Most of the time, PTs need only think about the patient in front of them. But therapists who work with the elderly are frequently working with more than just one person.

Understanding the needs and dynamics of family members and caregivers is “absolutely critical” for PTs who work with elderly patients, says Patty Antony, PT, GCS, CAPS, the founder and president of Elder Advocates Incorporated, a company based in Orlando, Fla. that helps the elderly and their families access needed services.

“You can’t really work with the senior without working with the family, because they come as a unit,” she says.

Providing the best care means understanding the needs and concerns of caregivers and family members. It can include helping caregivers devise strategies for providing quality care, or helping them cope with burnout, a common problem caused by the challenge of caring for an elderly person with health problems. Understanding the abilities and limitations of caregivers must be considered when deciding on hospital discharge options. At times, the PT’s caregiver involvement may become more personal, because many act as caregivers themselves for an elderly friend or family member.

Assessment

Patient caregivers — a group estimated to include as many as 44 million Americans — are frequently women who already have a lot of responsibilities. Often in their late 40s to early 60s, many are still seeing children through school or are occupying high-level management positions heading toward retirement at the time a parent or friend gets sick. “You have people who are just really stretched to the limit,” Antony says.

Experts in geriatrics who understand the difficulties of being a caregiver advise caregivers to reduce burnout by learning as much as they can about their loved one’s health problems; helping the patient maintain as much independence as possible; asking for help from trustworthy family members, neighbors, or friends; joining support groups; and getting in touch with organizations that assist caregivers.

Anne Coffman, PT, MS, GCS, vice president of the APTA’s Section on Geriatrics, emphasizes that sometimes caregivers need a break. Adult daycare centers are one good option; alternatively, caregivers can pay someone to come in for a few hours on a daily or weekly basis, she says. Depending on the patient’s physical and cognitive level, the caregiver’s job can be extremely overwhelming.

Caregivers should make sure they take care of themselves, “because they can’t take care of anyone else if they aren’t taking care of themselves as well,” Coffman says.

In Coffman’s experience, having a support system helps. Patients may need care in the middle of the night or help with each meal, or might have to have medication prepared or administered. “That’s a lot for one person to take care of,” she says.

Involvement

Jacqueline Lovejoy Osborne, PT, DPT, GCS, assistant clinical professor at the University of South Florida School of Physical Therapy and Rehabilitation Sciences, observes that a lot of caregiver stress and burnout comes from caregivers not knowing what to do or how to do it efficiently. A simple event such as transferring from the toilet to a wheelchair can be very stressful for some caregivers, she says. To reduce this stress, Osborne tries to enhance communication between the patient and caregiver during caregiver training sessions.

“It’s one thing to hear the description of what they do, [but to] see them implement it is another story,” she says. Performing the transfer with PT feedback helps both the caregiver and the patient identify places for improvement, and improves communication.

Osborne also requests that caregivers keep a diary of any particular difficulties they’re having, which helps her understand the challenges patients and caregivers face at home. For example, a patient with Parkinson’s disease whose physical and communication abilities fluctuate according to medication levels may perform a task perfectly in the clinic but may not be able to repeat the task successfully at a different time of day.

Recommendations

Many PTs are involved in the discharge plan, helping decide whether a patient is able to go home or should transfer to another facility. During the initial evaluation, Coffman, who works in a number of nursing homes in Milwaukee, Wis., asks how the patient was functioning and how much assistance he or she needed before being admitted to the nursing home, and what the family’s plans are for the person returning home.

“Sometimes the caregiving burden has just gotten to the point that [when patients] go to the hospital, they need to come to a nursing home for rehabilitation and the family just says, ‘We can’t do this anymore,’” in which case there are long-term or assisted living options, Coffman says.

Although PTs are trained to make people functionally independent, going home isn’t always the best option, Antony says. “Sometimes physical therapists assume [that everyone] going home is the ultimate goal, but sometimes physical therapists need to dig a little bit deeper and make sure that home really is the right place to go, and [shouldn’t] dangle it if it’s not a realistic goal,” she says.

Antony suggests that before making a recommendation, PTs should perform a home evaluation. Conditions at the hospital or rehab facility can be very different from conditions in the patient’s home, and “what [the patient] tells you and what’s real can be two different things, especially if the patient really wants to go home,” she says.

When making a discharge recommendation, PTs should make sure they’re dealing with the primary family member the patient has selected to help make decisions. Just because one relative is more vocal in a care plan meeting doesn’t mean they are the decision maker, Antony says.

Other factors to consider when deciding upon the best discharge option for a patient include looking at how much time the patient will be alone, determining what kind of support system is available, and examining the patient’s ability to cook, shop, perform ADLs, and manage his or her own finances. When patients need more than 20 hours per week of help, Antony starts to look at other options than home.

Personal experience can be helpful, but there are limitations: In addition to her professional work, Antony cares for her own elderly parents, and finds her PT background helpful in negotiating the healthcare system. But being a PT isn’t a panacea for caring for her elderly parents. “My parents don’t listen to a thing I say unless I hire someone to say it,” she says.