September, 1963 P H Y S I O T H E R A P Y Page 3 A CONCISE GUIDE T O TH E ASSESSM ENT O F THE GERIATRIC PATIENT A N D TH E APPROACH T O TREATM ENT A Paper delivered by M iss A. J . Savin, M .C .S .P ., S .A .S.P ., during th e session on G eriatrics o f the 4th Congress o f the W orld Confederation for Physical Therapy, on the m orning o f 21st June, 1963. In conjunction with it is a p rin ted chart, “ A Concise G uide to the Assessment o f the G eriatric Patient and the A pproach to T reatm ent, designed to answ er the question “ W here is your Patient on th e ro ad to Independence?” , A copy o f the printed chart was issued to members on entering the auditorium , at the beginning o f th e session. T he Society aim s at co-operation with o th er bodies, it also encourages the co-operation o f its individual mem bers with o th e r medical workers. This is o f particular im portance in th e approach to treatm ent of the G eriatric P atient, where a com m on aim m ore easily produces satisfactory results. The Assessment C hart: T he im portance o f co-operation is reflected in th e text o f the printed chart, which you received at the beginning o f the session. This ch art can be used in practice to assess the position o f the individual p atient as suggested by the heading “ W here is your patient on the ro ad to Independence ?” though it m ay be o f m ore value in indicating the attitu d e necessary in the Physiotherpist and her co-w orkers to obtain an all-round assessment and approach to treatm ent. T he need for a ch art was possibly m ore evident som e years ago, but one still finds occasions when the ideas need re-statem ent, for example, in the chronic w ard where the patient still rem ains in bed, o r in th e acute w ard o f a general hospital where, even though th e p atient is perm itted to sit o ut o f bed, the tem po o f w ork in the w ard, high beds and slippery floor m ilitate against the rehabilitation o f any less agile person. O n the ch art you will find th e factors favourable to the p atient’s recovery set out on top. By contrast, those factors unfavourable to recovery, will be found in the colum ns below. T he factors, chosen as being o f most interest to the Physiotherapist, a re divided into five sections: The care of the aged, as an organised effort on a n atio n ­ wide basis, is com paratively new in South Africa. Much has been done to create public interest in the past six years, by the form ation o f the N ational Council for th e Welfare o f the Aged, to which the South A frican Society o f Physio­ therapy and many o f th e local institutions are now affiliated. T he South A frican Society o f Physiotherapy is deeply co n c e rn e d th at Physiotherapy should be available, through Jthe developing Medical and W elfare Services, to all persons in South A frica handicapped by the disabilities o f old age. M any organisations, both state-aided and private, offer services to the elderly and aged, some in hospitals, some in Old People’s H om es, and others in the aged person’s own home. F o r example, the D epartm ent of Social W elfare and Pensions, subsidises 78 Old People’s H om es throughout South A frica, and th e beautiful seaside resort o f D u rb an can boast of over 20 private old people’s hom es in its vicinity. Old People’s H om es are available for all racial groups in this m ulti-racial country; the A frican B antu, the Coloured, the Indian, the A siatic and the E uropean. There is a higher proportion of organised old people’s hom es fo r the E uropean population than for the African. D ue to their particular social structure, th e elderly B antu are m ore likely to be cared for back in the kraal, in the family circle by children and grandchildren. This family care is sadly lacking in some of our m odem com m unities which consider th a t old people are not the responsibility o f the family, but o f the State. M any of the O ld People’s H om es in South Africa being new have the advantage o f the latest ideas in construction and equipm ent. O f course, buildings are n o t everything; the success o f the hom e depends far m ore on the spirit inside, and on w hether the people in it are happy. W hen I went to see the A frikaans H om e in P retoria, the residents ishowed me round and I was passed on from friend to friend. JThey were pro u d of the building, which obviously was con­ venient, but the residents very strongly m ade the point that they had found friendship and com panionship and were never lonely. I knew then why th e hom e was called “Ons T uis”— O u r Home. T he South A frican Society o f Physiotherapy, feels, th a t now th a t the ancillary services are being established in many of the new Old People’s Hom es, it would be regrettable if, with such excellent living conditions, the elderly people in them lacked adequate Physiotherapy and rehabilitation on the spot. The V ice-Chairman o f the South A frican Society of Physiotherapy, Mr. Alfred R othberg, o f the Southern Transvaal B ranch, has been o u r pioneer in this field. H e implemented a pilot scheme un d er which a num ber of Physiotherapists have, on a voluntary basis, visited several Old People’s H om es in Johannesburg, once a week to give treatm ent. F rom this small beginning th e W itw atersrand Jewish Aged H om e now has a well-developed Physiotherapy d ep artm en t with paid staff, and the Bramley Old People’s rwume , Just appointed a part-tim e paid Physiotherapist. JJtner branches o f the South A frican Society o f Physio­ therapy have followed the idea, and mem bers have offered Practical help in their own districts. 1. Physical factors; 2. M ental and Econom ic fa c to rs; 3. Bed R est factors; 4. M obility factors; and finally 5. T reatm ent and Tim e factors. Section 1: T he first section indicates the need to review the state o f all the body systems, because one w ould expect th at, after so m any years o f life, some of them w ould be wearing out. It also shows som e o f the conditions com m only treated by the Physiotherapist. Section 2 : T he second section shows the contributory factors which may have to be overcome. It is interesting, and surprising, to see how these tw o sets o f factors sometimes balance each o ther out in the final state o f the p atien t’s m obility. F o r example, one patient w ith num erous physical disabilities, failing sight, a w eakening heart and stiffening joints may m anage to keep going and will recover with treatm ent, because o f h er grit, courage, and will pow er; while another, far less disabled, will fail, having apparently neither the will to recover, iior anything to live for. Section 3 : In this section, the adverse effects o f prolonged Bed R e s t; Bed sores; C ontractures; Incontinence, and M ental A pathy are stressed pictorially. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) I have often seen an apparently senile, incontinent patient nursed in a cot bed, who recovers dram atically when lifted out o f bed into a com fortable chair th a t gives her safe support and brings her into a more upright position. Section 4 : Section 4 shows th e need for equipm ent which will help the progression into the upright as soon as possible, from bed to chair, and from standing to walking. The basic equipm ent should be re-assessed and, if neces­ sary, redesigned, to suit the size and needs o f the individual patient. While allowing for nursing care and fo r support o f the painful joints, th e bed and chair m ust give the mech­ anical aid and the feeling o f security which will encourage the patient to m ove autom atically and to change her position. T he elderly p atient m ust feel safe when carrying ou t a movem ent, especially if it is a new manoeuvre, and advan­ tage should be taken o f mechanical aids and helpers to effect a progression. In o rder to give the patient assurance th a t it is safe to move and then confidence in her ability, it is b etter to overdo help at first, than to have insufficient help. T he elderly p atient will discourage excessive help once she is capable o f doing w ithout it, as long as she knows th at it is available if necessary. W hen the patient is in bed, forw ard placed handles will give a better mechanical advantage for sitting forw ard than th e usual single backw ard pulley over her head. A bed-chair back-rest, shaped like the top h alf o f a chair with arms, will enable her to rock to and fro, lean forw ard o r sideways. It can be used as a support when she sits over the side o f the bed and provided her feet are supported on a foot stool o r can reach the floor, she will start to turn her tru n k and move her feet and knees autom atically. W hen she starts to get o u t o f bed, the height o f the bed is o f prim ary im portance. A lthough a high bed may be needed at first fo r nursing procedures, it should then be changed to a lower bed for rehabilitation purposes o r the m attress lowered on the existing frame. A lthough it is found in our m odern G eriatric U nits and Old People’s H om es, the lower bed is often condem ned in a G eneral H ospital, as it is said to m ake care and bed-m aking a back-breaking jo b , b u t it is not realised th at, if used a t the right stage in recovery, it makes getting the p atien t into a chair or w alking a far easier jo b for the staff and far less painful o r risky fo r th e patient. Similarly the height o f the chair seat is im portant when the patient is trying to stand up, balance, and sit down. H er feet m ust be able to reach the floor, bu t if the seat is to o low, and her knees and hips too bent, she will n o t have the power to straighten them . A higher chair will be o f m ore use for practising this, especially if th e patient has a stiff hip. In hospital, when walking is abo ut to be started, it is often wise to bring parallel bars to the low bed side, with the bed turned broadside against the wall to m ake it quite stable. T he patient can walk to and fro, from the bed to a rest chair o r back, with the effort o f getting out reduced to th e minim um , and the bed is ready to hand when a longer rest is required. It m ust be rem em bered th a t the elderly p atient has only a certain am ount o f expendable energy, depending on her heart, respiration, and general health. T he physiotherapist will direct her p atien t’s energy to m aking useful movements. Simple repetitive movem ents which the p atient can rem em ­ ber and carry out during the day are best. Small progressions should be m ade within the p atien t’s know n capacity, and should be suggested to her in turn. M any an elderly patient, lying in bed, has been dis­ heartened and has refused to move when she has been told by a well-meaning nurse o r therapist th a t th e doctor says she m ay now get up and walk, fo r she knows th a t even to sit up o n the side o f th e bed o r in a chair will take practice. Page 4 P H Y S I O T She must be helped by having the prelim inary stages through which she will have to pass explained to her, and she need n o t even be faced with the final target. T hen she will p robably agree to start at once and to omit some o f the stages. Section 5: T he fifth and final section indicates the necessity for early treatm ent carried out by a team with an activity spirit and using a tem po suited to the elderly. O ne might com pare the potential progress o f the elderly patient with the tortoise in the story o f the race between the hare and the tortoise. T he form er races on and loses time as he stops to look about, while the latter wins the race. The elderly patient cannot expect to recover at the same rate or to the same degree as a young person, but if given time to progress slowly and steadily, she may reach her goal o f independence in a bed, o r in a chair or w alking far sooner than expected. H E R A P Y September, 1963 T H E A P P R O A C H T O TRE A TM EN T Assessment by means o f the chart leads to the “ A pproach d to T reatm ent” as shown beneath each section and which is V sum m arised as follows: Strive fo r the best approach to tre a tm e n t: 1. Find the Precipitating Cause. 2. L ook for the C ontributory Causes. 3. A void prolonged dependence in bed. 4. Progress to the upright as soon as possible, using equipm ent, favourable to movement. 5. Give early treatm ent rem em bering the slower tem po o f the elderly. Epidiascope: This is the W itw atersrand Jewish Aged H om e in Johannes­ burg, to which I have referred. Slide 1—H ere is a picture o f M r. R othberg who started the G eriatric Physiotherapy there, w ith his band o f volun­ tary helpers. Slide 2—H ere is the voluntary w ork in progress at the Bramley Home. Slide 3—This shows som e o f the patients playing skittles in th e gymnasium. T he frames in the background are designed to slide over the beds for suspending apparatus. Slide 4— This is the A frikaans Old People’s H om e in Pretoria “ Ons T uis” . Slide 5— Mrs. J. M undt, one o f the residents with som e o f her friends, who showed me around. Mrs. M undt is of H ugenot and G erm an decent. She talked to me o f South Africa history. ' Slide 6— This was Mrs. M u n d t’s original hom e which was built by the V oortrekkers, and which she presented to the country as a N ational M onum ent when she came to “ Ons T uis” . Slide 7—This shows M rs. Hall, aged 95 o f N elspruit, Eastern Transvaal. She and her husband were from G reat Britain and were the first settlers to live and survive in the lowveld, then a malarial area. They built up w hat is now one o f the largest Citrus Estates in South Africa. H er account o f her life and experiences are described in her book N o Time to Die, which she w rote at the age o f 90, a copy o f which you can also see on our stand. Slide 8—This is a hom e for sick and aged B antu in Venda- land, N o rthern T ransvaal, ru n by a Mission Church. The residents themselves have nam ed it K hathutshelo— “ Place o f Com passion” . R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )