that “is readily
accessible to and useable by individuals with disabilities”
(U.S. Department of Justice, 2010, p. 6).
Accommodation. In the context of vision, the ability of
the lens to change shape in response to the distance of
an object.
Achalasia. The failure of the lower esophageal sphincter
(LES) to properly relax on swallowing.
Active life expectancy. The average number of years an
individual at a given age will survive and remain in an
active or nondisabled state.
Activities of daily living (ADL). Bathing/showering, toi-
leting and toileting hygiene, dressing, eating and feeding,
functional mobility, personal device care, hygiene and
grooming, and sexual activity.
Active living. A way of life that integrates physical activity
into the daily routine (Deshpande, Dodson, Gorman, &
Brownson, 2008).
Adaptable design. Modifications to a standard design for
the use by a particular individual with a disability.
Adherence. The extent to which a client follows a health-
care professional’s advice or recommendations.
Advance care planning (ACP). The process of preparing
directives for end of life care in advance of the time when
they might be needed.
Advocacy. “Pleading in support of another, defending or
recommending in favor of a proposal” (Sykes, 1976, p. 16).
Age in place. To remain in one’s own home and community.
Age-related macular degeneration (AMD). Retinal atro-
phy and scarring, along with hemorrhages in the macula,
resulting in a gradual loss of the central field of vision.
Ageism. A negative view of older adults accompanied by
discriminatory beliefs and action.
Agency. The ability to act on the environment.
Aging. A process that occurs throughout life.
Alternating attention. The ability to direct or switch atten-
tional resources between two or more tasks or activities.
Amyloidosis. A histologic feature of aging observed in many
organs, including the heart and vasculature.
Anorexia of Aging. “An unintentional decline in food intake,
and, as a result, of body weight, that begins near the end
of life; it represents a sign of failure to preserve steady-
state levels of body weight and energy stores” (Donini,
Savina, & Cannel, 2003).
Antagonistic pleiotropy theory (Williams, 1957). Late-
acting deleterious genes that may be favored by selection
and actively accumulated if they have any beneficial effects
early in life.
550
Assistive technology device. Any item, piece of equipment,
or product system, whether acquired commercially off the
shelf, modified, or customized, that is used to increase,
maintain, or improve functional capabilities of individuals
with disabilities (Technology Related Assistance for
Individuals Act of 1988, 1994, n.p.).
Astigmatism. A defect in the eye or in a lens caused by a
deviation from spherical curvature.
Attractor well. Level of flexibility that allows the individual
to deviate from a preferred motor pattern.
Basic cognitive processes. The foundation or building
blocks for higher ordered cognitive processes.
Benefit period. A Medicare construct that describes a period
that begins with admission to the hospital and continues
until the beneficiary has been out of a hospital or skilled
nursing facility for 60 days.
Bisphosphonates. Prescribed to minimize osteoporosis.
Blocking. Process resulting in the “tip of the tongue” phe-
nomenon; difficulty accessing specific information precisely
when it is needed.
Bridge employment. Changing jobs and moving to part-time
employment; common as a transition to retirement.
Cardiac output. The amount of blood the heart pumps
through the circulatory system within a minute.
Case management. A process comprising a culmination of
consecutive collaborative phases that assist clients to access
available and relevant resources necessary to attain identi-
fied goals.
Case manager. An individual who navigates, as applicable,
each element of the case management process, taking
into consideration the client’s individual, diverse, and
special needs, including aspirations, choices, expecta-
tions, motivations, preferences and values, and available
resources, services, and supports (Marfleet, Trueman, &
Barber, 2013).
Cataract. A lenticular opacity.
Catecholamines. A class of amines that includes neuro-
transmitters such as epinephrine and dopamine.
Centenarians. People older than 100 years of age.
Cognitive behavior therapy (CBT). A short-term psycho-
logical therapy that challenges maladaptive thinking
patterns and thoughts.
Cognitive reserve. The amount of cognitive resources avail-
able after an individual engages in a task, which uses up
some of the capacity.
Cohorts. Groups that share a common set of historical
events that influence personal behavior and the experience
of aging.
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Colostomy. An opening in the abdominal wall with a bag
to allow for collection of body waste.
Competence. The ability to do something successfully or
efficiently (Oxford University Press, 2014).
Comprehensive geriatric assessment (CGA). An approach
designed to improve the health of the older adult that
defines care for this client population (Rubenstein, 2004);
tends to be the norm in geriatric care.
Comprehensive outpatient rehabilitation facilities
(CORFs). Facilities that offer a more comprehensive array
of services than typical outpatient rehabilitation settings and
use interdisciplinary team goals (Capilouto, 2000).
Conceptual framework. A conceptual structure that explains
the relationship among key factors, concepts, and variables
(Miles & Huberman, 1994).
Conditions for Coverage (CfCs). Criteria a beneficiary
must meet to be eligible for coverage of services under
Medicare. There are CfCs for all areas of practice in
health care.
Conditions of Participation (CoPs). Regulatory mandates
with which a provider must comply to participate in the
Medicare and Medicaid program.
Conductive hearing loss. Block of acoustic energy that
prevents the conduction of sound to the inner ear.
Confined to home. A Medicare home health requirement
generally referred to as “being homebound.”
Conservation. In terms of cultural change, reflects a valuing
of tradition and conformity.
Continuum of care. The system of services that supports the
well-being of older adults at every stage of functioning.
Contrast sensitivity. The ability of the visual system to
distinguish between an object and its background.
Cross-sequential research design. Research that collects
data from two or more groups of participants at two or
more time measurement periods.
Crystallized intelligence. The accumulation of knowledge,
experience, and acculturation that is highly representative
of individual differences.
Cultural competence. “A set of congruent behaviors, atti-
tudes, and policies that come together in a system, agency,
or among professionals that enables effective work in
cross-cultural situations” (U.S. Department of Health and
Human Services Office of the Secretary, 2000, p. 80865).
Culture. “Shared symbols and meanings that people create
in the process of social interaction,” that orient “people in
their ways of feeling, thinking, and being in the world”
(Jenkins & Barrett, 2004, p. 29).
Custodial care. Care in which the home aspect of nursing
home care is most prominent.
Dead space. Areas in the lung that are ventilated but not
perfused.
Declarative learning. Consciously recalling learning and the
information learned.
Dementia. A global term used to describe changes in cog-
nitive functioning that are atypical or pathological in
nature.
Glossary 551
Dependency ratio. The ratio of those in the workforce to
children and elders depending on workers to provide their
financial support.
Depth perception. A monocular skill that allows one to
judge distances away from the self.
Dermatitis. Skin irritation.
Developmental explanations. Represented by Erikson’s
(1950) stages of development (in adulthood and old age,
the stages of generativity versus stagnation and integration
versus despair
Developmental genetic theories. Propose that the process
of aging is continuous with and probably operating through
the same mechanisms as development and hence is genet-
ically controlled and programmed.
Developmental life span approach. States that develop-
ment occurs across the life span and incorporates both
biological and environmental aspects.
Diabetic retinopathy. Damage to the blood vessels of the
retina due to diabetes.
Diffusing capacity. The ability of oxygen to diffuse from the
alveolar airspaces into the pulmonary capillary.
Disengagement theory. Explains human aging as an in-
evitable process of individuals and social structures mutually
disengaging and adaptively withdrawing from each other in
anticipation of the person’s inevitable death (Cumming &
Henry, 1961).
Dismobility. Very slow gait speed (0.6 m/s or slower).
Disposable soma theory. Refers to a process in which there
is limited investment in soma cell durability because such
cells have a short expected duration of use (Kirkwood,
2001).
Distal determinant explanations. Postulate factors that
exert their influence over time and are responsible for
age-related differences evident in the level of cognitive
performance.
Diuresis. Excessive production of urine.
Divided attention. The ability to allocate attentional resources
to two or more tasks or activities at the same time.
Drusen. Yellow deposits of extracellular material in the
macula.
Dynamic acuity. The measure of one’s ability to distinguish
details of objects in motion.
Empowerment theory. Supporting individuals and organi-
zations in developing the skills to advocate for themselves.
Encoding. Transfer of new information in which informa-
tion enters the memory system.
Environment. Physical aspects, such as natural terrain or
the manmade, “built” environment (such as buildings,
tools, and other objects), and sociocultural environment
that influences the attitudes and expectations of perform-
ance, through policies, customs, or societal prejudices.
End of life. The total circumstances of a person with a life-
threatening illness.
End-of-life care. Helps those with advanced, progressive,
incurable illness to live as well as possible until death
(Lunney et al., 2003).
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552 Glossary
Environmental press. Demands of the environment.
Episodic memory. Memories with a personal connection,
such as autobiographic memory.
Ergonomics. The study of humans, objects, or machines and
the interactions among them (Maltchev, 2012).
Error catastrophe theory. Proposes that a defect in the
mechanism used for protein synthesis could lead to the
production of error-containing proteins, resulting in
the dysregulation of numerous cellular processes, even-
tually resulting in death.
Errorless learning. Strategies to encourage learning in very
small steps that greatly reduce the potential for mistakes.
Eudemonic well-being. A sense that one is living a life of
meaning.
Everyday competence. A person’s ability to perform a broad
array of activities considered essential for independent
living.
Evolutionary senescence theory. The idea of the “selection”
of aging mechanisms through evolution.
Examples. (In the context of elder abuse): illustrations of
elder abuse.
Extended family. Nieces, cousins, aunts.
Familism. Valuing of family as a central element of life.
Fictive kin. Neighbors and friends who have both instru-
mental and emotional relationships with the individual.
Flow, involvement, serious leisure, committed leisure. The
total engagement in an activity that characterizes leisure.
Fluid intelligence. The ability to use abstract reasoning,
flexibly shift one’s mental set, and initiate and complete
purposeful action.
Form of abuse. The way in which abuse occurs, including
physical, financial, and sexual, as well as neglect.
Frailty syndrome. “1) is a clinical syndrome, 2) indicates
increased vulnerability to stressors, leading to functional
impairment and adverse health outcomes, 3) might be
reversible or attenuated by interventions” (Chen, Mao, &
Leng, 2014, p. 434).
Free radical. Highly chemically reactive agents generated in
single electron reactions to metabolism.
Free radical theory. Suggests that most aging changes are
due to the production of free radicals during cellular respi-
ration (Harman, 1956).
Free recall. Highly effortful and dependent on spontaneous
strategy use when learning and retrieving new information.
Function. “In ICF, the term functioning refers to all body
functions, activities and participation” (World Health
Organization, 2002, p. 2).
Functional performance. The capacity or performance of an
individual to carry out activities required for daily living.
Geriatric assessment units (GAUs). Provide rehabilitation
with an interdisciplinary team trained in the care of the eld-
erly, with attention to medical, psychosocial, and functional
issues and particular emphasis on assessing performance.
Geriatric rehabilitation units (GRUs). Distinct units housed
within community hospitals, freestanding rehabilitation
hospitals, or long-term care facilities and are staffed by
multidisciplinary teams specializing in the management of
the medical, social, physical, psychological, and economic
well-being of older adults.
Gerogogy. An approach to learning that recognizes the
special needs of older adults.
Glaucoma. A group of diseases characterized by progressive
optic nerve damage.
Happiness. A sense of pleasure or a positive affect in the
present.
Health. “A state of complete physical, mental and social
well-being and not merely the absence of disease or infir-
mity” (World Health Organization, 2007, p. 100).
Health coaching. A client-centered approach that is based
on behavior change models and uses motivational inter-
viewing to help individuals develop and implement a
plan of action to achieve goals (Butterworth, Linden, &
McClay, 2007).
Health education. “Any combination of planned learning
experiences using evidence-based practices and/or sound
theories that provide the opportunity to acquire knowl-
edge, attitudes, and skills needed to adopt and maintain
health behaviors” (Joint Committee on Health Education
and Promotion Terminology, 2011, p. 12).
Health literacy. The ability of individuals to gain access
to, understand, and use information in ways that pro-
mote and maintain good health (World Health Organ-
ization, 2009).
Health promotion. “The art and science of helping peo-
ple discover the synergies between their core passions
and optimal health, enhancing their motivation to strive
for optimal health, and supporting them in changing
their lifestyle to move toward a state of optimal health”
(O’Donnell, 2009, pp. iv–v).
Healthy aging. “The process of slowing down, physically
and cognitively, while resiliently adapting and compen-
sating in order to optimally function and participate in all
areas of one’s life (physical, cognitive, social, and spiritual)”
(Hansen-Kyle, 2005, p. 52).
High-tech devices. Computer hardware and software, such
as voice recognition and screen magnification software.
Higher order processes. Typically require additional cogni-
tive resources and are conceptualized as more complex
processes.
Home health agency (HHA). An organization that is pri-
marily engaged in providing skilled nursing services and
other therapeutic services in the home.
Hospice. The foundation for today’s end-of-life care, based
on the central idea that death is part of life and that the
experience of dying should be meaningful.
Iatrogenic factors. Secondary effects from the medical care
that an individual may be receiving
Idiopathic. Of uncertain origin.
Immunological theory of aging. The functional capacity
and fidelity of the immune system declines with age, as
indicated by the strong age-associated increase in autoim-
mune disease (Walford, 1969).
Independent/instrumental activities of daily living (IADL).
Complex activities that support life within the home and
4605_Glossary_550-556 31/10/17 12:38 PM Page 553
community including care of others, care of pets, child rear-
ing, communication management, driving and community
mobility, financial management, health management and
maintenance, home management, meal preparation and
clean up, and spiritual activities.
Inositol. A carbohydrate molecule manufactured from
glucose and found in human cells.
“Institution”. Community-based institutions, such as assisted
living facilities (ALF) as described in the home health
lexicon.
Instrumental activities of daily living. Requirements for
community living.
Integrated care pathways. Documents that outline the
essential steps of multidisciplinary care in addressing a
specific clinical problem.
Integration. Association of information regarding sensory
modalities.
Interdisciplinary team. Involved in problem-solving beyond
the scope of their own discipline.
Kinesthesis. The sensation and awareness of active or passive
movement.
Learning. New neural connections that are strengthened
with repetition, rehearsal, or a one-time highly salient
exposure, such as fear conditioning.
Legal blindness. (1) visual acuity of 20/200 or less in the
better eye after best possible standard correction or (2) a
visual field of no greater than 20 degrees in the better eye.
Leisure. Generally defined in one of three ways (Csikszent-
mihalyi & Kleiber, 1991):
■ discretionary time—time not obligated to work, self-care,
or instrumental activity (e.g., shopping, child care);
■ culturally sanctioned activity—an activity readily recog-
nized as leisure (e.g., fishing, quilting);
■ a state of being relaxed, contented.
Lewy body dementia (LBD). A progressive dementia and
represents two related diagnoses, dementia with Lewy
bodies and Parkinson’s disease dementia.
Life satisfaction. An overall life evaluation with which one
is content.
Lifelong education. A cradle-to-grave approach to educa-
tion recognizing that adults of any age can be learners
(Manheimer, Snodgrass, & Moskow-McKenzie, 1995).
Life-span development theory. Conceptualizes ontogenetic
development as biologically and socially constituted and
as manifesting both developmental universals (homo-
geneity) and interindividual variability (e.g., differences in
genetics and in social class)
Life-threatening illness. One that presents a very real risk
of causing death and implies limited survival time (World
Health Organization, 2004).
Long-term memory. Memory for which the traces (physical or
neural substrates of memory) last more than a few seconds.
Long-term potentiation. New connections that constitute
learning are associated with changes in the synaptic con-
nections in the brain (Martinez & Derrick, 1996).
Low-tech devices. Devices traditionally used by therapists,
such as button hooks and reachers.
Glossary 553
Low vision. An untreatable loss of sight that is not correctable
with standard eyeglasses and interferes with the functioning
of the individual, thereby creating a disability.
Macula. Central area of the retina with a concentration of
cone cells that allow for color vision and fine-detail discrim-
ination and rod cells that are extremely sensitive to light and
are responsible for peripheral vision and night vision.
Meaning. “The extent to which people comprehend, make
sense of, or see significance in their lives, accompanied
by the degree to which they perceive themselves to have
a purpose, mission, or over-arching aim in life” (Steger,
2009, p. 679).
Meissner’s corpuscle. One of two receptors (with Pacinian
corpuscles) in the skin responsible for perceiving light
touch and pressure.
Memory trace. Physical or neural substrate of memory.
Metabolic equivalent (MET). A unit of measure describing
the demand of an activity.
Metacognition. Refers to higher level processing skills that
are used in the implementation, verification, and regula-
tion of goal-directed activity (Nelson & Narens, 1994).
Middle-old. Individuals aged 76 to 84 years.
Minimum data set (MDS). A component of the Resident
Assessment Instrument (RAI) used in long-term care
settings as mandated by Medicare and Medicaid.
Modality. Sensory channel.
Motivation. The reason one chooses to engage in an activity.
Motor learning. “A set of processes associated with practice
or experience learning to relatively permanent changes in the
capability for movement” (Schmidt & Lee, 2005, p. 302).
Motor performance. The acquisition of a skill, but not
necessarily the retention of the skill.
Mnemonic. A memory device based on patterns, letters, or
ideas to support recall.
Multidisciplinary teams. Discipline-oriented groups with
each team member responsible for his or her own unique
scope of practice, and the team’s outcome is the sum of
each team member’s efforts.
Muscle quality. The force produced by a single muscle cell,
related to the normal aging process.
Mutation accumulation theory (Medawar, 1952). States
that aging is an inevitable result of the declining force of
natural selection with age.
Mutual cultural accommodation. A process through which
all parties arrive at a compromise that preserves their most
central beliefs but also supports a decision that facilitates
progress.
Narrative ethics. Focuses on the patient’s lifeworld and
experiences.
Navigators. Individuals specifically trained to support and
assist patients in maneuvering through complex health
systems and situations.
Neuroendocrine theories. Posit functional decrements in
neurons and their associated hormones as central to the
aging process.
Neuroplasticity. Making a new neural connection; brains
are constantly evolving their connectivity.
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554 Glossary
Neuropsychology of aging. A relatively new discipline that
scientifically investigates, clinically assesses, and develops
treatments for age-related and neurodegenerative changes
in brain function and behavior.
Nondeclarative learning. Learning demonstrated without
awareness and the procedural memory that underlies skill
learning.
Nuclear families. Spouse, children, and grandchildren.
Occupational justice. A belief that everyone should
have access to and support for engaging in meaningful
occupations.
Occupational performance. The act of engaging in activi-
ties, typically functional activities to fulfill life demands or
roles within varying contexts.
Occupational value. The individual’s assessment of the
importance of the activity.
Oculomotor skills. Responsible for the coordinated use of
extraocular eye muscles necessary for binocular vision and
the efficient performance of conjugate eye movements
(Warren, 2006).
Old age. A period of life typically considered to begin at
some point at an age in the mid-60s.
Old-old. Those aged 76 years and older.
Oldest old. Individuals older than 85 years.
Orthostatic intolerance. Postural hypotension.
Orthostatism. The ability of the body to maintain normal
cardiac output, in particular, cerebral perfusion, during
assumption of the upright body position. Pacinian
corpuscles—one of two receptors (with Meissner’s cor-
puscles) in the skin responsible for perceiving light touch
and pressure.
Palliative care. The active total care of patients whose disease
is unresponsive to curative treatment.
Parenchyma (lung). Composed of spongy alveolar tissue
that is designed to be ventilated and provide an interface
with the pulmonary blood through the alveolar capillary
membrane.
Patient satisfaction. In the field of rehabilitation: “a construct
reflecting the overall experience of an individual receiving
examination and treatment in a given environment during
a specific time period” (Hossain et al., 2012, p. 1047).
Perception. A higher sensory function and a middle ground
between sensation and comprehension.
Peripheral neuropathy. A condition that reduces neuronal
response to sensation.
Peripheral vision. The ability to perceive the presence or
movement of stimuli in the periphery beyond the area of
immediate focus that constitutes one’s central vision
(Warren, 2006).
Personality trait explanations. Based on the “big five” factors
of personality (neuroticism, extroversion, openness to
experience, agreeableness, and conscientiousness).
Phantogeusia. Taste hallucination.
Phantosmia. Smell hallucination.
Pharmacodynamics. What a drug does to the body.
Pharmacokinetics. The impact of body function on a drug.
Phased retirement. Employees stay with the same employer
while gradually reducing work hours and effort (Hutchens,
2010).
Postprandial. After eating.
Preclinical disability. The period between the onset of
impairment and the onset of disability (Fried et al., 1991).
Preclinical mobility. The frequency and method with which
everyday tasks are undertaken.
Presbycusis. Age-related hearing loss; a typical degradation
of the hearing sensory system associated with age.
Presbyesophagus. Reduced primary and secondary peristal-
sis within the esophageal system.
Presbyglutition. The normal age-related changes associated
swallowing.
Presbyopia. Difficulty focusing on near objects.
Pressure sores. Damage to the skin (usually over a bony
prominence) as a result of lengthy pressure, usually due to
prolonged bed rest.
Primary care. The element within primary health care that
focuses on health-care services, including health promo-
tion, illness, and injury prevention, and the diagnosis and
treatment of illness and injury (Health Canada, 2012).
Primary health care. An approach to health and a spectrum
of services beyond the traditional health-care system.
It includes all services that play a part in health, such as
income, housing, education, and environment (Health
Canada, 2012).
Priming. Learning demonstrated without awareness.
Procedural memory. System that underlies skill learning of
well-established habitual actions.
Productive aging. “The capacity of an individual or pop-
ulation to serve in the paid workforce, to serve in vol-
unteer activities, to assist in the family, and to maintain
himself or herself as independently as possible” (Butler
& Schecter, cited in Hinterlong, Morrow-Howell, &
Sherraden, 2001, p. 7).
Productive occupations. Undertakings that have economic
value but do not come with a paycheck.
Products and technology. “Natural or human made products
or systems of products, equipment, and technology in
an individual’s immediate environment, that are gathered,
created, produced or manufactured” (World Health
Organization, 2001, p. 591).
Pruritus. Excessive itching.
Psychological theories of aging. Seek to explain the multi-
ple changes in individual behavior, across these domains,
in the middle and later years of the life span.
Public Policy. Actions taken by government (or others who
play a role in policy, like school officials or city council
members) to address problems presented to them.
Quality of life. Conveys satisfaction with circumstances
and health and also reflects external, concrete markers
of well-being, such as income, type of housing, and
education.
Quarter. In Social Security and Medicare law, a 3-month
period in a given year.
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Rate pressure product. The product of heart rate and systolic
blood pressure.
Readability. Characteristics of written material that make
the material either easier or more difficult to read (Kahn
& Pannbacker, 2000).
Reciprocity. Opportunities that allow elders to help others
(Greenfield, 2009).
Registry. An information system for recording relevant
patient care information (Institute of Healthcare Improve-
ment, 2015).
Rehabilitation efficiency. The amount of functional gain
per day of service.
Rehabilitative. Care in facilities that includes stays of several
weeks to several months during which time the individual
is expected to improve and, probably, to return to a less-
restrictive environment.
Religious. An understanding of the force that animates
living things according to a particular religious doctrine
or faith.
Religious occupations. Those undertaken in association
with formally constituted religious organizations, such as
churches, mosques, or synagogues.
Respite services. Temporary care for dependent older adults
to relieve informal caregivers.
Risk factors (in the context of abuse). Represent character-
istics of victims, perpetrators, or environments found
through research to be associated with the problem.
Rituals. Ordinary activities that are invested with symbolic
meaning when performed to celebrate, commemorate, or
sanctify important events or ideas (MacKinley, 2006;
Niven, 2008; Thibeault, 2011).
Roster size. The number of patients affiliated with a primary
care practice.
Sarcopenia. Decline of muscle mass, the number of muscle
cells, and muscle quality.
Scotoma. Partial loss of vision or blind spot in a visual field
that is otherwise normal.
Self-advocacy. A process in which an individual (or group)
advocates for her or his own needs (Hagan & Donovan,
2013).
Self-care. Daily activity composed of duties and chores rang-
ing from personal care (e.g., bathing, dressing, grooming)
to personal business (e.g., using the telephone, managing
medications, banking, or shopping for food).
Self-efficacy. A belief that one can organize and execute
courses of action needed to achieve a desired goal or suc-
ceed at desired undertakings.
Self-management. A “dynamic and continuous process of
self-regulation” to “manage the symptoms, treatment,
physical and psychosocial consequences and life style
changes inherent in living with a chronic condition” and
to “monitor one’s condition and to effect the cognitive,
behavioral and emotional responses necessary to maintain
a satisfactory quality of life” (Barlow, Wright, Sheasby,
Turner, & Hainsworth, 2002, p. 178).
Semantic memory. The factual memory system.
Glossary 555
Senile miosis. A condition in which the pupil decreases in
size and becomes more fixed.
Senior centers. Community focal points, providing oppor-
tunities for older adults to come together for services and
programs.
Sensorineural hearing loss. Loss or damage to the sensory
hair cells of the cochlea, a pea-sized snail-shaped organ of
the inner ear.
Short-term memory. Storage of memory for 15 to 20 seconds.
“Signs”. The consequences of elder abuse examples.
“Silent” symptoms. Symptoms that are vague, nonspecific,
or hard to distinguish from declining function associated
with aging.
Skilled. Care in a facility that provides high-level medical
care immediately after a hospitalization (this includes
subacute and some ventilator care).
Skilled nursing facilities (SNF). Long-term care facilities
in which intensive medical interventions like tube feeding
are provided.
Social constructivism. Focuses on individual agency and
social behavior within larger structures of society, and
particularly on the subjective meanings of aging.
Social determinants of health. “The conditions in which
people are born, grow, live, work and age, including the
health system. These circumstances are shaped by the dis-
tribution of money, power and resources at global, national
and local levels, which are themselves influenced by policy
choices. The social determinants of health are mostly
responsible for health inequities - the unfair and avoidable
differences in health status seen within and between coun-
tries” (World Health Organization, 2014, n.p.).
Sociocusis. Environmental noise exposure.
Somatic mutation theory. States that accumulation of
mutations and other genetic damage produces functional
failure, eventually resulting in death.
Somesthesis. Includes the sensations that arise from light
and deep touch of the skin.
Spaced retrieval (SR). Involves giving persons with mem-
ory deficits practice at successfully remembering informa-
tion over increasingly long periods of time, and it has
been shown to enable persons with a variety of different
dementing conditions to retain new information across
clinically meaningful periods of time.
Speed of processing. An index of how fast information can
be cognitively processed.
Spiritual. Related to the spirit.
Spiritual occupations. Those that individuals identify as
connecting them to a higher power.
Spirituality. The state or condition of being spiritual.
Statins. A class of medications that reduce low density
lipoprotein.
Stochastic theories. Explain aging as resulting from the
accumulation of “insults” from the environment, which
eventually reach a level incompatible with life.
Strengths-based approaches. Focus on identifying strengths
and abilities rather than deficits and limitations.
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556 Glossary
Successful aging. Supporting older adults in remaining
functional and active.
Supportive care. Care that helps the patient and his or her
family to cope with a condition and its treatment from pre-
diagnosis, through the process of diagnosis and treatment,
to cure, continuing illness or death, and into bereavement.
Sustainable growth rate (SGR). A method currently used
by the Centers for Medicare and Medicaid Services
(CMS, 2014e) to control spending on physician services.
Sustained (or focused) attention. The ability to direct
attentional resources to a single task or activity.
Technology. In its broadest sense, the making, modifying,
and using of tools, machines, and methods of organizing
to solve a problem or achieve a goal (Schulz et al., 2015).
Telerehabilitation. The delivery of rehabilitation services
which may include assessment, monitoring prevention,
interventions supervision, education, and consultation
through information and communication technologies
(Brennan et al., 2010).
Theories of aging. Attempts to go beyond the what of
symptoms or disabilities associated with aging to examine
the why and how of changes related to age.
Theory. An attempt to explain what we observe in empirical
research or practice.
Tinnitus. The perception of sound in the absence of an
acoustic stimulus.
Transdisciplinary D teams. Teams in which one team
member is chosen to be the primary leader or therapist
depending on the specific needs of the client.
Transgenerational, or life-span, design. Considers the
changes individuals experience as they age (Deardorff,
2003).
Very old. Those aged over 85 years (Velkoff, He, Sengupta,
& DeBarros, 2006).
Universal design. “The design of products and environments
that can be used and experienced by people of all ages
and abilities, to the greatest extent possible, without
adaptation” (Deardorff, 2003).
Useful field of view (UFOV). The spatial area within which
an individual can be quickly alerted to visual stimuli in a
variety of situations (Keplinger, 1998).
Value-based purchasing. Links payment to improvement
in provider performance.
Vascular dementia. Dementia due to an overall inefficient
supply of oxygenated blood to the brain that can be due
to small transient ischemic attacks.
Well-being. A person’s perceptions related to positive affect,
negative affect, life satisfaction, and domains of life (e.g.,
work, family, leisure, health, finances, self, and group;
Diener, Suh, Lucas, & Smith, 1999).
Wellness. “A multidimensional state of being, describing
the existence of positive health in an individual as exem-
plified by quality of life and a sense of well-being” (Corbin
& Pangrazi, 2001, p. 3).
Young-old. Those aged 55 to 75 years.
Xerosis. Dry skin.
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Index

A Advance care planning (ACP), 528 skin changes associated with, 138
Abledata, 333 Advantage Plans, Medicare, 36 social factors, 80
Abuse. See Elder abuse Advocacy societal, 19–20
Accessible designs, 328–329 definition of, 39 sociocultural factors that affect, 8–10
Accessory apartments, 447t description of, 33 socioeconomic status effects on, 11
Accommodation, 132 for individuals, 40–41 stereotypes of, 9
Acculturation, 541 models of, 39–41 successful, 4, 12, 92, 422
Acculturative stress, 77 occupational therapists in, 41 theories of. See Theories of aging
Action tremor, 239t Olmstead Act and, 42 wealth effects on, 4–5
Active aging, 428t–429t physical therapists in, 41 wisdom and, 5
Active living programs, 428–429 for policies, 39–40 in women, 5
Activities of daily living (ADLs) self-advocacy, 40–41 Aging and Disability Resource Center
assessment of ability to perform, 114, 284 Advocating mode, of Intentional Relationship (ADRC), 441
basic, 147 Model, 376 Aging in place, 8, 330–331, 439
bathroom modifications, 287, 288f Aerobic exercise, 122, 423t Agrarian societies, 6
body position changes for, 114–115 Affordable Care Act (ACA), 37–38, 405, 438, Airways, 110
classification of, 280 441, 460, 473, 511, 546 Akinesia, 238t
cultural influences on, 77–78 Africa, 76. See also South Africa Alcohol consumption, 374
dementia effects on, 283 African Americans Alternate heel to knee test, 169
difficulties in performing, 281 aging of, 77 Alternate nose to finger test, 168
dressing area modifications, 287, 288f caregiving by, 375 Alternating attention, 96
in end-of-life patients, 527 hypertension in, 207 Alveolar capillary membrane, 110
environmental modifications for, 287f–288f, life expectancy in, 4 Alzheimer’s Association, 187
287–288 Age Discrimination in Employment Act Alzheimer’s disease. See also Dementia
functional performance evaluation of, 412, (ADEA), 442 biomedical research on, 545
414–415 Age in place, 8 cultural influences on, 79
instrumental. See Instrumental activities of Age stratification perspective, 24 description of, 22
daily living (IADLs) Age-friendly cities, 430, 431t–432t, 446 diagnosis of, 186–187
interventions for, 286–289 Ageism, 9, 94 driving performance affected by, 346
kitchen modifications, 288 Agency for Healthcare Quality and Research episodic memory impairments in, 386
limitations of, prevalence of, 282 (AHRQ), 458 medications for, 187
metabolic demand of, 113–114 Age-related macular degeneration nonpharmacological interventions for,
monitoring of, 123–124 (AMD), 219, 219f 187–188
muscle strength effects on, 150 Age-restricted retirement community, 447t prevalence of, 184
prescribing of, 119b–120b, 122–123, 257 Ageusia, 136 progression of, 186–187
safety considerations, 124 Aging. See also Population aging sexuality in, 375
as self-care activities, 280 active, 428t–429t visual impairments caused by, 222–223
skill training for, 286–287 attitudes about, 5, 8–9 American Association of Retired Persons
stroke effects on, 282–283 chronological, 492 (AARP), 313–314, 317
task modifications for, 289 cognition and, 23, 385. See also Cognitive American Journal of Occupational Therapy
thermoregulation impairments and, 116 aging (AJOT), 425
vision impairment effects on, 283 cultural factors that affect, 9–10, 75–77, 541 American Medical Association (AMA), 347
Activities of Daily Living Interview as developmental process, 19–20 American National Standards Institute
(ADL-I), 530 economic circumstances and, 4–5 (ANSI), 328
Activities-specific Balance Confidence (ABC) factors that affect, 4f, 7–11 American Occupational Therapy Association
scale, 172 functional performance and, 327–328 (AOTA)
Activity, 28 gender effects on, 4–5 advocacy and, 41–42
Activity Card Sort, 412 genetic factors that affect, 10–11 certification with, 348
Activity limitations, 28 healthy, 422 community mobility as defined by, 359
Activity theory, 24 history of, 4–6 court legislation and, 36
Acute care, 497 at home, 8 description of, 272, 318, 331, 342, 372
Acute conditions, 265 individual characteristics that affect, 10–11 end-of-life care, 528
Acute hospitalization, 497 international context of, 76–77 evaluation process, 481
Adaptability, 11 leisure and, 296–297 productive aging, 422
Adaptable design, 329 migration effects on, 8 resources, 425
A-delta fibers, 139 performance skills affected by, 64 spirituality and, 65
Adherence, 500 personality and, theories regarding, 23, 23t American Public Transportation Association
Administration for Community physical environment effects on, 7–8 (APTA), 363
Living (ACL), 438 physiological, 492 American Thoracic Society, 113
Administration on Aging, 442 positive, 12, 155, 280, 541 Americans with Disabilities Act, 42, 79, 321
Adult day care facilities, 497–498 as positive phenomenon, 9 Amputation, limb, 236–238
Adult day services, 444 productive, 422 Amyloidosis, 112
Adult protective services, 445 psychology of, 22 Anaerobic exercise, 122

557
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558 Index

Analysis of occupational performance, 81 Atlantic, The, 546 Bisphosphonates, 270

Angle-closure glaucoma (ACG), 220 Atrial fibrillation, 111 Blocking, 387
Anosmia, 136, 239t Attentional resources, 96 Blood, 112
Antagonistic pleiotropy accumulation theory, of Attitudes Blood pressure control, 206
aging, 21, 21b about aging, 5, 8–9 Blood vessels, 112
Anticipatory postural control, 170 education effects on, 9 Body functions, 28
Anxiety disorders, 191–192 negative, 9 Body structures, 28
Apartheid, 53–54 positive, 8 Body weight assessments, 114
Apocrine glands, 138 Attractor well, 26 Bone, 151–152, 152t
Appreciation of nature, 402 Audiogram, 132 Bone mineral density (BMD), 233
Arm–hand function tests, 169 Auditory habituation, 134 Bone quality, 233
Arnadottir OT-ADL Neurobehavioral Auditory processing, 95 Bone remodeling, 151
Evaluation (A-ONE), 285, 412 Auditory system. See also Hearing Bone–muscle crosstalk, 152
Aromatase inhibitors, 265 age-related changes in, 130t, 132–136 Boredom, 302
Arthritis anatomy of, 133f–134f Borg scale of exertion, 211
degenerative, 264 functional performance and, 132–136 Braden Scale for Predicting Pressure
driving affected by, 347 pathology of, 224 Sore Risk, 224
osteoarthritis, 231–232, 460 Auditory system disorders Bradyphemia, 239t
rheumatoid, 283 description of, 224 Braille output devices, 334–335
self-care affected by, 283 hearing loss. See Hearing loss Breast cancer, 265
Asian American elders, 440 presbycusis, 132, 134 Bridge employment, 315
Assessment of Driving Related Skills tinnitus, 133–134 Bristol Activities of Daily Living Scale, 285
(ADReS), 348 Australia, 390, 484 Broca’s aphasia, 241t
Assessment of Living Skills and Resources, Autonomous stage, of motor learning, 388 Built environment, 328–331
285, 412 Autonomy, 82, 265, 360, 484 Buses, 362
Assessment of Motor and Process Skills
(AMPS), 81, 285, 409, 530 B C
Assisted living, 5, 447t, 511 Baby Boomers, 6t, 6–7, 11, 313, 316, 540–541 Canada, 38, 425, 546–547
Assisted suicide, 546–547 Back pain, 225 Canadian Association of Occupational
Assistive devices “Back-scratch test,” 154 Therapists, 12
for fall prevention, 257 Bag-and-carry test (BCT), 116 Canadian Model of Occupational Performance,
for limb amputation patients, 237 Balance 12, 399
for self-care, 288–289 age-related changes in, 166–167 Canadian Occupational Performance Measure
Assistive listening devices (ALDs), 136, 336 assessment of, 169–172, 254–255, 413 (COPM), 68, 81, 408–409, 530
Assistive technology cognitive demand for, 172 Cancer
abandoning of, 336–337 exercise for, 174, 257 description of, 204, 208, 265–266, 272
acceptability of, by patient, 337 functional, 170 fatigue caused by, 529
braille output devices, 334–335 problems with, 174–175 pain caused by, 273
case study of, 338 static, 170 Cane, 257
closed circuit televisions, 334 Balance ability, self-report measures of, 172 Carbidopa, 238
devices for, 330, 332b Balance Evaluation Systems Test (BESTest), Cardiac output, 208
environmental control units, 333 170–171 Cardiopulmonary system
in Europe, 337 Balance tests, 171 age-related changes in, 110–111, 111t
funding for, 337 Balance training, 424t assessment of, 121
for hearing impairments, 335–336 Balanced Budget Act of 1997, 36, 473, 482 exercise testing of, 210–211
home living enhanced with, 430 Ballistic stretching, 158 extrinsic factors that affect, 209
interdisciplinary approach to, 337 Basal ganglia, 167 health of, factors affecting, 202b, 202–210
issues related to, 336–337 Basic-level palliative care, 524 intrinsic factors that affect, 209–210
for memory loss, 336 Bathroom modifications, 287, 288f noncommunicable diseases of, 203–204
mobile devices, 335 Bedrails, 83 rehabilitation of, 119, 121
needs assessment for, 331–332 Behavioral rehabilitation, for depression, 191 Cardiovascular disease, 283
optical character recognition system, 335 Behaviors Cardiovascular system
reasons for failure of, 337 dementia effects on, 186 age-related changes in, 111–112, 112t
robots, 333–334 stroke effects on, 189 anatomy of, 111–112
screen enlargement software, 334 Behind-the-ear hearing aid, 136 exercise testing of, 210–211
screen reading software, 335 Being in control, 299 extrinsic factors that affect, 209
for visual impairments, 334–335 Belonging, sense of, 297 health of, factors affecting, 202b, 202–210
voice recognition, 335 Beneficence, 82 intrinsic factors that affect, 209–210
walking aids, 333 Beneficiaries (Medicare), 36 noncommunicable diseases of, 203–204
wheelchairs, 333 Benefit period, 35 progressive changes in, 113
Association of Driving Rehabilitation Specialists Benserazide, 238 Caregiving/caregivers
(ADED), 348 Benzodiazepines, 192 end-of-life, 532
Associative stage, of motor learning, 388 Bereavement, 531–532 ethnographic interviewing, 377, 377b
Asthma, 203 Berg Balance Scale (BBS), 170, 255, 408 by family, 375, 440
Astigmatism, 131 Biological theories, of aging, 20–21, 21b functional performance evaluation
Atherosclerosis, 203, 204t Biomedical research, 545 considerations for, 416
Atherosclerotic plaque, 205 Bipolar disorder, 192–193 informal, 376–377, 471
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Index 559

Intentional Relationship Model, 376–377 hearing loss effects on, 224 in hearing loss, 135b
rehabilitation affected by, 500 learning affected by changes in, 385 in low-vision patients, 132b
techniques of, 377 loss of, 513 in pain assessments, 225
Cartilage, 152–153 on-the-road assessment of, 352 Community environment, 424–425
Case management, 495–496 Cognitive aging Community Long-Term Care Insurance Law
Case managers, 322, 495 description of, 93 (CLTCI), 46–47
Cataracts, 218f, 218–219 developmental life span approach to, 94 Community mobility. See also Transportation
Catastrophic disability, 493 inhibition and, 103 alternative solutions for, 362–364
Catecholamines, 210 interindividual differences that affect, 94 case study of, 365
Center for Universal Design, 329 methodological considerations for, 94 clinicians’ involvement in, 361–362
Central auditory processing disorder, 133 optimizing of, 103–105 cognitive interventions for, 365
Central nervous system tenets of, 94 definition of, 359
description of, 129 theories of, 102–103 direct interventions for, 365
disorders of, 153–154 Cognitive behavioral therapy (CBT), 464 driving for. See Driving
Cerebellum, 167 Cognitive conditions. See also Mental health environmental factors, 363
Cerebral cortex, 129 conditions evidence-based practice, 364–365
Cerebrovascular disease, 347, 374 dementia. See Dementia in India, 359
Certified nursing assistants (CNAs), 515 Developmental Lifespan Approach to, 183 methods of, 361–362
Cerumen, 133 Environmental Press Model of, 183, 196 as “occupation enabler,” 359
Cervical spondylosis, 164 illness experience of individuals with, Community participation, 541–542
C-fibers, 139 194, 195b Community-based rehabilitation, 454
“Chair sit-and-reach test,” 154 objective indicators of, 183 Community-based services
Chaplain, 401 rehabilitation and treatment plans for, adult day services, 444
Chedoke Arm and Hand Activity Inventory, 414 194–196 adult protective services, 445
Chemosensory loss, 137 self-care abilities affected by, 283 barriers to use, 440
Chest wall, 110–111 strengths-based approach to, 184, 196 caring and, 444–445
Childlessness, 371 stroke, 188–189, 194, 206–207 case study of, 448
Chile, 76–77 understanding of, 182–184 classification of, 438–439
China Cognitive impairment comprehensive assessments, 438–439
older adults in, 9, 75–76 description of, 285 congregate meal programs, 443–444
“one-child” policy in, 540 functional performance evaluation continuum of care, 438–439
Choice reaction time, 167 affected by, 416 coordination of, 447
Chondroblasts, 153 rehabilitation outcome affected by, 500–501 enabling characteristics and, 440
Chronic Care Model (ECCM), 456 in rehabilitation patients, 493 for experiencing, 443–444
Chronic Disease Self-Management Program Cognitive processes function-based classification of, 439
(CDSMP), 429 basic, 96–99 function/performance areas for, 442–444
Chronic obstructive pulmonary disease (COPD), everyday cognition, 100 for giving, 442–443
206, 374 executive functioning, 99 global use of, 440
Chronic systemic low-grade inflammation expertise, 101 housing, 445–446, 446t–447t
(CSLGI), 204–205 explicit processing, 101 in-home care, 439
Chronically ill patients, 399 higher-level, 99–101 for learning, 442
Chronological aging, 492 implicit processing, 101 linkage of, 441, 441t
Civic engagement, 104, 442 intellectual abilities, 101–102 location-based classification of, 439
Client-centered approaches language production, 100–101 Medicaid funding of, 438
Model of Human Occupation, 27–28 memory. See Memory need characteristics and, 440
overview of, 26 perception, 95–96 occupational therapist promotion of, 440
systems theory of motor control, 26–27 problem-solving, 99–100 occupational therapists in, 446–447
Client-centered practice, 409 sensory, 95 outside-of-the-home assistance, 439
Clinical note, 515b speech comprehension, 100–101 overview of, 437
Clinical Test of Sensory Interaction in Balance wisdom, 101 physical therapists in, 446–447
(CTSIB), 171 Cognitive reserve, 104, 391–392 predisposing characteristics and, 440
Closed circuit televisions (CCTVs), 334 Cognitive stage, of motor learning, 387–388 public policy influences on, 438
Coaching, health, 427, 463 Cognitive-perceptual screenings, 351 senior centers, 443
Cochlea, 134f Cogwheel rigidity, 238t state revenues for, 438
Cochlear implants, 335–336 Cohorts, 6, 6t, 540–541 supportive services, 445t
Code of Federal Regulations (CFR), 477 Co-housing, 447t utilization of, 439–441
Cognition Cold therapy, 226 for working, 442
aging and, 23, 385 Collaborating mode, of Intentional Relationship Competence, 280
atypical changes in, 182–184 Model, 376 Compliance, 110
bipolar disorder-related symptoms, 193 Collagen, 152t, 153 Comprehensive geriatric assessment, 498–499
declines in, 114 College of Occupational Therapists, 243 Comprehensive outpatient rehabilitation facilities
dementia-related symptoms, 185 Color vision, 346 (CORFs), 35, 498
everyday, 100 Colostomy, 266 Concepts, theories and, 19
functional performance evaluation affected by, Common cause hypothesis, 103 Conceptual frameworks
415–416 Communication definition of, 409
health promotion through cognitive cultural influences on, 79 for functional performance evaluation,
activities, 430 dementia effects on, 185–186 409–411
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Conditioning, 118–119 social participation affected by, 78–79 Dermatitis, 224

Conditions for Coverage (CfCs), 477 temporality affected by, 80 Dermis, 138
Conditions of Participation (CoPs), 477, 481 in United States, 77 Detection thresholds, 137
Conductive hearing loss, 132 work activities affected by, 78 Developmental explanations, 23
Confidentiality, 477 Current Procedural Terminology (CPT), 35 Developmental Lifespan Approach, 183
Confined to home, 475–476 Custodial care, 508 Developmental-genetic theories, of aging,
Congregate care facility, 447t Custodial grandparents, 371 21, 21b
Congregate meal programs, 443–444 Diabetes mellitus
Connective tissue, 152–153 D foot care program in, 237–238
Conservation, 541 Day hospital care, 497–498 management of, 266–268
Consolidation, 386 Day-care centers, 47–48 motor vehicle accident risks, 347
Continuity theory, 24, 315–316 Dead space, 203 type 2, 204, 204t, 207–208
Continuous care retirement community, 447t Death. See also End of life Diabetic retinopathy (DR), 220f, 220–221
Continuous-Scale Physical Functional falls as cause of, 250 Diagnosis-related groups (DRGs), 35, 472
Performance Test, 155 good, 525–526, 526b Diaries, 533
Continuum of care, 438–439 leading causes of, 203t Diet. See also Nutrition
Contrast sensitivity, 132, 345, 351 spousal, 372 lifestyle-related noncommunicable diseases
Control Decision-making, 27 and, 205–206
description of, 65 Declarative learning, 386 muscle mass affected by, 150
freedom of choice created by, 299–300 Declarative memory, 22, 98 Diffusing capacity, 110
home and, 473 Deconditioning, 118, 265, 272 Direct spiritual interventions, 401, 401f
in leisure, 299–302 Deep brain stimulation, 240 Disability
outcomes determined because of, 300 Degenerative arthritis, 264 catastrophic, 493
Convergence, 130 Dementia. See also Alzheimer’s disease functional performance affected by, 328
Coordination. See also Balance assessment of, 182 intellectual, 491–492
age-related changes in, 165–166 behaviors affected by, 186 late-life, in women, 11
assessment of, 168–169 case example of, 185b mobility, 413
definition of, 166 cognitive loss associated with, 513 nursing home residents with, 511
driving and, 350 cognitive symptoms of, 185 in older adulthood, 490–491
problems with, 174 communication in, 185–186 physical, 492
Coordination of Patient Services, 477 with delirium, 186 preclinical, 408
Coordination tests, 168–169, 414 diagnosis of, 186 preexisting, 491–492
Copiloting, 347, 360 driving performance affected by, 346–347 prevalence of, 490
Copresence, 297 emotions affected by, 186 progressive, 493
Core competencies, 123 episodic memory impairments in, 386 rehabilitation for. See Rehabilitation
Coronary artery disease, 203 etiology of, 184–185 spirituality and, 399
Cranial nerves, 136–137 evidence-based care approaches for, 516–517 Disability-specific laws, 328
Creativity, 402 fall risks in, 513 Disabling events, psychological
Critical gerontology, 25 functional engagement in, 185–186 consequences of, 491
Critical perspectives of aging, 24t, 25–26 hearing loss as marker for, 224 Discharge planning, 495
Cross-linkage, 153 irreversible, 184 Disengagement, 304
Cross-sectional research designs, 94 Lewy body, 187 Disengagement theory, 24
Crystallized abilities, 23 medications for, 187 Dismobility, 460
Crystallized intelligence, 101–102 mental health affected by, 186 Disposable soma theory, of aging, 21, 21b
Cultural competence, 81, 400, 472–473 Myers-Menorah Park/Montessori-based Distal determinant, 23t
Cultural contexts, 343 Assessment System for, 517 Disuse atrophy, 149
Cultural values, 75 nonpharmacological interventions for, Diuresis, 209
Culture 187–188 Divided attention, 96
activities of daily living affected by, 77–78 pharmacological interventions for, 187–188 Domiciliary care, 498
activity demands affected by, 80–81 prevalence of, 184 Down syndrome, 492
aging affected by, 9–10, 75–77, 541 rehabilitation and treatment plans for, Drawing a circle test, 169
as contextual factor, 76 194–195 Dressing areas, 287, 288f
definition of, 75 reversible, 184, 186 Driver’s license
education affected by, 78 self-care abilities affected by, 283 importance of, in Western society, 359
end of life affected by, 526 semantic, 386 renewal of, 351, 353
ethical dilemmas affected by, 82–83 sexual dysfunction associated with, 374 Driving
family affected by, 368 spaced retrieval in, 516–517 autonomy associated with, 360
grandparenting and, 371 symptoms of, 185–186 body functions relevant to, 343
habits and routines affected by, 79 types of, 184–185, 186–187 case studies of, 354, 365
instrumental activities of daily living affected vascular, 187 cessation of, 360–361
by, 78 well-being outcomes in, 194 client factors affecting, 343, 343t–344t
intervention process and, 81–82 Dependency ratio, 10, 367 clinical assessment of, 348–352
motor skills affected by, 79 Depression contextual issues that affect, 345t
occupations affected by, 77–79 description of, 190–191 copiloting, 347, 360
performance patterns affected by, 79–80 personal meaning as method of reducing, 542 cultural differences in, 345
performance skills affected by, 79 rehabilitation outcomes affected by, 493, 500 dementia effects on, 346–347
roles affected by, 79–80 sexuality affected by, 374–375 description of, 100, 341
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Index 561

difficulties with, signs of, 353–354 Elderhostel, Inc., 390 Ergonomics, 319–320
engagement in, 342 e-learning, 392, 393f Erikson, Erik, 63
evidence-based practice for, 352–353 Electronic magnification, 223t Error catastrophe theory, 20, 21b
family involvement in decisions regarding, 361 Electronic medical records (EMRs), 270, 458 Errorless learning, 386
losing of ability to drive, 359–360 Emancipatory knowledge, 26 Ethics/ethical dilemmas
medical history and, 349–350 Emanuel, Ezekiel, 546 about death and dying, 526
motor vehicle crashes, 341–342 Emotions cultural influences on, 82–83
movement assessments, 350 dementia effects on, 186 sexuality assessments, 375
night, 131 stroke effects on, 189 technology issues, 545
as occupation, 342–343 Empathizing mode, of Intentional Relationship Ethnicity, 77
Parkinson’s disease effects on, 347 Model, 376 Ethnocultural diversity, 385
performance patterns that affect, 343, 344t Empowerment theory, 39 Ethnographic interviewing, 377, 377b
performance skills for, 342–343, 343t–344t Encoding, 386 Europe
psychometric tests for assessing ability to Encouraging mode, of Intentional Relationship assistive technology in, 337
drive, 352 Model, 376 baby boom in, 541
self-regulation by older adults, 360 End of life home health care in, 471
sensory functions that affect, 345–346 caregiving during, 532 European Association for Palliative Care
skill areas and changes that affect, 346t cultural influences on, 526 (EAPC), 523, 528
transition from, 361 definition of, 522 European Organization for Research and
visual function and, 345–346 existential dimensions/needs during, 526 Treatment of Cancer (EORTC), 530
Driving Habit Questionnaire, 350 family affected by, 526–527, 531–532 Evaluative meanings, 64
Driving history, 349–350 needs during, 526–527 Event-based prospective memory, 387
Driving rehabilitation specialists, 348 overview of, 521–522 Everyday cognition, 100
Dry age-related macular degeneration, 219 physical dimensions/needs during, 526 Everyday competence, 280
Dual energy x-ray absorptiometry (DEXA), 233 psychological dimensions/needs during, 526 Everyday problem-solving, 99–100
DUTI. See Urinary tract infections (UTIs) social dimensions/needs during, 526 Evidence-based practice (EBP), 544–545
Dying process. See also End of life End-of-life care. See also Palliative care Evolutionary theories, of aging, 21, 21b
family affected by, 526–527 assessments in, 530 Exchange theory, 24
stages of, 525 bereavement during, 531–532 Executive functioning, 99, 103
Dynamic Gait Index (DGI), 170, 173 case study of, 534 Exercise. See also Physical activity
Dynamic stretching, 158 definition of, 522 adherence to, 155
Dynamometers, 154–155, 414 factors that affect, 528 aerobic, 423t
Dysgeusia, 136 goal setting in, 530 balance improvements with, 174
Dyskinesias, 238 health policies affecting, 528 balance training, 424t
Dysosmia, 136 hospice for, 523 barriers to, 155
Dysphagia, 269 occupational therapy in, 524, 527–531 benefits of, 175, 209, 426
outcomes for, 533 considerations for, 157
E physiotherapy in, 524, 527–531 depression managed with, 191
Ear, 133f–134f Endurance assessments, 118 distress during, 124
Eburnation, 232 Energy conservation, 122 fall prevention through, 256–257
Eccentric viewing, 219 Engagement in Meaningful Activities Survey, 68 flexibility, 158
Economics, 4–5 England, 38 frailty syndrome managed with, 269
Eden Alternative, 510 Environment functional performance evaluation of, 412
Education accessible designs, 328–329 gait improvements with, 174
attitudes toward aging changed through, 9 adaptable design, 329 metabolic demand of, 113–114
cultural influences on, 78 assessment of, 285–286 monitoring of, 123–124
fall prevention through, 255 built, 328–331 osteoporosis management through, 234–236
lifelong, 442 changing of, 328–330 oxygenation benefits of, 209
meaningfulness of, 541 community mobility affected by, 363 recommendations for, 423t–424t
Educational level, 416 fall risks, 250 resistance training, 155, 156–158
Ego integrity versus despair, 63 health and wellness affected by, 424–425 safety considerations, 124
Elastin, 152t, 153 home, 424, 430 self-efficacy and, 155
Elder abuse life-span design, 329 strength training, 123, 156–158, 424t
approaches for, 85–86 modifications of, for activities of daily living, subjective scales of responses to, 116t
definition of, 83 287f–288f, 287–288 Exercise prescription
environmental risk factors for, 85 self-care affected by, 280, 285–286 description of, 122–123
examples of, 84 transgenerational design, 329 evidence-based, 157t, 170t
forms of, 83 universal design, 329–330 parameters for, 119, 119b–120b
incidence of, 83–84 Environmental Analysis of Mobility Exercise stress, 208–210
multidisciplinary teams for, 86 Questionnaire (EAMQ), 412 Exercise testing
prevalence of, 83–84 Environmental control units, 333 assessments before, 210, 210t
reporting of, 84 Environmental Press Model, 183, 196 cardiovascular and cardiopulmonary
risk factors for, 84–86 EPESE survey, 410 health conditions evaluated using,
screening or assessment instruments for, 84–86 Epidermis, 138 210–211
signs of, 84–85 Episodic memory, 386–387 Exercise tests
Elder cottage housing opportunity Erectile dysfunction, 374 measures used in, 210
(ECHO), 447t Erection, penile, 373 submaximal, 117b, 117–118
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562 Index
Exercise training
exercise test findings applied to, 211, 211b
maintenance phase of, 211
older adults’ enjoyment of, 211
specificity of, 210
Existential meanings, 64–65
Expanded Chronic Care Model (ECCM),
456–458, 457f, 457t
Experience Corps (EC), 430
Explicit processing, 101
Extended family, 369, 370t
External memory aids, 195
Extrapyramidal system, 166
Eye, 131, 131f, 166
Eye conditions
age-related macular degeneration, 219, 219f
behavioral adaptations for, 221–222
cataracts, 218f, 218–219
diabetic retinopathy, 220f, 220–221
diseases that cause, 222–223
functional adaptations for, 221–222
glaucoma, 219f, 219–220
optic devices for, 222, 223t
overview of, 217–218
questionnaires for assessing, 221
Eyeglasses, 334
Eye–hand coordination tests, 169
F cycle of, 253f
Falls
age-related risk factors for, 251, 251f
balance exercise for prevention of, 257
behavioral risk factors for, 252–253
biological risk factors for, 251, 251f
case study of, 259–260
cognitive risk factors for, 252–253
community risk factors for, 253, 257
consequences of, 250–251
definition of, 249
in dementia patients, 513
description of, 27
education to prevent, 255
environmental factors involved in, 250, 253,
257, 259t
environmental modifications for, 259t
exercise for prevention of, 256–257
facts regarding, 249–250
fractures caused by, 250
global incidence of, 250
history-taking about, 254–255
interventions for, 255–259
location of, 250
in long-term care facilities, 250, 253
medical costs for, 249–250
medications as cause of, 251, 252t, 258
mortality caused by, 250
multifactorial programs for, 256
prevention of, 253–255, 426, 483–484, 546
registry for, 458
restraints and, 259
risk assessments for, 171, 253–255
risk factors for, 175, 251–253, 257t
self-care considerations, 281–282
sequelae of, 250–251
underreporting of, by patients, 254
urinary incontinence as risk factor for,
257–258
Family Formal learning, 388–391
addressing of issues in health-care Fracture Risk Assessment (FRAX), 233
environment, 378 Fractures
caregiving by, 375, 440 falls as cause of, 250
case study of, 378 fragility, 233–234
cultural effects on, 368 hip, 250, 512
in driving-related decisions, 361 Fragility fractures, 233–234
end of life effects on, 526–527, 531–532 Frail Elderly Functional Assessment, 408
extended, 369, 370t Frailty, 493, 499
geographic mobility effects on, 370 Frailty syndrome, 269–270
importance of, 367 FRAME, 460
leisure activities in, 370 Free radical theory, of aging, 21, 21b
network typology of, 368t Free recall, 387
nuclear, 369, 370t Freedom of choice, 299–300
occupations in, 370–371 Fullerton Advanced Balance (FAB) scale, 170
reciprocal roles in, 367–368 Function
rehabilitation affected by, 500 International Classification of Functioning,
social issues that affect, 368 Disability, and Health definition
special circumstances, 371 of, 26, 28
structure of, 369–370, 370t public policy influences on, 33–34
Family constellations, 369–371 Functional abilities, 280–282
Family Health Teams (FHTs), 458 Functional Activities Questionnaire, 408
FAST, 188 Functional Acuity Contrast Test (FACT), 351
Fast-twitch fibers, 149–150 Functional Assessment and Safety Tool, 286
Fatigue, 415, 529 Functional Autonomy Measurement System
Fear of falling (SMAF), 412, 415–416
behavioral strategies for, 258b Functional Behavior Profile, 409
cognitive strategies for, 258b Functional capacity
assessment of, 116–118, 122
description of, 252 evaluation of, 319
interventions for, 257, 258b exercise program to improve, 119b–120b, 121
signs/clues of, 253 exercise sessions frequency matched with, 211
Federal Medical Assistance Percentage Functional engagement, in dementia, 185–186
(FMAP), 37 Functional Independence Measure
Federal policies (FIM), 409, 416
Medicaid, 37, 438, 472, 508–509 Functional mobility, 350
Medicare. See Medicare Functional performance
Older Americans Act, 37 aging and, 327–328
overview of, 34 assessment of, 114–116
Patient Protection and Affordable Care Act, built environment and, 328–331
37–38 definition of, 407–408
Social Security, 34 disability effects on, 328
Festinating gait, 239t screening for problems in, 408
Fever, 264 threshold of, 112–116
Fictive kin, 369, 370t Functional performance evaluation
Finances, 11, 542–543 activities of daily living, 412, 414–415
Finger opposition test, 168 areas of assessment in, 411–416
Finger to finger test, 168 caregiver support and, 416
Finger to nose test, 168, 414 case study of, 417
Finger to therapist’s finger test, 168 cognition effects on, 415–416
Finland, 390 conceptual frameworks for, 409–411
Fitness. See also Exercise; Physical activity descriptive purpose of, 408–409
functional consequences of, 118–119 educational level effects on, 416
programs for, 427 fatigue effects on, 415
Fitness-to-Drive Screening, 361 Glass model used in, 410–411
Fixation test, 169 instrumental activities of daily living, 412,
Flexibility 414–415
assessment of, 154 International Classification of Functioning,
description of, 153 Disability, and Health framework
exercises for, 158 used in, 410, 410f
Florida Senior Safety Resource Center, 364 issues related to, 415–416
Fluid intelligence, 23, 101–102 lower extremity function, 412–414
Focused attention, 95 mobility, 412–413
Food activities, 137 overview of, 408–409
Foot care program, in diabetes mellitus, 237–238 Person–Environment–Occupation
Footwear, 253 model, 411
Forgetfulness, 185 reasons for, 408
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sensory loss effects on, 415 Health. See also Wellness Healthy behaviors, 393
upper extremity function, 414 active living programs for, 428–429 Hearing. See also Auditory system
Functional Reach Test (FRT), 170, 408 cognitive activities for promotion of, 430 age-related changes in, 130t, 132–136
Functional residual capacity, 111 community effects on, 424–425 functional performance and, 132–136
concepts related to, 421–422 Hearing aids, 136, 336
G in current health-care environment, 430, 432 Hearing Handicap Inventory for the Elderly, 135
Gait definition of, 109–110, 421 Hearing impairments, 335–336
age-related changes in, 166–167, 167 determinants of, 4, 210 Hearing interventions, 284
assessment of, 172–174, 413 environmental factors that affect, 424–425 Hearing loss
attentional capacities on, 172 environmental interventions for, 430 activity limitations caused by, 284
cadence of, 172 factors associated with, 422–425 assistive listening devices for, 136
cognitive demand on, 172 genetics and, 423 assistive technology for, 335–336
exercise for, 174 home environment effects on, 424 cochlear implants for, 335–336
festinating, 239t learning and, 391–393 cognitive decline secondary to, 224
in Parkinson’s disease, 239t Lifestyle Redesign intervention for, 427 communication strategies for, 135b
problems with, 174–175 nutrition effects on, 424 conductive, 132
stride length in, 172 occupation factors that affect, 423–424 environmental modifications for, 135b
velocity of, 172 occupational therapy interventions for, hearing aids for, 136
Gait Assessment Rating Scale (GARS), 173 425–430 interactions with others affected by, 136
Gait speed, 173, 460 optimizing of, 103–105 prevalence of, 132, 335
Gardening, 424f, 516f physical activity benefits for, 423, 423t–424t, safety considerations for, 135
Gay elders, 371, 373 426 sensorineural, 133–134
Gender physical therapy interventions for, 426–430 social consequences of, 135–136
aging affected by, 4–5 professional development programs for, 430 speech perception affected by, 134
in modern times, 11 psychological characteristics that affect, 423 in stressful listening conditions, 135
roles affected by, 369 quality of life affected by, 422 Heart
Generalized anxiety disorder (GAD), 192 retirement and, 542 electrical behavior of, 111
Generation X, 6t, 317 self-care effects on, 281–282 mechanical behavior of, 111–112
Generation Y, 6t, 317 self-efficacy effects on, 423 Heart blocks, 111
Generativity, 541 self-management programs for, 429–430 Heart rate reserve, 122
Generativity versus stagnation, 63 social determinants of, 425 Heel on shin test, 169
Genetics, 10–11, 423 spirituality and, 423 Helplessness, 302, 439
Geriatric assessment units (GAUs), 497–498 staying active programs for, 428–429 Hemorrhagic strokes, 188
Geriatric Certified Specialists (GCS), 494 World Health Organization definition of, High-tech assistive technology devices, 330–331
Geriatric Depression Scale, 408 109–110, 421 Hip fractures, 250, 512
Geriatric evaluation and management services Health Canada, 425 Hispanics
(GEMS), 498 Health care community-based service use by, 440
Geriatric rehabilitation units (GRUs), 497 access to, 10, 455–456 in United States, 77
Geriatric syndromes, 490–491 evidence-based practice, 544–545 Home and Community Environment
Geriatrician, 494 health and wellness affected by current Instrument, 286
Gerogogy, 384 environment of, 430, 432 Home environment, 424, 430
Gerontechnology, 320 in Israel, 48–49 Home Environment Lighting Assessment
Gerontologists, 19–20 in Mexico, 50–52 (HELA), 221
Glass model, 410–411 national expenditures on, 546 Home health care
Glaucoma, 219f, 219–220 paying for, 546 case study of, 485
Glycoproteins, 152t reforms in, reasons for, 459–460 confidentiality, 477
Good death, 525–526, 526b single-payer systems in, 405 cultural competence, 472
Grading of Recommendations, Assessment, in South Africa, 54–56 documentation of, 480–481
Development and Evaluation (GRADE) systems of care, 544 in Europe, 471
approach, 234 theoretical framework for utilization of, 456 fall prevention, 483–484
Grandparenting, 5, 371 trends in, 544–546 growth of, 471–472
Grantsmakers in Aging, 442 utilization of, 456 history of, 472–473
Gravitational stress, 208–210 Health coaching (HC), 427, 463 informal caregivers in, 471
Gray Panthers, 41 Health education, 427 initial visit and comprehensive assessment,
Great Depression, 6, 10, 541 Health Insurance Portability and Accountability 478–480
Grief, 491 Act (HIPAA) interventions, 483–485
Grip strength, 414 chronically ill individual as defined by, 281 legislation and, 474
Guided imagery, 226 home health care and, 473 Medicare coverage of, 474–477
Gustation, 136 patients’ rights under, 477 Conditions for Coverage, 477
Health Insurance Prospective Payment System Conditions of Participation, 477, 481
H (HIPPS), 482 “confined to home” requirement, 475–476
Habits and routines, 79 Health literacy, 392 initial visit and comprehensive assessment,
Habituation, 27 Health promotion, 427, 546 478–480
Happiness Health-care professionals Outcome and Assessment Information
activities and, 541 rehabilitation team participation by, 494, 494f System, 475, 479–480
life satisfaction versus, 64 spirituality and, 398 plan of care, 477–478
Hard rehabilitation, 501, 501f Healthy aging, 422 reasonable and necessary, 476
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564 Index
reassessments, 481
reimbursements, 481–483
therapy assistants, 478
therapy services, 478
“under the care of a physician”
requirement, 476
occupational therapy in, 472, 476
outcome measures in, 484
patient-centered care, 472–473
patients’ rights, 477
payment systems for, 481–483
physical therapy in, 476
potentially avoidable events in, 484
process measures in, 484
quality measurements, 484
reassessments, 481
regulations’ effect on, 477–480
rehabilitation in, 498
reimbursement for, 481–483
skilled nursing care in, 476
speech-language pathology in, 476
Home health-care agencies, 474, 482
Home palliative care, 524
Homebound patients, 475–476, 481
Homelessness, 8
Homonymous hemianopsia, 241t
Hong Kong, 78, 390, 393
Hormone replacement therapy (HRT), 152
Hormones, 150
Hospice, 523, 529
Hospitalizations
acute, 497
deconditioning secondary to, 272
impact of, 265
incidence of, 263
medical conditions that cause, 263–264
Housing, 445–446, 446t–447t
Housing modifications, 439
Human immunodeficiency virus (HIV),
268–269, 375
Hunger, 443
Hyaluronic acid, 152t
Hyperkyphosis, 164
Hypertension
description of, 203–204
risk factors for, 207
stroke risks associated with, 206–207
Hypodermis, 138
Hypogeusia, 136
Hypokinesia, 238t
Hypokinetic dysarthria, 239t
Hypomimia, 238t
Hyposmia, 136
I Integrated care pathways, 528
IADL Screener, 408
Iatrogenic factors, 209
Identity
creation of, 63
leisure as statement of, 297–298
meaning and, 65–66
Idiopathic pain, 271
Immigrants, 77
Immunological theory, of aging,
21, 21b
Impairments, 28
Implicit processing, 101
Improving Medicare Post-Acute Care
Transformation Act (IMPACT), 41,
473–474
Incontinence
fall risks secondary to, 257–258
urinary tract infections secondary to, 268
Indebtedness, 301
Independent Transportation Network (ITN),
363–364
India
community mobility in, 359
older adults in, 76
Indirect spiritual interventions, 401
Individual characteristics, 10–11
Individual Prioritized Problems Assessment
(IPPA), 530
Individual retirement accounts (IRAs), 543
Infectious diseases, 268–269
Inflammation, 272
Influenza, 264, 268
Informal caregiving, 376–377, 471
Informal family caregivers, 183
Informal learning, 388–391
Information gathering, 305
Inhibition, 103
In-home care, 439
Inpatient Geriatric Consultation Services
(IGCS), 498
Institute of Medicine, 508, 525
Institution, 475
Institutional care, 48–49
Institutionalization, 8
Instructing mode, of Intentional Relationship
Model, 376
Instrumental activities of daily living (IADLs)
assessment of, 284–285
assistive devices for, 289
classification of, 280
dementia effects on, 283
description of, 147, 185
difficulties in performing, 281
functional performance evaluation of, 412,
414–415
hearing loss effects on, 283
home-based assessment of, 285
limitations of, prevalence of, 282
occupational therapy interventions for
improving, 426
stroke effects on, 283
upper extremity function assessments and, 414
vision impairment effects on, 283
Instrumental ADL Scale, 412
Instrumental meanings, 63–64
Insulin resistance, 208
Intellectual abilities, 101–102
Intellectual disabilities, 491–492
Intelligence, 101–102
Intensive care unit, 265
Intentional Relationship Model (IRM), 82,
376–377
Interaction skills, 79
Interdisciplinary care, 546
Interdisciplinary teams
in nursing homes, 514–516
in rehabilitation, 493, 495
Intermediate care, 496
International Classification of Functioning,
Disability, and Health (ICF)
applicability of, 28
assistive technology, 331
description of, 110, 409
functioning as defined in, 26, 28
health as defined by, 109–110
model of, 146, 146f
osteoporosis assessments, 235f
palliative care, 532
purpose of, 28
International countries. See also specific country
aging in, 76–77
public policies in, 38–39
Internet, 392–393, 393f
Interprofessional team, 183
Interval training, 123
Interventions
culturally sensitive, 81–82
goals of, 124
implementation of, 82
Intervertebral disc degeneration, 164
Interviewing, 377, 377b
In-the-canal hearing aid, 136
In-the-ear hearing aid, 136
Iris, 131, 131f
Irreversible dementias, 184
Ischemic heart disease, 203, 205–206
Isokinetic dynamometers, 155
Isokinetic strength, 148
Isokinetic testing, 154
Isometric strength, 148
Israel
Community Long-Term Care Insurance
Law in, 46–47
day-care centers in, 47–48
demography of, 46
disabled elders in, long-term care for, 47
ethnic diversity in, 46
health and welfare services in, 46–47
health system of care in, 48–49
homemaking services in, 47
immigration in, 46
institutional care in, 48–49
issues and challenges in, 49
life expectancy in, 46
long-term care institutions in, 49
meals-on-wheels in, 47
National Health Insurance Law in, 46–47
National Insurance Institute in, 46
population aging in, 45–46
respite care in, 48
social formal system of care in,
47–48
supportive communities in, 48
J
Japan
aging population in, 540
family in, 369
life-time employment in, 321
older adults in, 76, 80, 369
phased retirement in, 315
Jimmo v. Sebelius, 35–36, 476, 511
Job Accommodation Network, 321
Job redesign, 542
Joint inflammation, 283
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Joints, 152–153 Leisure Lifelong education, 442

Justice, 82 aging and, 296–297 Lifelong Learning Institute (LLI), 390
assessment of, 305b, 305–306 Life-space mobility, 360
K benefits of, 296 Life-Space Questionnaire (LSQ), 412
Karvonen formula, 211 case study of, 307–308 Life-span design, 329
Kierkegaard, S_ren, 525 challenges of, matched with skills of Life-span theory, of aging, 22–23, 23t 63–64
Kinematic analysis, 172 individual, 300–301 Lifestyle Redesign intervention, 427
Kinesthesis, 138 choice in, optimal levels of, 301 Lifestyle-based occupational therapy
Kitchen modifications, 288 control element of, 299–302 interventions, 155
Kitchen Task Assessment, 412 cultural influences on, 78 Life-threatening illness, 524–525, 529
Kohlman Evaluation of Living Skills, 415 definition of, 296 Life-time employment, 321
Kübler-Ross, Elisabeth, 525 disengagement used to produce, 304 Limb amputation, 236–238
Kuhn, Maggie, 41 education programs for, 306, 306t Literacy
elements of, 299–304 definition of, 392
L in families, 370 functional performance evaluation affected
Language production freedom from unnecessary constraints of reality by, 416
description of, 100–101 as element of, 304 health literacy versus, 392
stroke effects on, 189 freedom of choice in, 299–300 Lithium, 193
Language proficiency, 79 as fully engaging experience, 298–299 Liverpool Care Pathway, 528
Late Life Function and Disability Index identity and, 297–298 Living arrangements, 500–501, 543–544. See also
(LLFDI), 412–413 life satisfaction and, 296 Residence
Late-life disability, 11 as means of taking control’s of one’s life, 302 Local policies, 38
Late-onset schizophrenia, 192 model of, 304–307 Loneliness, 302
Lateral medullary syndrome, 242t motivation elements of, 302–304 Long-Distance Corridor Walk, 412
Lawton Instrumental Activity of Daily Living outcome determinations, 300 Longevity, 1, 4, 295
Scale, 285 personality and, 303 Long-term care
LEA Low Contrast Flip Chart, 351 physical therapist’s role in promoting, 306–307 interdisciplinary teams in, 514–516
Lead pipe rigidity, 238t promotion of, 299, 305b nursing homes. See Nursing homes
Leading causes of death, 203t psychological comfort created by, 301 occupation in, 512–513
Learning quality of life and, 296 overview of, 507–508
benefits of, 390t reciprocity as element of, 301–302 Long-term care facilities
case study of, 394 retirement and, 320–321 falls in, 250, 253
cognitive changes effect on, 385 self-actualization benefits of, 298, 305 Medicaid funding of, 438
cognitive processes in, 384 in Western countries, 296 Long-term care hospitals (LTACHs), 35
community-based services for, 442 Lens, 131–132, 131f Long-term memory, 97–98, 385
declarative, 386 Lesbian, gay, bisexual, or transgender Long-term nursing homes, 37
definition of, 386 community-based service use by, 440 Long-term potentiation, 386
e-, 392, 393f culture, 76 Loss, 491
errorless, 386 family issues, 371 Loudness, 132
ethnocultural diversity effects sexuality issues, 373 Low functional health literacy, 392
on, 385 Levodopa, 238 Low vision
formal, 388–391 Lewy body dementia, 187 communication strategies in individuals
free recall in, 387 LGBT culture, 76 with, 132b
gerogogy, 384 Life course perspective definition of, 218
health and, 391–393 of aging, 24, 24t interprofessional treatment of, 220–221
informal, 388–391 of transition, 315 intervention strategies for, 221–222
Internet for, 392–393, 393f Life engagement, 422 occupational therapist’s role in treating, 222
later-life, 389 Life expectancy physical therapist’s role in treating, 222
memory and, 385–388 in African Americans, 4 prevalence of, 218
motivation for, 391 in ancient Greece, 4 Lower extremity function, 412–414
motor, 387–388, 389t in Down syndrome, 492 Low-tech assistive technology devices, 330–331
nondeclarative, 386–387 factors that affect, 1 Low-vision rehabilitation, 222
nonformal, 388–391 historical changes in, 4 Lung parenchyma, 110
psychological and physical changes increases in, 1, 295, 456 Lymphedema, 272
that affect, 385 in intellectual disability patients, 492
sensory system changes and, 384 in Israel, 46 M
skill, 388 in Middle Ages, 4 MacArthur Foundation, 442
sociocultural factors that affect, 385 in serious mental illness patients, 492 Macula, 131, 131f
supported recall in, 387 in 20th century, 4 Macular degeneration, age-related, 219, 219f
written educational materials for women, 547 Madrid Plan, 38
for, 384 Life review, 427–428 Magnifiers, 223t
Legal blindness, 218 Life satisfaction Major depressive disorder (MDD), 190. See also
Legally blind, 218 happiness versus, 64 Depression
Legislation. See also specific legislation leisure and, 296 Masking, 134
description of, 39–40, 321 Life Satisfaction Index, 67–68 Mass grasp test, 168
home health care, 473–474 Life Space Diary, 412 Maximal muscle strength, 148, 148f
nursing home, 508–510 Life span development, 315 MDS 3.0, 508–509
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566 Index
Meaning
cultural influences on, 80
definition of, 62–63
depression and, 542
evaluative, 64
existential, 64–65
identity and, 65–66
individualistic nature of, 63
instrumental, 63–64
late-life activities to support, 68
occupation and, 62–63, 280
in occupational therapy interventions, 66–69
in physical therapy interventions, 66–69
search for, 61–62
in self-care, 280–281
themes of, 63–66
in Western culture, 62
Meaning in life, 62, 541
Meaningful Activity and Life Meaning Model
(MALM), 67, 67t
Meaningful occupations
benefits of, 61, 64, 297
cultural influences on, 80
identity through, 65–66
importance of, 62–63
quality of life benefits of, 531
Medicaid, 37, 438, 472, 508–509
Medical care, 182
Medical conditions
acute, 265
cancer, 204, 208, 265–266
chronic nature of, 272
diabetes mellitus, 266–268
disability caused by, 490
factors that affect, 264–265
frailty syndrome, 269–270
human immunodeficiency virus, 268–269
infectious diseases, 268–269
inflammation associated with, 272
influenza, 268
nutritional deficiencies, 269
obesity, 266–268
oral health, 269
pneumonia, 268
posthospital syndrome, 269–270
preexisting, 264–265
presenting symptoms of, 264
self-care affected by, 282–284
self-management programs for, 461–462
“silent” symptoms of, 263
swallowing difficulties, 269
urinary tract infections, 265, 268
Medical history, 349–350
Medical Research Council, 56
Medicare
Advantage Plans, 36
“confined to home” requirement, 475–476
dependent services under, 475
enrollment statistics for, 34
future of, 546
gaps in, 405
history of, 34, 472
home health care coverage by. See Home
health care, Medicare coverage of
Hospital Insurance, 473
Jimmo v. Sebelius, 35–36, 476, 511
nursing home payment by, 508–509
Part A, 34–35, 473
Part B, 35–36, 473
Part C, 36, 473
Part D, 36, 473
Plan of Care, 478
Resource Utilization Groups, 509
skilled services under, 35t
social services under, 475
Supplementary Medical Insurance, 473
“under the care of a physician”
requirement, 476
Medicare Access and CHIP Act (MACRA), 36
Medicare Act, 34
Medicare Benefit Policy Manual, 474
Medications
fall risks associated with, 251, 252t, 258
principles for, 270–271
sexual activity affected by, 374, 375t
Meditation, 401f
Meissner’s corpuscle, 138
Melbourne Low Vision ADL Index, 284
Memory
declarative, 22, 98
episodic, 386–387
free recall of, 387
learning and, 385–388
long-term, 97–98, 385
procedural, 98, 195, 386–387
prospective, 98–99, 387
retrieval of, 386
semantic, 98, 386–387
sensory, 97
short-term, 97, 183, 385
supported recall of, 387
types of, 96–97
working, 97, 102–103, 385
Memory loss, 336
Memory trace, 385–387
Mental health
dementia effects on, 186
medication effects on, 202
socioeconomic status and, 11
Mental health conditions
anxiety disorders, 191–192
bipolar disorder, 192–193
depression, 190–191, 374–375, 493, 500
description of, 189–190
rehabilitation and treatment plans for,
194–196
schizophrenia, 192
sexual dysfunction associated with, 374–375
substance use disorders, 193–194
Mental illness, 492
Mesenchymal stem cells (MSCs), 152
Metabolic equivalent, 113, 211
Metabolic syndrome, 207–208
Mexico
health-care systems in, 50–52
life expectancy in, 49
sociodemographic context of, 49–50
Micrographia, 238t
Middle cerebral artery stroke, 241t
Middle ear diseases, 133
Migration, 8
Mild cognitive impairment, 416
Millennials, 6t
Mind-body-spirit triad, 398
Mindfulness, 226
Mini-Balance Evaluation Systems Test, 171
Mini-Mental State Exam, 222
Minimum data set (MDS), 508
Miosis, senile, 131
Mobility. See also Community mobility;
Transportation
assessment of, 254, 413
cultural influences on, 79
definition of, 413
functional performance evaluation of, 412–413
preclinical limitations, 413
Mobility disability, 413
Mobility-related physiological limitations
(MOBLI), 414
Mobility–Tiredness Scale, 415
Model of Human Occupation (MOHO), 27–28,
66, 67t, 318
Modeling, bone, 151–152
Modernization theory, 24
Modified Falls Efficacy Scale (MFES), 172, 409
Modified shuttle walking test (MSWT), 116
Monosynaptic connections, 130
Montessori-based activities, 517
Montreal Cognitive Assessment (MCA), 408
Motivation
complexity of, 303–304
definition of, 302
for later-life learning, 391
for leisure activities, 302–304
rehabilitation outcomes affected by, 499–500
Motivational interviewing (MI), 463–464
Motor coordination tests, 169
Motor learning, 387–388, 389t
Motor neurons, 150
Motor performance, 387
Motor skills, 79
Motor unit, 150
Motor vehicle crashes (MVCs), 341–342
Motor-Free Visual Perception Test
(MVPT), 352
Movement assessments, 350
Movement therapy, as spiritual intervention, 402
Multidimensional Fatigue Inventory, 415
Multi-Directional Reach Test (MDRT), 170
Multidisciplinary teams (M-teams)
elder abuse managed with, 86
rehabilitation, 493
Muscle atrophy, 149
Muscle fibers, 149–150
Muscle mass, 149, 149f
Muscle power
assessment of, 154–155
declines in, 148, 150f, 151
Muscle strength
assessment of, 154–155
declines in, 148–150, 150f
Muscle synergies, 165
Mutation accumulation theory, of aging, 21, 21b
Mutual cultural accommodation, 377
Myers-Menorah Park/Montessori-based
Assessment System (MMP/MAS), 517
MyPlate, 115f
N
Nagi Model of Disability, 189, 410, 483
Narratives, 401
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National Assessment of Adult Literacy, 392
National Association of Social Workers, 41
National Council of Palliative Care, 522
National Health Insurance Law (Israel), 46–47
National Health Insurance (South Africa), 56
National Highway Traffic Safety Administration
(NHTSA), 341, 346
National Institutes of Health Stroke Scale
(NIHSS), 189
Native American culture
elder victimization concerns, 440
family decision-making in, 81
older adults in, 5–6, 77
Naturally occurring retirement communities
(NORC), 8, 447t, 543
Nature, appreciation of, 402
Navigators, 40
Near-fall, 249
Nervous system, 153b, 153–154
Neurodegenerative illnesses
Alzheimer’s disease. See Alzheimer’s disease
dementia. See Dementia
description of, 183
Neuroendocrine theories, of aging, 21, 21b
Neuromusculoskeletal system. See also Skeletal
system
age-related changes in, 146–148
assessment of, 154–155
description of, 145–146
impairments in, 155–156
muscle mass, 149, 149f
muscle power, 148, 150f, 151, 154–155
muscle strength, 148–150, 150f, 154–155
Neuromusculoskeletal system conditions
amputation, 236–238
limb amputation, 236–238
osteoarthritis, 231–232, 460
osteoporosis. See Osteoporosis
overview of, 231
Parkinson’s disease. See Parkinson’s disease
stroke. See Stroke
Neuroplasticity, 386
Neuropsychological theories, of aging, 21–22
Night driving, 131
Nightingale, Florence, 472
NMDA receptors, 22
Nocturia, 257–258
Noncommunicable diseases
asthma, 203
atherosclerosis, 203, 204t
cancer, 208
cardiopulmonary system, 203–204
cardiovascular system, 203–204
coronary artery disease, 203
description of, 201–202
diabetes mellitus, type 2, 204, 204t, 207–208
diet and, 205–206
disability secondary to, 460
epidemiology of, 203–208
etiology of, 203–208
hypertension, 203–204, 206–207
ischemic heart disease, 203, 205–206
lifestyle-related behaviors associated with,
204–205
metabolic syndrome, 207–208
obesity, 208
pathophysiology of, 203–208
primary care for, 462–463
psychosocial stress as risk factor for, 206
risk factors for, 206, 462
signs and symptoms of, 204t
smoking and, 206
types of, 204t
Nondeclarative learning, 386–387
Nonformal learning, 388–391
Nongovernmental organizations (NGOs), 38–39
Nonmaleficence, 82
Nonmedical care, 182
Nonpharmacologic treatments
for dementia, 187–188
for pain, 226–227
Non-physician practitioner (NPP), 476
Norway, 390
Nuclear family, 369, 370t
Nursing homes
case study of, 518
custodial care, 508
dining experience in, 510
disabilities in, 511
evolution of, 508
history of, 508
legislative initiatives regarding, 508–510
Medicare and Medicaid regulation of, 508–509
models of care, 510–511
occupational therapy in, 511–512, 514b
older women in, 510
Omnibus Budget Reconciliation Act effects
on, 508–510
physical therapy in, 513–514, 514b
regulation of, 508–510
rehabilitative, 508
Resident Assessment Instrument, 508
Resident Classification System, 509
residents of, 511
sexuality in, 373
skilled, 508
social activities in, 512
in Spain, 511
state regulations for, 510
statistics regarding, 445, 508
therapeutic environment in, 516
therapy in, 511–516
Nutrition. See also Diet
health and wellness affected by, 424
self-care effects on, 281
Nutritional deficiencies, 269
Nutritional status, 114
O Older Americans Act (OAA), 37,
Obesity
diabetes mellitus risks, 267–268
health risks caused by, 208
insulin resistance associated with, 208
sarcopenic, 149
Occupation(s)
cultural influences on, 77–79
driving as, 342–343
family, 370–371
identity through, 65–66
in long-term care, 512–513
meaningfulness in, 67, 280, 522
productive, 78
religious, 65
sense of control through, 65
Index 567
spiritual, 65
staying active through, 423–424
Occupational justice, 41
Occupational participation, 27
Occupational performance, 411
Occupational profile, 318
Occupational science, 63
Occupational therapists
advocacy role of, 41–42
in community-based services, 446–447
community-based services promoted by, 440
fall prevention role of, 257
hospitalizations and, 272
primary care role of, 458–459, 465
spirituality and, 398–399
Occupational therapy
description of, 12
future of, 546–547
in home health care, 476
home-based visits for, 472
in nursing homes, 511–512, 514b
in palliative care, 524, 528–533
physical therapy and, for rehabilitation, 496
referral for, 529
Occupational therapy interventions
guidelines for, 243
for health, 425–430
lifestyle-based, 155
in limb amputation patients, 237
meaning in, 66–69
in palliative care, 530–531
in Parkinson’s disease patients, 240–241
in stroke patients, 189
for wellness, 425–430
Occupational Therapy Practice Framework,
29, 66
Occupational value, 63
Old Age Homes Law of 1965, 48
Old Testament, 5
Older adults
attitudes about, historical perspective on, 5
client-centered approaches, 26–28
historical roles of, 6
at home, 8
institutionalization of, 8
protective factors for, 11
in rural environments, 7
stages for, 63
stereotypes of, 9
in suburban environments, 7
in urban environments, 7
438, 443
Older men, 11
Older women
in nursing homes, 510
older men versus, 11
Older workers. See also Work
assistive technologies for, 319–320
ergonomics for, 319–320
occupational therapy and, 318–319
physical therapy and, 319
Olfaction
age-related declines in, 137
description of, 136–137
Olmstead Act, 42
Olmstead v. L.C., 42, 438
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568 Index

Omnibus Budget Reconciliation Act (OBRA), outcomes of, 533 Person–Environment–Occupation (PEO)
508–510 physiotherapist in, 529 model, 411
Optical character recognition system, 335 physiotherapy in, 524, 527–528, 531–533 Phantogeusia, 136
OPTIMAL, 462 principles of, 523b Phantom limb pain, 237
Optimal experiences, 62 specialized-level, 524 Phantom limb sensation, 237
Optimization, 23 team-based approach to, 532–533 Phantosmia, 136
Oral health, 269 Pallidotomy, 240 Pharmacodynamics, 270
Oral hygiene, 512 “Parkinsonian retinopathy,” 222 Pharmacokinetics, 270
Organ of Corti, 133 Parkinson’s disease Phased retirement, 314–315
Organization for Economic Cooperation and case study of, 243–244 Phonemic regression, 134
Development (OECD), 388–389 description of, 238 Physiatrist, 494
Orthostatic hypotension, 258 driving affected by, 347 Physical activity. See also Exercise
Orthostatic intolerance, 114–115, 209 levodopa for, 238 benefits of, 175, 423, 426
Orthostatism, 208–209 management of, 238–240 cultural influences on demands for, 80–81
Osteoarthritis (OA), 226, 231–232, 460 prevalence of, 238 health and wellness benefits of, 423, 426, 428
Osteoarthritis of the Knee (OAK) program, 461 surgery for, 240 importance of, 68, 123
Osteoblasts, 151 symptoms of, 238, 238t–239t recommendations for, 122b, 423t–424t
Osteoclasts, 151 visual impairments secondary to, 222 Physical disabilities, 492
Osteocytes, 151 Part A (Medicare), 34–35, 473 Physical environment
Osteophytes, 232 Part B (Medicare), 35–36, 473 aging affected by, 7–8
Osteoporosis Part C (Medicare), 36, 473 customizing of, 124
assessment of, 234t, 235f Part D (Medicare), 36, 473 place of residence, 7
definition of, 233 Participation, 28 Physical function, 147f
description of, 264 Participation restrictions, 28 Physical Functioning Assessment in Your
exercise for, 234–235, 234–236 Patient activation measure (PAM), 462 Environment, 67
fragility fractures caused by, 233–234 Patient education materials, 385 Physical Performance Test, 155, 412
management of, 234–236 Patient navigation, 458 Physical Self-Maintenance Scale, 412
Otago Exercise Programme (OEP), 256 Patient Protection and Affordable Care Act, Physical therapists
Ototoxic drugs, 134 37–38, 405, 438, 441, 460, 511, 546 advocacy role of, 41–42
OTPF-3, 512 Patient satisfaction, 464 in community-based services, 446–447
Outcome and Assessment Information System Patient Satisfaction Questionnaire fall prevention role of, 257
(OASIS), 475, 479–480 (PSQ-18), 464 hospitalizations and, 272
Outpatient rehabilitation, 498 Patient-centered care, 472–473 leisure promotion by, 306–307
Outside-of-the-home assistance, 439 Patient-Specific Function Scale, 408 primary care role of, 459, 465
Overhead lift, 334f Peak bone mass (PBM), 151–152 scope of practice, 12
Overtreatment, 82–83, 264 Peak power, 151 Physical therapy
Oxygen consumption, 121 Pensions, 5, 10, 543 future of, 546–547
Oxygen transport, 208 People With Arthritis Can Exercise (PACE) in home health care, 476
program, 462 in nursing homes, 513–514, 514b
P Perceived self, 298 occupational therapy and, for
Pacific Islander elders, 440 Perception rehabilitation, 496
Pacing, 122 definition of, 129 older workers and, 319
Pacinian corpuscle, 138 description of, 95–96 Physical therapy interventions
Pain pain, 139b for aging in place, 439
assessment of, 225–226 Performance Assessment of Self-Care Skills for health, 426–430
back, 225 (PASS), 285 in limb amputation patients, 237
behaviors suggestive of, 226 Performance capacity, 27 meaning in, 66–69
cancer-related, 273 Performance patterns, 343, 344t, 349 in Parkinson’s disease patients, 240–241
definition of, 225 Performance skills for wellness, 426–430
description of, 138–139, 139b community-based services, 446 Physically dependent individuals, 147, 147f
health conditions that cause, 225 cultural influences on, 79 Physically elite individuals, 147, 147f
idiopathic, 271 for driving, 342–343, 343t–344t Physically fit individuals, 147, 147f
interventions for, 226–227 Performance-Oriented Mobility Assessment Physically frail individuals, 147, 147f
managed with, 271 (POMA), 170 Physically independent individuals, 147, 147f
nonpharmacologic treatments for, 226–227 Peripheral nervous system, 129 Physiological aging, 492
phantom limb, 237 Personal experiences, 11 Physiotherapy, in palliative care, 524, 527–528,
Pain Coping Skills Intervention (PCSI), 464 Personal health records (PHRs), 465 531–533
Palliative care. See also End-of-life care Personal historian, 427 Pill-rolling tremor, 239t
basic-level, 524 Personal meaning, 542 Pitch, 132
case study of, 534 Personal trace, 386 Place of residence, 7
definition of, 522–523, 523b Personal value, 280 Plan of care, 477–478
European Association for Palliative Personality Play. See also Leisure
Care, 523, 528 aging and, theories regarding, 23, 23t cultural influences on, 78
global, 524 description of, 11 in families, 370
goals of, 523b leisure and, 303 Pneumonia, 268
in home, 524 success and, 384 Pointing and past pointing test, 169
occupational therapy in, 524, 527–533 Personality trait explanations, 23 Political economy of aging, 24t, 24–25
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Polypharmacy, 270 reforms in, reasons for, 459–460 spiritual effects on, 80
Population aging. See also Aging rehabilitation professionals and services wellness effects on, 422
demographic trend in, 3, 9, 539–540 integrated into, 454 Quality of life technologies, 327
in developing world, 9 technology integration into, 465 Quarter, 34
global statistics regarding, 9 Primary health care (PHC)
growth of, 3 definition of, 453–454 R
international, 45 primary care versus, 454 Race, 77. See also specific race
in Israel, 45–46 Primary open-angle glaucoma (POAG), 219–220 Range of motion, 153–154, 158
social consequences of, 3–4 Priming, 386 Rate pressure product, 114
societal trend in, 539–540 Problem-solving, 99–100 Reaction time, 167
sociodemographic changes associated with, 20 Problem-solving mode, of Intentional Reactive postural control, 170–171
statistics regarding, 3 Relationship Model, 376 Reading glasses, 223t
trends in, 9 Procedural memory, 98, 195, 386–387 Rebound test, 169
Position holding test, 169 Process skills, 79 Reciprocal roles, 367–368
Positive aging, 12, 103, 155, 280, 541 Productive aging, 422 Reciprocity, 301–302, 368
Positive psychology, 62 Productive occupations, 78 Recumbency, 209
Positive self-esteem, 11 Program for All-Inclusive Care for the Elderly Refusal of treatment, 83
Posterior cerebral artery stroke, 242t (PACE), 498 Registries, 458
Posterior inferior cerebellar artery stroke, 242t Programmed longevity, 21, 21b Rehabilitation
Posthospital syndrome, 269–270 Progressive disability, 493 acute care, 497
Postmenopausal women, 374 Progressive resistance training, 156 adult day care facilities, 497–498
Post-polio syndrome, 6 Project ANSWERS, 196 assessment instruments used in, 499
Postural alignment, 163–165, 164f Pronation test, 168–169 benefits of, 501
Postural control Proprioception biological factors in, 493
anticipatory, 170 age-related changes in, 167 caregivers effect on, 500
definition of, 166 definition of, 167 case study of, 502
physiology of, 166b Proprioceptive neuromuscular facilitation, 158 in cognitive impairment patients, 500–501
reactive, 170–171 Prospective memory, 98–99, 387 comorbidities that affect, 500
Postural hypotension, 114 Prospective payment systems (PPS), 35, 482, 517 comprehensive geriatric assessment in,
Postural orientation, 166 Prostate cancer, 264 498–499
Postural stability, 166–167 Prostatectomy, 374 comprehensive outpatient rehabilitation
Postural Stress Test (PST), 170 Protecting Access to Medicare Act of 2014, 480 facilities, 498
Postural sway, 167, 170 Protective services, 445 day hospital care, 497–498
Posture Proteoglycans, 152t definition of, 489
age-related changes in, 163–165, 164f Proximal determinant, 23t delivery systems for, 496–498
assessment of, 167, 350 Pruritus, 224 depression effects on, 500
problems with, 174 Psychological comfort, 301 discharge planning, 495
Poverty, 11 Psychological theories, of aging, 22–23 domiciliary care, 498
Preclinical disability, 408 Psychological well-being, 282 environmental factors that affect, 500–501
Preclinical mobility, 459 Psychometric tests, 352 evaluation of, 498–499
Preexisting conditions, 264–265 Psychosocial stress, 206, 375 evidence regarding, 501
Premature ventricular contractions, 111 Public health interventions, 34 family members effect on, 500
Presbycusis, 132, 134 Public housing, 447t frailty effects on, 499
Presbyglutition, 269 Public policies geriatric rehabilitation units, 497
Presenting symptoms, 264 advocacy for, 39–40 goals of, 493, 494b
President’s Council on Physical Fitness and community-based services affected by, 438 hard, 501, 501f
Sports, 422 definition of, 33 home health care, 498
Pressure, 138 description of, 10 living arrangements effect on, 500–501
Pressure sores, 224 enactment of, 34 low-vision, 222
Primary care (PC) federal, 34–38 motivation for, 499–500
access to, 455–456 function affected by, 33–34 occupational therapy–physical therapy
case study of, 466 health care access affected by, 10 partnership for, 496
clinic-based care models, 454 international, 38–39 outpatient, 498
definition of, 453–454 local, 38 patient satisfaction with, 464
Expanded Chronic Care Model for, 456–458, Medicare. See Medicare personal factors that affect, 499–500
457f, 457t Social Security, 34 principles of, 493b
for lifestyle conditions, 462–463 state, 38 for prospective memory impairments, 387
mental health services included in, 454 Public transportation, 362 settings for, 496–498
motivational interviewing, 463–464 Pupil, 131, 131f skill training for, 286–287
multimorbidity and, 459 soft, 501, 501f
occupational therapists’ role in, 458–459, 465 Q telerehabilitation, 465, 484
patient satisfaction with, 464–465 Quality of life therapist–client interaction effects on, 501
patient-centeredness in, 459–465 definition of, 64 transitional care facilities and units, 497
physical function as outcome of, 460–461 health effects on, 422 uniqueness of, 492–493
physical therapists’ role in, 459, 465 leisure and, 296 World Health Organization definition of, 489
primary health care versus, 454 meaningful occupations’ effect on, 531 Rehabilitation counselors, 321–322
purpose of, 454 physical function effects on, 66 Rehabilitation nurses, 494
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570 Index

Rehabilitation team Road Scholar, 390 performance measurements for, 284

case management, 495–496 Robots, 333–334 practical importance of, 281–282
coordination of, 495–496 Role Checklist, 412 psychological well-being affected by, 282
interdisciplinary, 493, 495 Roles safety affected by, 281–282
members of, 494, 494f cultural influences on, 79–80 self-identity through, 282
multidisciplinary, 493 gender differences in, 369 sensory problems that affect, 283–284
teamwork among, 495 Romberg sign, 168 significance of, 281
transdisciplinary, 493 Rosow–Breslau Scale, 412 smell sense effects on, 283–284
Relationships Rowe and Kahn Model of Successful Aging, 422 socialization benefits of, 282
dependency ratios, 367 Rural environments, 7 stroke effects on, 282–283
family, 367–368 task modifications for, 289
misconceptions about, 367 S touch sense effects on, 283–284
reciprocity in, 368 Saccades, 222 value in, 280–281
social, 368–372 Sacred understanding, of spirit, 398 Self-driving cars, 545
spousal, 371–372 Safe Functional Motion test (SFM), 233 Self-efficacy, 155, 423, 461, 464, 500
Relaxation, 226 Safety Self-identity, 282
Religion, spirituality versus, 398 assessment of, 286 Self-management programs, 429–430, 461–462
Religious occupations, 65 in hearing loss patients, 135 Self-paced walking test, 116
Religious understanding, of spirit, 397–398 olfaction’s role in, 137 Semantic dementia, 386
Religiousness, 65 self-care effects on, 281–282 Semantic memory, 98, 386–387
Reminiscence, 65, 68 Safety Evaluation of Function and the Senile miosis, 131
Residence Environment for Rehabilitation—Health Senior centers, 443
changing of, 446 Outcome Measurement and Evaluation Senior Community Services Employment
cultural influences on choice of, 80 (SAFER-HOME v3), 286, 412 Program (SCSEP), 442
description of, 7 Sandwich generation, 500 Sense of control, 65
statistics regarding, 445–446 Sarcopenia, 148–150, 149f, 204 Sensorineural hearing loss, 133–134
Resident Assessment Instrument (RAI), 508 Sarcopenic obesity, 149 Sensory function. See also specific sense
Resident Classification System, 509 Satisfaction With Life Scale (SWLS), 67 age-related changes in, 130t, 384
Residual volume, 111 Saudi Arabia, 345 deficits of, 284–285
Resistance training Saunders, Cicely, 523 description of, 103
description of, 155, 156–158 Schizophrenia, 192 learning affected by, 384
fall prevention through, 256–257 Sclera, 131, 131f loss of, 223
Resource Utilization Groups (RUGs), 509 Screen enlargement software, 334 skin. See Skin
Respiratory muscles, 111 Sebaceous glands, 138 Sensory memory, 97
Respite services Secular understanding, of spirit, 398 Sensory problems. See also specific sense
definition of, 40 Sedentary living, 209 education regarding, 224
in Israel, 48 Selection, optimization, and compensation functional performance evaluation
Restraints, 83, 259 (SOC), 64, 67 affected by, 415
Restrictive lung disease, 203, 204t Selective attention, 95 hearing loss. See Hearing loss
Retirement Selective optimization with compensation theory, self-care affected by, 283–284
adaptation to, 315 of aging, 23, 23t vision impairment, 218, 221–222, 283. See also
Atchley’s stages of, 315, 315b Selective serotonin reuptake inhibitors Visual system conditions
case study of, 322–323 (SSRIs), 191 Serious mental illness, 492
cultural influences on, 317 Self Determination Theory of Motivation Services and Advocacy for Gay, Lesbian,
description of, 542 (SDT), 280 Bisexual, & Transgender Elders (SAGE),
in developed countries, 62 Self-actualization, 298, 305 440–441
generational perspectives in, 317–318 Self-advocacy, 40–41 Sexual activity
global, 317 Self-care age-related physical changes that affect,
health and, 542 arthritis effects on, 283 373–374, 374t
health-care providers involved in, 321–322 assistive devices for, 288–289 medications that affect, 374, 375t
history of, 5 cardiovascular disease effects on, 283 metabolic demand of, 113
involuntary, 315 cognitive impairment effects on, 285 Sexual attitudes and behaviors, 373
leisure and, 320–321 competence in, 280–281 Sexual response, 374t
models of, 314–316, 315–316 deficits in, 284–285 Sexuality
occupational therapy applications in, 542 definition of, 280 age-related physical changes that affect,
occupational transition to, 318f dementia effects on, 283 373–374, 374t
phased, 314–315 difficulties with, 408 assessment of, 375
process of, 315–316 environment effects on, 280 defining of, 372–373
theory perspectives on, 318–320 evaluation of, 284 disease effects on, 374–375
transition to, 314–315 general health affected by, 281–282 ethical considerations in dealing with, 375
Retirement planning, 316 goal setting for, 286b factors that affect, 374–375
Retrieval, memory, 386 hearing loss effects on, 283 gays and lesbians, 373
“Reverse migration,” 8 joint inflammation effects on, 283 health-care provider considerations, 375
Reversible dementias, 184, 186 meaning in, 280–281 life-stage effects on, 373
Rheumatoid arthritis, 283 medical conditions that affect, 282–284 in nursing homes, 373
Ricœur, Paul, 525 nutrition affected by, 281 research on, 372–373
Ritual, 401 overview of, 279 Sexually transmitted diseases, 375
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Index 571

Shared housing, 447t Social support Static stretching, 158

Shivering, 140 disease and, 264 Statins, 265, 270
Short Physical Performance Battery, 412 importance of, 368 Staying active, 423–424, 428–429
Short-term memory, 97, 183, 385 in nursing homes, 513 Stereotypes, 9
Simple reaction time, 167 Social workers, 322 Stochastic theories, of aging, 20–21, 21b
“Sit-and-reach test,” 154 Socialization, 282, 545 “Stops Walking When Walking” test
Sit-to-stand test, 155 Societal aging, 19–20 (SWWT), 173
Skeletal deformities, 174 Society Strength training, 123, 156–158, 424t
Skeletal muscle aging population effects on, 3–4 Strengths-based approach, 184, 196
activities of daily living affected by, 150 agrarian, 6 Stress
protein metabolism and, 150 Society for the Advancement of Rehabilitative exercise, 208–210
Skeletal system. See also Neuromusculoskeletal and Assistive Technology (RESNA), 337 gravitational, 208–210
system Socioacusis, 134 psychosocial, 206, 375
age-related changes in, 151–153, 152t Socioeconomic status (SES), 11 Stressful listening conditions, 135
bone, 151–152, 152t Socioemotional selectivity theory, of aging, 23, 23t Stroke
cartilage, 152–153 Sociological theories, of aging, 24t, 24–26 case study of, 244
functions of, 151 Soft rehabilitation, 501, 501f description of, 188–189, 194
joints, 152–153 Somatic mutation theory, 20, 21b global incidence of, 241
tendons, 152–153 Somesthesis, 138–140 hemispheric domination in, 241
Skill learning, 388 South Africa. See also Africa hypertension as risk factor for, 206–207
Skill training aged in, role of, 56–57 incidence of, 241
for activities of daily living, 286–287 apartheid in, 53–54 middle cerebral artery, 241t
considerations for, 388 challenges in, 57–58 posterior cerebral artery, 242t
Skilled nursing facilities (SNFs), 35, 497, 508 health care in, 54–56 posterior inferior cerebellar artery, 242t
Skin National Health Insurance in, 56 risk factors for, 207
age-related changes in, 138, 224 private health care in, 55–56 self-care abilities affected by, 282–283
conditions involving, 224 Rainbow Nation, 54 signs and symptoms of, 241t–242t
thermal injury to, 224 traditional medicine in, 56 upper extremity functional assessments after, 414
tools for assessing, 224 Spaced retrieval (SR), 195, 516–517 vertebral basilar artery, 242t
Skype, 545 Specialized-level palliative care, 524 Stroke volume, 118
Slow-twitch fibers, 149–150 Specialty Certified in Driving and Community Subculture theory, 24
Smart homes, 329, 424 Mobility (SCDCM), 348 Subjective usefulness, 64
Smartphones, 335 Speech comprehension, 100–101 Subjective well-being, 64
Smell sense Speech discrimination, 134–135 Submaximal exercise tests, 117b, 117–118
age-related changes in, 130t, 136–137 Speech perception, 134 Sub-Saharan Africa, 38
functional performance and, 136–137 Speech-language pathology, 476 Substance abuse, 271–272
self-care affected by declines in, 283–284 Speed of processing theory, 102 Substance use disorders, 193–194
Smoking Spirit, 397–398 Suburban environments, 7, 359
cessation of, 123, 206 Spiritual History Scale in Four Dimensions Success, determinants of, 384
noncommunicable diseases caused (SHS-4), 67 Successful aging, 4, 12, 92, 422
by, 206 Spiritual issues, 400 Suicide, assisted, 546–547
Snellen acuity, 217 Spiritual occupations, 65 Superficial sensation, 130t
“Snowbirding,” 8, 370 Spiritual-care professional, 400–401 Supination test, 168–169
Social breakdown/competence theory, 24 Spirituality Supported recall, 387
Social constructionist perspective, 24t, 25 approaches to, 400–402 Supportive care, 522
Social constructivism, 24t, 25 case study of, 402 Supportive services, community-based, 445t
Social determinants of health, 4, 425 chronically ill patients and, 399 Suprathresholds, 137
Social engagement, 104, 372 cultural competence and, 400 Sustained attention, 95
Social environment, 286 defining of, 397–398 Swallowing, 269
Social exchange theory, 23–25, 24t definition of, 423 Sweat glands, 139–140
Social gerontologists, 20 description of, 12, 65 Sweden, 390, 405
Social gerontology, 24 direct spiritual interventions, 401, 401f Symptom cycle, 462
Social interactions in elder care, 399–400 Synovial joints, 153
importance of, 367 health and, 423 Synovial membrane, 153
meaningfulness of, 378 health professionals and, 398 Systems of care, 544
in nursing homes, 513 human beings and, 398 Systems theory of motor control, 26–27
Social isolation, 540 indirect spiritual interventions, 401
Social media, 545 occupational therapists and, 398–399 T
Social network/networking patients with disabilities and, 399 Tai chi, 256
aging affected by, 367 quality of life affected by, 80 Tamoxifen, 265
description of, 39 religion and, differentiation between, 398 Tapping test, 169
driving cessation effects on, 360 wellness and, 423 Task modifications, 289
importance of, 368 Spirituality Index of Well-Being (SIWB), 67 Taste receptors, 136
Social participation, 78–79 Spongy bone, 151 Taste sense
Social relationships, 368–372 Spousal relationships, 371–372 age-related changes in, 130t, 136–137
Social Security, 10, 34, 542–543 State policies, 38 functional performance and, 136–137
Social Security Act, 4, 34, 438 Static balance, 170 self-care affected by declines in, 283–284
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572 Index

Teaching, 5 Touch sense, 138, 283 Visual impairments

Tear production, 130 Trabecular bone, 151 assistive technology devices for, 334–335
Technology Traditionalists, 6t description of, 218, 221–222, 283
assistive. See Assistive technology Trail Making tests, 352 Visual Object and Space Perception (VOSP)
future of, 545 Training, 210. See also Exercise; Exercise training battery, 223
primary care use of, 465 Transdisciplinary rehabilitation team, 493 Visual processing, 95
social media, 545 Transgenerational design, 329 Visual system
tele-technology, 496 Transient ischemic attack (TIA), 188 age-related changes in, 130t, 130–132, 166
Telemedicine, 545 Transitional care facilities and units, 497 anatomy of, 131, 131f
Telerehabilitation, 465, 484 Transportation communication strategies, 132b
Telescopes, 223t access to, 362 interactions with others affected
Tele-technology, 496 alternative solutions for, 362–364 by, 136
Temperature, 139–140 continuum of, 438 Visual system conditions
Temporality, cultural influences on, 80 facilitating change in, 364 age-related macular degeneration,
Tendons, 152–153 Independent Transportation Network, 219, 219f
Terminal illnesses, 522 363–364 behavioral adaptations for, 221–222
Testosterone, 373 options for, 361–362 cataracts, 218f, 218–219
Thalamotomy, 240 pilot programs for, 363 diabetic retinopathy, 220f, 220–221
Theories of aging public, 362 diseases that cause, 222–223
antagonistic pleiotropy accumulation, 21, 21b in suburban environments, 7 functional adaptations for, 221–222
biological, 20–21, 21b Transtheoretical Model of Change, 463 glaucoma, 219f, 219–220
cognition, 23, 23t Trauma, 491 optic devices for, 222, 223t
critical perspectives of aging, 24t, 25–26 Treadmills, 211 overview of, 217–218
definition of, 19 Tricyclic antidepressants (TCAs), 191 questionnaires for assessing, 221
developmental-genetic, 21, 21b 20/20 vision, 218 Vitrectomy, 220
disposable soma, 21, 21b Two-Minute and Six-Minute Walk, 412 Vocational assessment, 113
evolutionary, 21, 21b Type 2 diabetes mellitus, 204, 204t, Voice recognition, 335
free radicals, 21, 21b 207–208 Volition, 27
immunological, 21, 21b Volunteering/volunteerism, 65, 104, 320–321,
life course, 24, 24t U 442–443
life-span development, 22–23, 23t 63–64 UFOV, 346, 352
mutation accumulation, 21, 21b Undertreatment, 82 W
neuroendocrine, 21, 21b United Kingdom, 390 Walker, 257
neuropsychological, 21–22 United Nations, 38 Walking, 123, 172, 173f, 252
personality, 23, 23t Universal design, 329–330 Walking aids, 333
political economy of aging, 24t, 25 University of the Third Age (U3A), 391 Walking speed, 412–413, 460
psychological, 22–23 Upper esophageal sphincter (UES), 269 Wallenberg’s syndrome, 242t
selective optimization with compensation, Upper extremity function, 414 Wealth, 4–5
23, 23t Urban environments, 7 Web-based personal health records, 465
social constructionist perspective, 24t, 25 Urinary incontinence, 257–258 Weight reduction
social exchange, 24t, 24–25 Urinary tract infections (UTIs), 265, 268 hypertension managed with, 207
socioemotional selectivity, 23, 23t type 2 diabetes mellitus managed with, 208
sociological, 24t, 24–26 V Well Elderly Program, 364
stochastic, 20–21, 21b Vaginal lubrication, 374 Well-being
Theories of cognitive aging, 102–103 Value, 280 definition of, 64
Theory Value-based purchasing, 546 in dementia, 194
concepts and, 19 Vascular dementia, 187 psychological, 282
definition of, 19 Vertebral basilar artery stroke, 242t after spousal death, 372
in gerontology, 19 Vertebral compression fractures, 164 Wellness. See also Health
Therapeutic environment, in nursing homes, 516 Vestibular system, 166 cognitive activities for, 430
Therapy assistants, 478 Videoconferencing, 545 community effects on, 424–425
Thermoregulation Village model, 447t concepts related to, 421–422
impairments in, 116 Vision, low in current health-care environment,
skin’s role in, 139 communication strategies in individuals 430, 432
Third-party payers, 378 with, 132b definition of, 422
Time for Dying, 525 definition of, 218 environmental factors that affect,
Time-based prospective memory, 387 interprofessional treatment of, 220–221 424–425
Timed Get-Up-and-Go test (TUGT), 172, intervention strategies for, 221–222 environmental interventions for, 430
233, 408 occupational therapist’s role in treating, 222 factors associated with, 422–425
Timed up and go test, 116, 172 physical therapist’s role in treating, 222 home environment effects on, 424
Tinnitus, 133–134 prevalence of, 218 life review for, 427–428
“Tip of the tongue” phenomenon, 387 Vision screening, 351 Lifestyle Redesign intervention
Tissue plasminogen activator (t-PA), 189 Visual acuity tests, 351 for, 427
Titmus Vision Screener, 351 Visual function nutrition effects on, 424
Toe to examiner’s finger test, 169 assessment of, 350–351 occupation factors that affect, 423–424
Too-Fit-to-Fracture Initiative, 235, 235b description of, 217–218 occupational therapy interventions for,
Total lung capacity, 203 driving and, 345–346 425–430
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physical activity benefits for, 423,
423t–424t, 426
physical therapy interventions for, 426–430
professional development programs for, 430
psychological characteristics that affect, 423
quality of life affected by, 422
self-efficacy effects on, 423
self-management programs for, 429–430
spirituality and, 423
Wellspring Program, 510
Wernicke’s aphasia, 241t
Wet age-related macular degeneration, 219
Wheelchairs, 333
White House Conference on Aging, 40
Widowhood, 371–372, 441
Wisdom, 5, 101
“Without rehearsal,” 97
Wolf Motor Function Test, 414
Women
aging of, 5
defined roles for, 5
financial difficulties for, 11
late-life disability in, 11
life expectancy declines for, 547
living arrangements for, 5
Work. See also Older workers
community-based services for, 442
generational perspectives on, 317–318
health-care providers involved in, 321–322
legislation issues, 321
patterns of, 314
policies that affect, 321
Index 573
as spiritual intervention, 402
theory perspectives on, 318–320
Work activities, cultural influences on, 78
Work Environment and Impact Scale
(WEIS), 318
Worker Role Interview (WRI), 318
Workforce, 314b, 542
Working memory, 97, 102–103, 385
World Health Organization
health as defined by, 109–110, 421
rehabilitation as defined by, 489
World War II, 6, 10, 540
Written educational materials, 384
X
Xerosis, 224
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