INTRODUCTION
Between 2014 and 2060, the number of Americans 65 years and older is projected to increase from 46 million to more than 98 million, rising from 15% to 24% of the US population.1 Biological aging is not a linear process, and older adults comprise a heterogeneous group of individuals that require individualized and comprehensive health care. This heterogeneity is attributed to factors such as genetics, level of participation in health-promoting behavior, physical and social environments, socioeconomic status, education, and area of residency.2 Of these factors, only genetics is not a modifiable risk factor. Through interventions to improve modifiable risk factors, health care providers, including physical therapists (PTs) and physical therapist assistants (PTAs), play a large role in optimizing the experiences of aging through prevention, promotion, and treatment.3
To enhance the care patients receive, all assessments and interventions performed by PTs and PTAs need to be person-centered and evidence-based. Unfortunately, person-centered and evidence-based care does not occur routinely even with well-established, evidence-based practices like assessment of vital signs and physical activity levels.4–6 During the 2020 inaugural Carole B. Lewis Award Lecture, Dr Dale Avers provided a rally-cry for clinical practice: “We can do better!” Dr Avers urged PTs to promote their value and to adopt best practice principles.7 Calls for geriatric best practice have been increasing across disciplines, and examples include frameworks like the Geriatric 5Ms of competent care, which include Mind/Mentation, Mobility, Medication, Multicomplexity, and what Matters most,8 social media campaigns (eg, #OldNotWeak), best practice guidelines for older adults,9,10 and clinical practice guidelines for specific conditions found in this population.11–13
The Geriatrics 5Ms help focus care for older adults by providing value and maximizing outcomes regardless of the pathology or condition that causes the need for medical care. Mobility, a key element of the 5Ms model, is of prime importance to older adults and is the frequent focus of rehabilitation.14 Since the movement system is a hallmark of physical therapy practice,15 mobility and functional status are central to PT and PTA practice. The 5Ms model highlights the importance of employing a team approach to the care of older adults, including PT and PTA collaboration. One example of the team approach is related to important observations about mind/mentation, when PTs and PTAs screen, document, and communicate fluctuations or subtle changes in cognition and mental health. In doing so, all geriatric care team members support rapid diagnosis and intervention efforts.14 While the Geriatric 5Ms provide a strong framework for best practice, they do not provide specific guidance for PT. To our knowledge, best practice guidelines for care in older adults have not previously been developed for the PT profession.
Given the paucity of perspective and guidance for physical therapy best practice principles, and persistent inappropriate underdosing of exercise among older adults, there is a need to develop PT-specific guidelines.7,16 Therefore, the American Physical Therapy Association's Academy of Geriatric Physical Therapy (APTA Geriatrics) placed best practice at the forefront of its 2021-2023 Strategic Plan as a way to support the mission of the Academy to optimize the aging experience.17 The development, dissemination, and adoption of best practices ensure the PT profession will advance confidently beyond its first 100 years through health care innovation and leadership. To achieve this mission, APTA Geriatrics convened a panel of clinical experts consisting of board-certified geriatric PTs from academia and practice settings across the continuum of care. Through biweekly meetings held between July and December 2020 and literature searches for previously published geriatric best practice guidelines, the expert panel identified 6 key best practice principles to address the current practice gaps that produce suboptimal care for aging adults. The identification of best practices across practice settings with an overt commitment to anti-ageist health care drove the development of these principles and their associated specific action steps. These Best Practice Guiding Principles were approved by the APTA Geriatrics Board of Directors in December 2020. Print-friendly, bulleted summaries of these approved principles and action steps are provided in Supplemental Digital Content 1 (available at: https://links.lww.com/JGPT/A106) and Supplemental Digital Content 2 (available at: https://links.lww.com/JGPT/A97).
FOUNDATION OF BEST PRACTICE PRINCIPLES
In alliance with the Mission and Vision of APTA Geriatrics, the physical therapy care of older adults encompasses the entirety of the aging person's abilities within their unique environment and throughout their aging process.17 We believe the PT/PTA must advocate to reduce health disparities and health care inequities, improve access to health care services, and address the health, wellness, and preventive health care needs of people. Concurrently, the PT must consider the influence and effects of a person's environment consistent with the American Physical Therapy Association's Code of Ethics.18 The pervasive culture of ageism also requires advocacy through lobbying efforts for improved access and appropriate payment, negotiation with providers about optimal practices, and referral to appropriate community programs and resources. Through this advocacy, the PT/PTA team is integral to optimize the aging process.
Best practice care requires value-based care, defined as the health outcomes achieved per dollar spent and reflective of the patient's experience of care.19 Physical therapists are accountable for providing best practice care, which is safe, effective, patient-/client-centered, timely, and efficient.20 Accountability includes both a lifelong dedication to learning and a recognition that as knowledge, skills, and cultural understanding evolve, so must one's practice.
Evidence-based practice is the foundation of best practice care. Evidence-based practice is care based on the best available evidence, the values of the patient/family, and the clinical reasoning and experience of the therapist.21 Evidence-based care is translated and communicated with a person-centered framework22 and with an anti-ageist attitude.23 Best practices comprise intentional care that considers value, optimal communication, interprofessional collaboration, consideration of the continuum of care, and sound assessment and intervention techniques and skills. Best practices are the fundamental professional endeavor, with the understanding that these practices evolve continually. Presented next are the guiding principles for best practices in the provision of geriatric physical therapy, a brief rationale, and suggested action steps to assist with translation into clinical practice.
PRINCIPLES
Principle 1: Utilize Person-Centered Care to Elicit and Prioritize the Individual's Preferences, Values, and Goals to Drive the Plan of Care
Person-centered care is 1 of the 6 pillars from the Institute of Medicine that supports quality health care.20 The PT and PTA should recognize the uniqueness of each individual when establishing a therapist-client relationship. During the initial episode of care, there must be efforts made to promote a person-centered approach based on trust, mutual respect, and understanding to ensure that the patient/client is empowered to be an active participant and driver of their care. Conversations must be initiated to understand the patient's unique values, goals, and preferences for the delivery of care and to ensure a successful and meaningful plan of care. The therapist needs to advocate to address barriers and promote successful implementation of the person-centered plan and provide resources when appropriate. Patient empowerment should be emphasized during and outside of the therapy session.
Suggested action steps
The patient is the primary driver of their plan of care. Look for the following key elements of best practice collaboration between the patient and the therapist: shared decision-making to create agreed-upon individualized, meaningful goals to ensure patient engagement24; inquiries about the patient's desires for and extent of involvement of individuals important to them in the creation of the plan of care24,25; provision of time and preparation to consider goals and plan of care options10; and avoidance of ageist practices including paternalism, persuasion, and coercion during the goal setting process.26 Creating an authentic patient-client relationship is dependent upon mutual trust, respect, active listening, being wholly present during the therapy session, acknowledgment of patients' concerns and viewpoints, and the use of clear effective communication strategies.27 Additionally, PTs and PTAs should establish an environment that encourages self-efficacy during each encounter.27 Patient autonomy can be fostered through education regarding outcomes and promotion of self-monitoring. For example, monitor and communicate clinical measurements and provide context by comparing those numbers against a sample of a similar population with use of strategies such as “people like me” charts to encourage patient monitoring.28 Promote patient engagement with individualized, higher intensity intervention programs that directly relate to the patient's stated goals.29,30 Utilize proactive risk management, including assessing positive risk of an activity for the individual in the medical, physical, psychological, and social domains.
“Care providers and health professionals have both a duty to uphold the basic rights and freedoms of their resident, and a duty of care to protect them from foreseeable harm. It is important to recognize that it is not possible to eliminate risk entirely, and that it is essential that residents are given the freedom of choice and the right to make their own decisions, on everything from how they want to be cared for, to how they want to spend their free time.”31(p516)
Principle 2: Strive for Anti-Ageist Practice
Anti-ageist practice resists the powerful stereotypes that demean individuals because of their age. Without overcoming these stereotypes there is greater risk for substandard care, increased health care costs, and shorter life span for patients who internalize ageist beliefs.32–34 An anti-ageist attitude is a proactive stance of valuing the aging adult, supporting the person's intentional aging, and empowerment to make informed decisions within the individual's value system and available resources.
Suggested action steps
To start, assess for implicit/unconscious bias and negative attitudes about age using freely available tools, for example the geriatric attitudes35 or the Harvard implicit bias tests,36 although due diligence concerning reliability and validity when selecting any test is recommended. Avoid images and language that portray youth as positive and age as negative.37–39 Use framing strategies to advocate for policy issues to reduce ageism. Framing strategies leverage common communication language and priorities to increase the effectiveness of a shared anti-ageist message.40 Suggested effective communication strategies include considering older individuals as an untapped resource that builds momentum with age rather than slows with decline; using discussions of justice to offer purpose to all marginalized populations including older adults; and explaining implicit bias and that ageism is one of those biases.40 Finally, be willing to reflect on practice, including an honest assessment of how or if we honor dignity and value the unique qualities/experiences of others. Physical therapists and physical therapist assistants should be open to lessons that live within each individual regardless of ability or age.39
Principle 3: Conduct a Holistic Assessment and Evaluation Utilizing Sound Outcome Measures That Help Inform the Treatment Plan and Relate to the Patient's Stated Goals
A PT's assessment is comprehensive and identifies the movement deficits and risk for frailty that impact the patient's ability to accomplish their personal goal(s). The assessment should also contain domains of health promotion, prevention, and rehabilitation across the life span.
Suggested action steps
Physical therapists should include best practice elements in all assessments. A comprehensive history should contain at least the following information: a comprehensive falls/fall risk assessment; assessment of functional mobility including getting up off the ground, walking a ¼ mile without stopping, crossing the street in time, and climbing a flight of stairs; general health rating and the reasoning behind that rating; current and recent changes in medications, and any known side effects experienced; any difficulties with bowel or bladder continence; vision and hearing including frequency of regular assessments and if any difficulties have been noticed; mental health including if the patient has been feeling down, depressed, and or anxious; detailed participation in physical activity and exercise and other lifestyle behaviors; the extent of the client's social network and support; societal roles (eg, occupation, work, community activities, and household activities); and environmental factors that impact the ability to complete goals such as access to food, technology, shelter, and safety.
Perform a functional mobility examination that aligns with the patient's stated goals and minimally includes the following measures identified as critical at the time of this publication: mobility (usual and fast walking speeds), strength (30-second sit to stand and handgrip dynamometry), balance with an appropriate and challenging measure (eg, with lower-level patients the Four Stage Balance Test, and for higher-level patients the Four Square Step Test), and endurance (6-minute walk test or 2-minute step test).41 To maintain the outcome measure's fidelity and ability to apply its psychometric properties, do not modify the standardized methodologies published in the original manuscript.
Before implementing new outcome measures, critically appraise the literature and the outcome measure's psychometric properties.42 Best practice also provides regular reassessment/examination to ensure the patient's goals are updated and the plan evolves to remain consistent with patient preferences and needs.25
Principle 4: Provide Positive Outcomes of Physical Therapy Care by Completing Intervention(s) That Are Based on the Best Available Evidence
Interventions must be informed by best available evidence, and then implemented with appropriate challenge, relevance, and creativity to empower patients to achieve what matters most to them.
Suggested action steps
Use high-intensity exercise whenever possible for strength, balance, endurance, and functional training. Prescription of high-intensity exercise is intentional and requires monitoring.43 Provide and advocate for appropriate dosage and challenge levels for exercise and physical activity. For example, over 50 hours of progressive and challenging balance activities are needed to obtain optimal balance outcomes.44 Design unique programs that fit the individual's needs based on goals and abilities, time commitment, travel concerns, financial limitations, and available resources. Exercises and training activities should be progressive, creative, variable, and challenging to enhance outcomes and patient engagement.
Principle 5: Prioritize Physical Activity to Promote Health, Well-being, Chronic Disease Management, and Enhance Mobility
Physical activity is the cornerstone of health, continued mobility, and quality of life. Yet, only 8% of older adults participate in the recommended 150 minutes of moderate-intense physical activity and 2 sessions/week of strengthening exercise.45,46 Every effort should be made to mitigate sedentary behaviors and promote physical activity appropriate to each individuals' abilities and readiness to participate.
Suggested action steps
Examine bouts of sedentary time and physical activity levels in all patients/clients. The Exercise Is Medicine Health Care Providers' Action Guide has useful information to improve practice regarding physical activity.47 Design physical activity programs that align with the patient's abilities, desires, interests, environment, and access. Utilize and create relationships with community resources to assist patients in the continuum of care (eg, National Council on Aging, Agency on Aging, and APTA Geriatrics Partnership Materials). Engage caregivers and other members of the patient's social network where appropriate to improve physical activity levels.45
Principle 6: Champion Interprofessional Collaborative Practice That Is Inclusive of Patients and Their Caregivers
Skilled PTs and PTAs working with older adults integrate their clinical expertise into a collaborative patient-informed management plan as equal partners with the patient, their caregivers as appropriate, and other health care team members bridging across all transitions of care.
Suggested action steps
Understand, respect, and utilize the different strengths and roles of the health care team members. Engage in clear, closed loop communication with the patient, caregivers, and other health care team members bridging across all transitions of care. Promote clarity by exchanging information with the patient, caregivers, and other health care team members to create an environment that promotes shared decision-making. Advocate for all team members to be accountable for patient needs and be available to ask and answer questions regarding the patient's management plan, especially when patient safety is at risk. Consider the patient's preferences, values, and beliefs in formulation of the patient/person-centered management plan to achieve positive patient outcomes.
DISCUSSION
The success of best practice principles depends on the implementation efforts put forth by individuals, coworkers, interdisciplinary team members, managers, facility or corporate structures, and policy stakeholders.48 Individually and together these entities can set expectations for best practice, monitor the implementation success through metrics related to quality care and patient outcomes, collaborate with the patient and other health care providers, and research efforts related to best practice. The action steps outlined earlier can increase ease of implementation, as they aim to provide examples of intentional efforts that will assist with adoption of these principles.
Individual clinicians are encouraged to self-reflect about their own practice and identify which of the aforementioned action steps are currently used and which need to be improved. Self-assessment should be used to guide continuing education and lifelong learning. Reflective practice and metacognition are hallmarks of expert clinical care, consisting of thinking about one's practice (reflection) as well as self-monitoring that reflective process (metacognition). Such expert practice involves not only review of knowledge and clinical reasoning, but analysis of what did and did not work for the patient with reflection on inconsistencies or similarities in data collected, and an understanding of the extreme importance of collaboration with the patient and other providers.49
Clinicians with highly self-reflective behaviors are more likely to use evidence-based practice and take actions to correct current practice patterns.50,51 While evidence-based practice barriers of time, access to articles, and organizational support are associated with reduced evidence-based practice implementation, high self-reflection behavior has a larger effect size than commonly cited barriers.51 This indicates that self-reflection is an essential skill that fosters evidence-based practice. For those working with older adults, self-reflection needs to include an honest self-assessment about attitudes and potential biases related to aging. By eliminating ageist practice, PTs and PTAs have the opportunity to improve a patient's health and the cost of health care.32,34 By elevating anti-ageist practice to a guiding principle, APTA Geriatrics makes a strong statement on the importance of viewing each individual's possibilities in addition to age-related challenges. By sharing the therapist's self-reflection assessment process and verbalizing goals for improvement with colleagues, a culture of best practice can be facilitated. For example, discussing how language perpetuates ageism and then asking for and providing feedback based upon what is seen and heard during patient interactions can be a powerful way to raise awareness of implicit age bias. Workplace support and application of evidence to each clinician's specific clinical practice through shared experiences are powerful motivators for using evidence.52,53
At the organizational level, use of the suggested guiding principle action steps to identify policies and practices that need refinement to develop best practice is strongly encouraged. Robust discussion with clinicians about where improvements can be made should be initiated. Organizational support in terms of time and resources to embark on an evidence-based project is essential.53 Consider how to efficiently incorporate best practice principles into a facility's regular routine. Decisions should be made collectively, rather than with a top-down mandate, to increase willingness to change and progress toward best practice. For instance, would having large wall posters with a rate of perceived exertion scale best encourage clinicians to monitor intensity, or would pocket cards with that information work better? With facility endeavors, consider using a structured quality improvement or implementation process to undertake best practice efforts one at a time with evidence to guide decisions. Discussions of knowledge implementation best practices are beyond the scope of this article, but excellent references exist to guide this process.54–58
APTA Geriatrics has a role in the facilitation of best practice beyond the establishment of these guiding principles. First, as the professional voice for physical therapy care of older adults, dissemination of best practice is needed not only within APTA Geriatrics, but to physical therapy colleagues in all areas of practice. With the world's aging population, PTs and PTAs in nearly all practice settings will treat older individuals regardless of whether they consider themselves to be in “geriatrics” work settings. These best practices should be used to guide education of students and practicing clinicians through academic education, continuing education offerings, and residency/fellowship training aligned with these recommendations. There is a need to increase education about shared decision-making, support for patient/client self-efficacy, key examination and intervention strategies that foster a more active and properly dosed plan of care, and mechanisms for improved intra- and interprofessional collaboration between practice settings and across the continuum of care.
Finally, the APTA Geriatrics Best Practice Guiding Principles are useful for all care providers and should be disseminated to other geriatric care team members to highlight our common interests, share our vision, and encourage adoption of age-friendly care principles. APTA Geriatrics should add its voice to many such efforts, collaborating with, for example, Reframing Aging, Age-Friendly Health Systems, and Exercise Is Medicine.40,47,59 Collectively, mutual agreement that we all need to provide better care for our older clients and an emphasis on shared common ground may encourage an optimal aging experience through increased physical activity, engagement with research priorities, and advocacy for policy improvement.
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