Article by:
Dr.Jayashri. Kale [Professor and Head Department Of Occupational Therapy]
Seth G.S.Medical College, KEM Hospital Parel Mumbai.
I was just a teen, and I have stepped into the fifties today! Am I growing old? Am I ageing? Has a change occurred in my life? Have I gone wiser than my teens or am I returning to my unit age? What exactly is ageing? It is indeed a challenge to define ageing. Is it a chronologic calendar mark equivalent to the biologic age? A Physiologic or a functional marker? Is it maturing by experience and wisdom or a decline in thinking ability?
When I worked at the U.S I was treating a patient named John. John would drive himself to the therapy every day, he played golf and did his instrumental ADLs like banking, shopping by himself, he drove the elderly in the community to reach to the airport, assisted them to shop for Christmas gifts and posted the gifts to their grand children who stayed out of states. He hated being called OLD, and proudly said he was 92 years young.
"The ageing process is of course a biological reality which has its own dynamics, largely beyond human control. However, it is also subject to the constructions by which each society makes sense of old age. In the developed world, chronological time plays a paramount role. The age of 60 or 65, roughly equivalent to retirement ages in most developed countries is said to be the beginning of old age. In many parts of the developing world, chronological time has little or no importance in the meaning of old age. Other socially constructed meanings of age are more significant such as the roles assigned to older people; in some cases it is the loss of roles accompanying physical decline which is significant in defining old age. Thus, in contrast to the chronological milestones which mark life stages in the developed world, old age in many developing countries is seen to begin at the point when active contribution is no longer possible." (Gorman, 2000).
Most developed world countries have accepted the chronological age of 65 years as a definition of 'elderly' or older person, at the moment, there is no United Nations standard numerical criterion, but the UN agreed cutoff is 60+ years to refer to the older population.
In our country 58-60 years, the retirement age marks the ebb of life. After accomplishing successful tenure in life, I would say retirement is the dawn of a new beginning in life. The vastness of life, the potential and expertise of abilities acquired over life time can only be experienced and acknowledged in this phase of life that we call as ``re-tyrement”. This may indeed be described as the experiential phase of life.
The latest concept of ageing is dynamic and believes in active ageing. Active ageing is the process of optimizing opportunities for health, participation and security in order to enhance quality of life as people age. It applies to both individuals and population groups. The word “active” refers to continuing participation in social, economic, cultural, spiritual and civic affairs, not just the ability to be physically active or to participate in the labor force. Older people who retire from work, ill or live with disabilities can remain active contributors to their families, peers, communities and nations. Active ageing aims to extend healthy life expectancy and quality of life for all people as they age.
How does ageing affect life?
Ageing is a process of growing old, and describes a wide array of physiologic changes in the body systems, ageing is a complex process, and it is developmental and occurs across life span.
With ageing there are changes at the cellular, tissue and organ levels. The changes at cellular levels are seen as decrease in cell capacity to reproduce, arrest of DNA synthesis and cell division. Tissue changes are seen as accumulation of lipofuscins, fats etc, degradation of collagen, and decreased elasticity of body tissues. The result is decrease in functioning of different organ systems, leading to decline in functional capacity, and homeostatic efficiency.
Concomitant to the above processes there is more susceptibility to disease and illness with gradual weakening of the body and immunologic system from adulthood through death.
“Health” refers to physical, mental and social well being as expressed in the WHO definition of health. Maintaining autonomy and independence for the older people is a key goal in the policy framework for active ageing.
Different branches of medicine are specialized in the care of the elderly. The branch of medicine that is concerned with illness of the old age is called “geriatrics”; while the scientific study of the factors impacting the normal ageing process and effects of ageing is called “gerontology”.
The other health specialty that is involved with the care of the elderly is “Occupational Therapy”, (O.T); mainly focuses around the well being, prevention of illness, rehabilitation, and maintenance of a productive life of the elderly.
Geriatric Occupational Therapy or elder care is a specialized field of O.T that deals with the problems related to physical , mental diagnoses, and Psychologic changes attributed to decline in function due to ageing. The tenets of Occupational therapy practice in geriatric rehabilitation are based on the theories of ageing .An Occupational Therapist takes into account socially constructed meanings of age ,significant roles assigned to older people; while designing a tailored rehabilitation program for the elderly client.
Occupational therapists allow people to realize and maintain their potential for physical, social and mental well being throughout life span and to productively participate in society.
Occupational therapy process follows a specific pathway in geriatric rehabilitation. The important steps that an Occupational therapist uses in the rehabilitation of the elderly begin with a thorough evaluation, problem identification, problem analysis and problem solving,and planning through scientific deductions.
Scientific Evaluation: An Occupational Therapist always begins with a scientific evaluation of physical, mental and psychological components of performance to determine what difficulties a person might be having that interfere with independence.
Assessment of physical abilities, deficits in performance due to physical problems that could be attributed to the neuro-musculo skeletal system are thoroughly assessed by the Occupational therapists for designing a goal based therapy program for the elderly.
Assessment of cardiopulmonary parameters that can support or could be the cause of impeding physical performance in therapeutic regime ,need a scientific assessment and inference from available medical reports to conduct the sessions on elderly.
Execution of physical ability in a productive way needs a minimal cognitive ability, assessment of cognitive abilities through scientific tests, and the potential to use these abilities in daily life to promote functioning with safety, is the role of the Occupational Therapist.
Roles of Occupational Therapy in different clinical conditions of the elderly:
Role in memory loss: Perhaps no other disease afflicting the elderly is as devastating as a dementia that impacts memory and abilities to communicate, solve problems and ultimately perform self-care tasks such as eating and toileting. Occupational therapists are trained to assess the patient’s cognitive status and use behavioral interventions to address the changes in personality that may be upsetting to caregivers. Occupational therapy during the early stages of disease centers on
- Adapting the home for safety.
- Maximizing the patient’s remaining skills in order to be as independent as possible.
- Educating caregivers and helping them find social and emotional assistance such as support groups and respite care.
Progressing Alzheimer’s disease: As the disease progresses, the role of the occupational therapist focuses on improving quality of life by simplifying activities and providing sensory stimulation that can ameliorate aggressive behaviors in the geriatric. Addressing behavioral changes through Behavioral or cognitive behavioral therapy is an important part in therapy. Regardless of the patient’s stage of Alzheimer’s disease- occupational therapists are a great resource for caregivers who want to learn how to interact with and enjoy progresses.
Fall prevention: Falls are a common feature of the elderly, assessing the patient for risk of falls is important. The cognitive and physical assessment in these patients is extremely essential to prevent falls.
Muscle strengthening exercises and proprioceptive training in the elderly is offered to enhance the physical abilities and joint position sense. One has to have a good judgment in prescribing exercises to the elderly, appropriate functional diagnosis and relevant exercises for therapeutic intervention is the keystone in therapy.
Environmental modifications in the homes and surrounding environment like bed and furniture heights, floors and carpets, contrasted steps and doorways, railing along the bed and in the toilet, lighting recommendations are advised by the Occupational therapists to prevent falls following a detailed assessment of the elderly and the pertinent environment.
Falls are subsequent to many factors of which balance is most important. Balance is the key to success for ADLs, mobility, maneuvering and navigation in daily life .Occupational Therapists assess the balance strategies in the elderly and treat the deficient components of balance for safe execution of the above tasks in environment. Intactness of cognitive abilities of the elderly is important in execution of fall prevention strategies, thus not only physical training but assessing the cognitive ability is also an important role of an OT in fall prevention.
Feeding in elderly: Therapists also make recommendations related to food textures dining equipment, and eating postures for dining. For example, a patient who has difficulty chewing may need to eat ground foods and use a spoon with a large handle. Assessment for aspiration of food, cognitive and motor ability to manage food textures are important roles of an Occupational Therapist.
Positioning for seating: In the elderly who are bed ridden or wheel chair bound, Occupational therapists asses seating and positioning needs in beds or wheelchairs. Recommendation for appropriate wheelchair and seating, through specialized evaluation is mandatory for the safety of the elderly. Proper seating and positioning is important to prevent bed sores, interact with the surrounding, and make effective communication for their needs.
Prevention of contractures and deformities and Pain: When in bed for a prolonged period following injury or illness the elderly are prone to develop joint and soft tissue tightness, deformities and pressure sores. May it be in the bed or the wheel chair, positioning patients in anti-deforming positions is important to combat the effect of age related soft tissue and joint contractures. One of the theories of ageing proposes –that use of self as a whole is important to sustain function-use it or lose it. Maintenance of the physical abilities through appropriate use of purposeful activities is more important than treating or curing dysfunction. Appropriate technology and methods, use of splints, mobilizing the body parts are essential to keep up the mobility and intactness of every body part.
Positioning is also important to prevent pain or relieve pain and pressure sores; stretching to the parts; judicial use of pain relieving modalities , use of selective orthotics to enhance routine functioning are important.
Pain or discomfort in the elderly can lead to abnormal behaviors in the elderly, identifying the cause of behaviors and addressing these behaviors by treating the cause, behavioral or cognitive behavioral therapy are some of the important roles in occupational therapy regime.
Caregiver education: Care giver education forms a very important role of Occupational Therapy practice. The Elderly is a very fragile group to handle physically and mentally, specifics in physical handling; emotional support to the elderly, understanding their needs with respect to certain behaviors can prevent elder abuse in many ways at home, hospitals, nursing homes and are all a part of the care giver education.
Not only are important the patients or elderly clients in this process, understanding the burden of the care givers and educating them to prevent caregiver burnout is equally important to avoid difficulties in elderly care.
Adaptation and compensation: Compensatory approaches to adapt to and overcome disabilities are popularly practiced by Occupational Therapists. Here are just a few examples of ways that an occupational therapist can help seniors with disabilities:
- Teach a person with arthritis to protect the joints and conserve energy.
- Help a person with limited range-of-motion to do stretching exercises and use adaptive equipment such as a sponge with a long handle.
- Train a person with an amputation to put prosthesis on and off, use his splints.
- Help a person with low vision adapt the environment to avoid glare and increase color contrast.
- Help a person with memory impairment organize and label draws and cabinets.
The other domineering areas of OT in elder care:
- Identifying and treating elder abuse.
- Cognitive and perceptual re- training.
- Cognitive behavioral training.
- Safety assessment, training an environmental modification for safety.
Activites of daily living: One of the major areas of life is also a major area of practice for Occupational Therapists. The most important for the elderly is being independent in the basic ADLs like dressing bathing, toileting, feeding and in instrumental ADLs like John was. ADLs both with independence, with assistance or compensation, reinforce a sense of independent living and self identity and should be encouraged until the end of life.
With the growth in the elderly population due to extended life span, and modern concepts of a limited family , the elderly are soon expected to outnumber the young population .Who will then take care of this growing population?
The society at large needs to incorporate newer concepts like assisted living facilities for the seniors, to serve the needs of the changing society.
Within the last 20 years, professionals in the field of eldercare have recognized the need to promote an active lifestyle within an environment where care is also provided. As a result, seniors no longer feel they are burdening their families with their needs, live independently in their own apartment, enjoy a full calendar of activities and feel secure in knowing assistance is always available.
Nursing homes for chronic or acute problems is also a concept that should be accepted by us to allow early and smooth recovery of the ill patients .the basic focus here is skilled medical care and skilled therapy.
Occupational Therapists are qualified professionals who are educated to handle different kinds of medical diagnoses .These range from physical, neuro-muscular skeletal, mental disorders, developmental disorders ,adult and geriatric rehabilitation. Medical basis of these conditions, classification, symptomatology, pharmaceutical effects are all a part of the curriculum. Thus it makes them competent to understand and handle the multidrug effects, related behaviors and implement scientific aspects of rehabilitation during the rehabilitation of elderly group. It would indeed be stated that they are the need of the hour.
Occupational Therapy adds life to years and not just years to life! May you add quality to life and enjoy it to the fullest, age gracefully with the help of an occupational therapy advocate.
Before I end, I must mention here about the elder care nursing home established and owned by my friends Dr.Shrirang Pandit and Dr. Jayashri Pandit at Pune. Probably many of the elderly may avail the benefits of this elder care nursing home and long term care facility now available at Pune. There are many others that may be mentioned-----
