Essential Competencies in the Care of Older Adults at the

Academy of Geriatric Physical Therapy

Essential Competencies

in the Care of Older Adults

at the Completion of the

Entry-level

Physical Therapist

Professional Program of Study

Essential Competencies in the Care of Older Adults

nticipating an impending health care crisis, the Institute

of Medicine charged its Committee on the Future Health

Care Workforce for Older Americans to determine the

health care needs of Americans over 65 years of age and to

analyze the forces that shape the health care workforce for

these individuals. The resulting 2008 report, Retooling for an

Aging America: Building the Health Care Workforce,

noted

that as the number of older adults grows to comprise almost

20% of the population in the U.S., they will face a health

care workforce that is too small and critically unprepared to

meet their health needs. The most recent analysis of practice

in physical therapy conrms that 40%- 43% of patient care

activity of physical therapists across a wide variety of

practice settings are for individuals 66 years of age or older.

One action taken as a result of the Retooling for an Aging

America report was the formation of the Partnership for

Health in Aging (PHA) by the American Geriatrics Society.

A PHA workgroup comprised of 10 health care disciplines,

including physical therapy, developed a set of overarching

multidisciplinary competencies in the care of older adults

across six different domains of practice.

Each competency

is deemed essential for practitioners to achieve by the

completion of an entry-level health professional program

of study. The Academy of Geriatric Physical Therapy of

the American Physical Therapy Association (APTA) was

involved with the development of these PHA overarching

multidisciplinary competencies. The competencies have been

endorsed by 28 national organizations, including the APTA

(in May of 2010).

The Partnership for Health in Aging expects each

professional group to individualize the overarching

competencies to elucidate the specic skills representing

competence in their eld. A Taskforce of the Academy of

Geriatric Physical Therapy, using the PHA document as a

framework, identied specic statements (we’ve termed

‘subcompetencies’) that clarify the skills essential for a

physical therapist to provide competent physical therapy

care to older adults within each domain and for each

PHA competency.

Academy of Geriatric Physical Therapy taskforce members,

all experienced educators with substantial expertise in

geriatric physical therapy, developed an initial list of

subcompetencies; rst, working in pairs and then as a

committee of the whole. Review and revisions continued

until all taskforce members agreed on all subcompetency

statements. The resultant rst draft document was brought

to the 2011 Combined Sections Meeting of APTA where

a group of 35 physical therapist volunteers attending the

convention participated in a validation activity, providing

feedback on the content and face validity of the document.

Further revisions were made based on this participant

feedback. The revised second draft document was circulated

via e-mail to each individual who attended the validation

activity. Their feedback was incorporated into the nal

review by the Taskforce. Final taskforce consensus and

approval of the Essential Competencies in the Care of

Older Adults at the Completion of the Entry-level Physical

Therapist Professional Program of Study document was

achieved in May 2011 and then prepared for distribution

to our membership. The following document represents

the nal work of this Taskforce. The Academy of Geriatric

Physical Therapy strongly encourages accredited physical

therapist educational programs to assure that their graduates

demonstrate competence in each of the competencies

described below.

Taskforce Members are:

Rita Wong, PT, EdD, (Taskforce Chair)

Marymount University, VA;

Dale Avers, PT, DPT, PhD,

SUNY Upstate Medical University, NY;

John Barr, PT, PhD,

St Ambrose University, IA;

Cathy Ciolek, PT, DPT, GCS,

University of Delaware, DE;

Dennis Klima, PT, PhD, GCS, NCS,

University of Maryland Eastern Shore, MD;

Mary Thompson, Ph.D, PT, GCS,

Texas Woman’s University, TX

References:

1. Institute of Medicine. Retooling for an Aging America:

Building the Health Care Workforce, 2008.

http://www.iom.edu/Reports/2008/Retooling-for-an-

Aging-America-Building-the-Health-Care-Workforce.

aspx

2. Knapp D, Russell T, Byrum C, Waters S. Entry-Level

Practice Analysis Update for Physical Therapist Licensure

Examinations Offered by the Federation of State Boards

of Physical Therapy. Prepared for: Federation of State

Boards of Physical Therapy (FSBPT), Alexandria, VA,

2007, pg 21 and 23.

http://www.fsbpt.org/download/PA2006_PTFinal

Report20070214.pdf

3. Multidisciplinary Competencies in the Care of Older

Adults at the Completion of the Entry-level Health

Professional Degree.

http://www.americangeriatrics.org/les/documents/

health_care_pros/PHA_Multidisc_Competencies.pdf

Continued on next page

Essential Competencies in the Care of Older Adults

DOMAIN 1: Health Promotion and Safety

A. Advocate to older adults and their caregivers about

interventions and behaviors that promote physical and

mental health, nutrition, function, safety, social interactions,

independence, and quality of life.

1. Identify and apply best available evidence to advocate

to older adults and caregivers about interventions and

behaviors that promote physical and mental health,

nutrition, function, safety, social interactions, independence,

and quality of life across domains and care delivery settings.

2. Value the advocacy role of the physical therapist in

promoting the health and safety of older adults.

B. Identify and inform older adults and their caregivers about

evidence-based approaches to screening, immunizations,

health promotion, and disease prevention.

1. Translate best available evidence about screening,

immunizations, health promotion, and disease prevention

to patient/client/caregiver(s) in a culturally appropriate

manner using health literacy principles.

2. Implement disease prevention, health promotion, tness

and/or wellness education programs that incorporate best

available evidence targeted to older adults and their

caregivers.

C. Assessspecicrisksandbarrierstoolderadultsafety,

including falls, elder mistreatment, and other risks in

community, home, and care environments

1. Perform health, tness and wellness screens (e.g., screens

for fall risk, elder mistreatment, environmental hazards)

that identify older adults at risk of injury.

D. Recognize the principles and practices of safe, appropriate,

and effective medication use in older adults.

1. Locate best up-to-date medication resources clarifying

common uses, side-effects, and signs and symptoms of

under and over dosing of prescription and non-prescription

medications commonly used by older adults.

2. Discuss common pharmacokinetic factors that should be

considered when providing physical therapy interventions

to older adults.

3. Describe the inuence of age and polypharmacy on

pharmacokinetics and drug interactions.

E. Apply knowledge of the indications and contraindications

for, risks of, and alternatives to the use of physical and

pharmacological restraints with older adults.

1. Dene physical and chemical restraints as they relate to

physical therapist practice.

2. Identify regulatory agencies responsible for monitoring and

enforcing restraint policies across health care settings.

3. Cite evidence that validates the impact of physical and

chemical restraint use on the restrained individual, the

restrained individual’s caregiver(s), and society.

4. Describe and advocate alternatives to physical and chemical

restraint use that are safe and least restrictive (e.g.,

positioning devices, enabling devices, environmental

adaptation, caregiver/careworker supervision or

intervention).

DOMAIN 2: Evaluation and Assessment

A. Denethepurposeandcomponentsofaninterdisciplinary,

comprehensive geriatric assessment and the roles individual

disciplines play in conducting and interpreting a

comprehensive geriatric assessment.

1. Describe the concept of, and various formats for,

interdisciplinary, comprehensive geriatric assessment

and explain the benet of this approach over single

discipline assessment for complex older adults.

2. Describe the role and contributions of each member of

a typical comprehensive geriatric assessment team (such

as geriatrician, geriatric nurse practitioner, pharmacist,

physical therapist, social worker, case manager, occupational

therapy, speech therapy).

3. Explain the role of the physical therapist as the movement

specialist on the geriatric assessment team.

B. Apply knowledge of the biological, physical, cognitive,

psychological, and social changes commonly associated

with aging.

1. Incorporate knowledge of normal biological aging across

physiological systems, effects of common diseases, and the

effects of inactivity when interpreting examination ndings

and establishing intervention plans for aging individuals.

2. Describe, identify, and appropriately respond to normal

biological changes of somatosensation and the special

senses that commonly occur with aging and as a result of

diseases common in older adults.

3. Interpret a patient/client’s behavior within the context

of various psychological and social theories of aging;

selecting appropriate action including referral.

4. Recognize the differences between typical, atypical, and

optimal aging with regards to all systems; develop

appropriate recommendations to reect the person’s goals,

needs, and environment.

C. Choose, administer, and interpret a validated and reliable

tool/instrument appropriate for use with a given older

adult to assess: a) cognition, b) mood, c) physical function,

d) nutrition and e) pain.

1. Select and administer valid and reliable tests for cognition

and depression (e.g., MMSE, Geriatric Depression Scale,

Clock Drawing Test); and determine need for referral.

2. Administrate and interpret functional tests that can

identify risk for falling and mobility decits (e.g., Berg

Balance Scale, Timed Up and Go, Timed Walk Tests, Gait

Speed, Balance Condence scales); communicating the

ndings, and making recommendations to the health

care team.

3. Objectively assess pain in any older person regardless of

cognitive or communication abilities.

4. Administer a basic nutritional assessment including key

questions regarding protein, calcium, Vitamin D, and

uid intake; taking appropriate action as indicated

including referral.

Domain 2 continued on next page

Essential Competencies in the Care of Older Adults

DOMAIN 2: continued from previous page

D. Demonstrate knowledge of the signs and symptoms of

delirium and whom to notify if an older adult exhibits

these signs and symptoms.

1. Differentiate between depression, delirium, and dementia

based on presentation and related conditions; and refer

as appropriate.

E. Develop verbal and nonverbal communication strategies to

overcome potential sensory, language, and cognitive

limitations in older adults.

1. Identify and assess barriers to communication (e.g., hearing

and/or sight impairments, speech difculties, aphasia,

limited health literacy, cognitive disorders).

2. Analyze how patient/client attributes and limitations,

health care professional and family attitudes, and societal

and cultural perspectives may impact communication

during the rehabilitation process.

3. Modify communication, including the use of adaptive

equipment, to deliver effective patient management for

older adults with depression, dementia, anxiety, or for older

adults who are in bereavement.

4. Develop alternative communication methods to deliver

effective patient management for older adults with limited

health literacy, hearing, sight impairments, or speech

difculties.

5. Consult other disciplines and make referrals where

appropriate.

DOMAIN 3: Care Planning and Coordination

Across the Care Spectrum (Including End-of-

Life Care)

A. Develop treatment plans based on best evidence and on

person-centered and person-directed care goals.

1. Develop evidence-based and patient-centered physical

therapy interventions for conditions commonly

encountered with older adults, utilizing enablement-

disablement frameworks, emphasizing functional

movement, and considering principles of optimal aging

across physiological systems:

a. Musculoskeletal (e.g., osteoarthritis, spinal stenosis,

spinal disc disease, fractures, joint arthroplasty,

amputation, disuse atrophy, incontinence).

b. Neuromotor (e.g., stroke, Parkinson’s disease,

Alzheimer’s disease, DJD with spinal nerve compression

injuries, vestibular disorder).

c. Cardiopulmonary (e.g., post-myocardial infarction,

post-coronary artery bypass surgery, cardiomyopathy,

COPD, pneumonia, aerobic deconditioning).

d. Integumentary (e.g., cellulitis, pressure ulcers, vascular

insufciency ulcers, lymphedema, burns).

2. Develop evidence-based prevention and risk reduction

programs for conditions prevalent in older adults ( e.g.,

skeletal demineralization, sarcopenia, exibility restrictions,

falls, cardiopulmonary disorders, impaired integumentary

integrity, postural decits).

3. Develop a plan of care for the physical therapy

management of patients/clients with complex medical

proles (e.g., frailty, heart failure, mechanical ventilation

dependency, multiple chronic health conditions, dementia,

malignant neoplasm, multiple traumatic injuries).

4. Adapt plan of care to address disabling psychosocial factors

(e.g., depression, learned helplessness, anxiety, fear of falling).

B. Evaluate clinical situations where standard treatment

recommendations, based on best evidence, should be

 modiedwithregardtoolderadults’preferences&

treatment/care goals, life expectancy, co-morbid conditions,

and/or functional status.

1. Synthesize and recommend intervention modications

based upon patient/client values and lifestyle, life

expectancy, co-morbid conditions, pharmacological prole,

lab values, domicile setting, and nancial resources.

2. Suggest environmental modications to the clinical practice

settings that better meet the needs of older adult (e.g.,

equipment adaptations, privacy, lighting, climate control,

accessibility).

C. Developadvancedcareplansbasedonolderadults’

preferences and treatment/care goals, and their physical,

psychological, social, and spiritual needs.

1. Dene advance directives and discuss implications for

physical therapy management.

2. Develop physical therapy plan of care for older adults

receiving end-of-life care which integrates the:

a. Patient/client goals

b. Treatment setting

c. Functional and palliative needs of the patient/client

D. Recognize the need for continuity of treatment and

communication across the spectrum of services and during

transitions between care settings, utilizing information

technology where appropriate and available.

1. Identify methods used to communicate among health care

professionals regarding the status and well-being of

geriatric clients (e.g., team meetings, electronic

documentation and review of medical records, discharge

summaries, falls surveillance tools, community

visit sessions).

2. Identify relevant evidence/literature guiding best practice

regarding continuity of treatment across services and

during transitions between care settings.

3. Value continuity of treatment across services and during

transitions between care settings.

Continued on next page

Essential Competencies in the Care of Older Adults

DOMAIN 4: Interdisciplinary and Team Care

A. Distinguish among, refer to, and/or consult with any of the

multiple healthcare professionals and providers who work

with older adults, to achieve positive outcomes.

1. Differentiate and choose appropriate healthcare

professional or provider for referral or consultation to best

meet the specic needs of an older adult.

2. Communicate appropriately and in a timely manner

with each individual provider the reason for referral or

consultation.

3. Provide consultation within the scope of practice of the

physical therapist.

B. Communicate and collaborate with older adults, their

caregivers, healthcare professionals, and direct care workers

 toincorporatediscipline-specicinformationintooverall

team care planning and implementation.

1. Select, prioritize, and communicate essential physical

therapy ndings to contribute to a team care plan.

2. Adapt communication to accommodate learning styles

and cultural, social, and educational perspectives and

stressors effecting:

a. Older adults

b. Caregivers

c. Healthcare providers

d. Direct care workers

DOMAIN 5: Caregiver Support

A. Assess caregiver knowledge and expectations of the impact

of advanced age and disease on health needs, risks, and the

unique manifestations and treatment of health conditions.

1. Effectively assess caregiver knowledge and perceptions

of the functional impact of advanced age and health

conditions on optimal aging.

2. Determine caregiver expectations of the health needs of

his or her patient/client/family member; and caregiver

ability to recognize and manage manifestations of the

patient’s common health conditions.

3. Communicate with caregivers in a culturally competent and

age-appropriate manner.

B. Assist caregivers to identify, access, and utilize specialized

products, professional services, and support groups that

can assist with care-giving responsibilities and reduce

caregiver burden.

1. Assess caregiver and patient goals for the care-giving

relationship, identify potential areas for conict, and refer

to other providers as appropriate.

2. Analyze needs and recommend products, services,

and support systems to provide ADL and IADL assistance,

considering individual needs of the patient and caregiver,

with sensitivity to resource constraints.

3. Advocate for caregiver access to appropriate services and

products that reduce caregiver burden and support

effective care.

C. Know how to access and explain the availability and

effectiveness of resources for older adults and caregivers that

help them [the patient] meet personal goals, maximize

function, maintain independence, and live in their preferred

and/or least restrictive environment.

1. Identify options for least restrictive environment that

maximizes physical functional ability and independence.

2. Educate caregiver in accessing and using resources for

optimal functioning in least restrictive manner.

D. Evaluate the continued appropriateness of care plans and

 servicesbasedonolderadults’andcaregivers’changesin

age, health status, and function; assist caregivers in altering

plans and actions as needed.

1. Monitor and adjust the plan of care in response to

changes in the patient, caregiver capacity, or care-giving

environment.

DOMAIN6:HealthcareSystemsandBenets

A. Serve as an advocate for older adults and caregivers within

various healthcare systems and settings.

1. Take history and ask questions regarding unmet needs of

older adults and caregivers.

2. Assist in obtaining needed services through referral or

consultation to facilitate optimal functioning of the

patient/client.

3. Provide information on best practice/evidence-based

practice to older adults, caregivers, colleagues, and

health care providers and agencies.

B. Know how to access, and share with older adults and their

 caregivers,informationaboutthehealthcarebenetsof

 programssuchasMedicare,Medicaid,Veteran’sServices,

Social Security, and other public programs.

1. Describe the various public programs for healthcare

available to older adults and the physical therapy services

available within each (e.g., Medicare, Medicaid, Veterans

Services, Social Security).

2. Utilize information technology to obtain information on

eligibility for services; effectively communicate these

resources with older adults and caregivers; and/or refer

patient to appropriate healthcare professional/social

services as indicated.

C. Provide information to older adults and their caregivers

about the continuum of long-term care services and

supports -

such as community resources, home care, assisted living

facilities, hospitals, nursing facilities, sub-acute care

facilities, and hospice care.

1. Discuss appropriate care settings available to extend

geriatric rehabilitation services (e.g., sub-acute rehabilitation,

home health care, skilled nursing facilities, assisted living

centers, senior centers, hospice care).

2. Identify resources available to facilitate community-

dwelling older adults’ ability to live independently (e.g.,

meal delivery, home care resources, social services,

electronic alert devices, community support groups,

transportation services, home modications, adaptive

equipment).