12 CHAPTER 1 Geriatric Physical Therapy in the 21st Century enough of the variance to be clinically useful.Under s are ular co for prognosis ange in di typically statistical analyses to evaluate the relative impact of one GRC scale during an exercise intervention.Thus,using the pts 器罗 be both s fndings (6MWT to he ne for the outhat are deemed starisicallye and pro community-dwelling older adult. the e many tools that do not have an establishe re dence that would be criti appraising a stud fo of ch ange represof ch deemed statisticall significant should be further evalu- one group versus amount of change in the comparison group)and make a clinical judgment, ased or expe ng mus onstrate statistically understanding of the co ition,abo ces d tha al assume clinical importance.An outcome deemed to Systematic Reviews.The purpose of a systematic repres ent a statistically significant improvement may, review is to aggregate the finding across studies to nonetheless a sma ct on the patien provide bout the streng amount nty the 0P (MCID A rep ents the smallest amount of cha deemed being reviewed in the svstematic review is based on the quality level of each included article as well as thee me tools,an ize nitud of the change the be cores res). ize may be cal A common approach for establishing a tool's MCID sized by the authors. or quantitatively ted link the patient's reported staten ent of outcome through a meta-analysis into with change in a too rived effect size across all studies. or a vana an er ect s ary es.The GRC is a 15-point rank-ordered scale A commonly applied rule of thumb is that with-7representing"a very great deal worse"0 repre ang no hang epresenting "a very grea ；and more than 0.8,a large effect n o calc izes likel been used to link the amount of change on the 6-minute across the p walk test (6MWT)and patient-reported outcomes of change;in community dwe e adults,a 20-m the strength of the recommendations can increase in distance ring the 6Mw I represents B0X1-3 Tool,as a very great deal better almost the same,hardly any worse at all deal bette 十4 a little hett -6 =almost the same,hardly any better at all -7=a very great deal worse =no change
12 CHAPTER 1 Geriatric Physical Therapy in the 21st Century Common Descriptors Used for Each of 15 Possible Responses to Patient-Reported Outcomes Using a Global Rating of Change Tool, as Described by Jaeschke et al.21 enough of the variance to be clinically useful. Underpowered studies are of particular concern for prognosis studies of adults aged 75 years and older. Therapy Studies. Therapy studies typically use statistical analyses to evaluate the relative impact of one or more interventions within or across groups of subjects. The concepts of statistical significance and clinical importance both need to be examined in assessing the findings of a study. Differences between or among groups that are deemed statistically significant are considered real, that is, not occurring by chance, and provide a reasonable level of confidence that similar outcomes would be obtained for comparable groups receiving comparable interventions. Only findings deemed statistically significant should be further evaluated for clinical importance. Although a finding must demonstrate statistically significant differences to be further evaluated for clinical importance, statistical significance alone does not assume clinical importance. An outcome deemed to represent a statistically significant improvement may, nonetheless, have such a small impact on the patient that the amount of change is clinically unimportant. The term minimum clinically important difference (MCID) represents the smallest amount of change deemed clinically important for the patient. An MCID has been established for many commonly used outcome tools, and the number of tools with established MCID scores is growing annually. A common approach for establishing a tool’s MCID is to link the patient’s reported statement of outcome with the amount of change obtained in a tool. The Global Rating of Change (GRC) tool,21 or a variation of it, is often used as an anchor for patient-reported outcomes. The GRC is a 15-point rank-ordered scale, with –7 representing “a very great deal worse”; 0 representing “no change”; and 17 representing “a very great deal better.” Box 1-3 lists all descriptors commonly used as labels across this scale. For example, this tool has been used to link the amount of change on the 6-minute walk test (6MWT) and patient-reported outcomes of change; in community-dwelling older adults, a 20-m increase in distance walked during the 6MWT represents a small but clinically meaningful improvement.22 This MCID was established from the average change in distance walked for patients who reported their improvements as 2 (a little better) or 3 (somewhat better) on the GRC scale during an exercise intervention. Thus, using the MCID of 20 m on the 6MWT as an example, the finding of a study must be both statistically significant AND demonstrate a change of at least 20 m on the (6MWT) to be deemed clinically important for the community-dwelling older adult. For the many tools that do not have an established MCID, the person critically appraising a study would simply identify the amount of change represented in the study (pretest to posttest change; or amount of change in one group versus amount of change in the comparison group) and make a clinical judgment, based on experience and an understanding of the condition, about the likelihood that the amount of reported change would be clinically meaningful to the patient. Systematic Reviews. The purpose of a systematic review is to aggregate the findings across studies to provide a recommendation about the “strength” (certainty) of the body of evidence on a given topic. The strength of the recommendation for each outcome being reviewed in the systematic review is based on the quality level of each included article as well as the effect size (magnitude of the change or the correlation of scores). Effect size may be calculated for each individual article and then descriptively discussed and synthesized by the authors, or quantitatively aggregated through a meta-analysis into one mathematically derived effect size across all studies. The specific metaanalysis used to calculate an effect size will vary based on the statistical analyses performed in the original studies. A commonly applied rule of thumb is that an effect size of at least 0.2 represents a small effect; 0.5, a medium effect; and more than 0.8, a large effect. A confidence interval is also calculated with the metaanalysis, which provides a range of effect sizes likely across the population. Many grading schemes are available to categorize the strength of the recommendations that one can draw from a systematic review. Some are fairly elaborate 17 5 a very great deal better 16 5 a great deal better 15 5 a good deal better 14 5 moderately better 13 5 somewhat better 12 5 a little better 11 5 almost the same, hardly any better at all 0 5 no change 21 5 almost the same, hardly any worse at all 22 5 a little worse 23 5 somewhat worse 24 5 moderately worse 25 5 a good deal worse 26 5 a great deal worse 27 5 a very great deal worse BOX 1-3
CHAPTER 1 Geriatric Physical Therapy in the 21st Century 13 pro the eralizability .h the exclusion criteria include rization of evidence to qualify the recommendations the findings to.It is fairly common for studies to exclude nerocohthefind subjects older than age 70 or 75 years,those with com ings of the systematic review provided good,fair,eak monly occurring comorbid conditions,or individuals wh everyone wh draw any conclusions from a study involvin se?In a g ofolder adult Applicability to a Specific Patient.Although examining this requirement would likely exclude at least half of the a study for the applicability of the hndings of the study to es.Consider the ity of the subiects of the study and the clinicale The te specific patients and clin r this que n an ho chose to participatein the stu dy should he Are these subjects reasonably similar to the patient spur uggest that the aim of an efficacy study is to determin ring the clinician's search for evidence?Or are the ces too arge to apply the nce deal pat nt,is th sary to apply the findings of the to your clinical world?Is this feasible?If the conclusion is typical patients including all their variability ular clinic, the studies are particularly applicable to every physica day practice an are worthy c smade that the ed f likely differ between the current cohort of older adults (on which cur refe h approach is required or for dults.Muc de of the curren evidenc stu he cap. lity or the equipment to pro 040 The olde Generalizing findings across broad groups of olde same older adult we anticipate in the next 20 vears.Baby adults can be particularly difficult in geriatrics.As stated boomers are approaching old age with a different per tieialteradhssagropaeewaordnalyaiabl spective and set of experie ices with s must ess w prior the are the confounding factors to mask real change.However. conditions and increased the likelihood of other condi the greater the number of exclusion criteria,the narrower tions associated with a longer life span. B0X1-4 One F rk for Ass mendations Emerging from a Systematic Review gth to Reco Good evidence n any im ortant v Fair evidence ings fro applicability Alth is support for the rec endation,there is a Weak evidence bly cons stent findings from primarily foundational studie
CHAPTER 1 Geriatric Physical Therapy in the 21st Century 13 ranking systems and others fairly simple. Box 1-4 provides this author’s suggestion for a simple and useful categorization of evidence to qualify the recommendations. Using this system, a reviewer could conclude that the findings of the systematic review provided good, fair, or weak evidence to support or refute an outcome, or one could conclude that there is insufficient evidence to allow one to draw any conclusions. Applicability to a Specific Patient. Although examining a study for the applicability of the findings of the study to particular patients is very straightforward, it is a step that is often forgotten. A thoughtful comparison of the similarity of the subjects of the study and the clinical environment in which the care is delivered to the target conditions of specific patients and clinical environment will allow you to answer this question. The inclusion and exclusion criteria for a study as well as the general characteristics of subjects who chose to participate in the study should be reviewed. Are these subjects reasonably similar to the patient spurring the clinician’s search for evidence? Or are the differences too large to apply the findings with confidence? What equipment, specialized knowledge, or availability of resources was necessary to apply the findings of the study to your clinical world? Is this feasible? If the conclusion is that the approach is not feasible in a particular clinic, the physical therapist should continue to look for alternative approaches with similar outcomes. If, indeed, a determination is made that the outcomes achieved from this approach are far superior to the alternatives available at your clinic, then a mechanism should be adopted to either refer the patient out when this approach is required or for the clinic to obtain the capability or the equipment to provide the approach. Generalizing findings across broad groups of older adults can be particularly difficult in geriatrics. As stated earlier, older adults as a group are extraordinarily variable. Researchers must balance inclusiveness with homogeneity. The more homogeneous the subjects in a study, the fewer are the confounding factors to mask real change. However, the greater the number of exclusion criteria, the narrower the generalizability. Often, the exclusion criteria include those patients the clinician is most interested in applying the findings to. It is fairly common for studies to exclude subjects older than age 70 or 75 years, those with commonly occurring comorbid conditions, or individuals who have any cognitive impairment. Was everyone who had heart disease, diabetes, or high blood pressure excluded from a study involving exercise? In a group of older adults, this requirement would likely exclude at least half of the patients treated in physical therapy practices. Consider the impact of the exclusion criteria on the ability to apply the findings to your typical patient world. The terms efficacy and effectiveness are frequently used to describe the aim of a study, particularly an intervention study. These terms give you a clue to the expectations of the researchers about the generalizability of the findings. The terms, commonly used in conjunction with the four levels of clinical trials as described by NIH, suggest that the aim of an efficacy study is to determine if a given intervention can work. Meaning, given an ideal situation and ideal patient, is the intervention successful? An effectiveness study is one that aims to determine if the intervention will work in the typical clinical world with typical patients including all their variability. Effectiveness studies are particularly applicable to everyday clinical practice and, therefore, are worthy of particularly close review and consideration. A challenge, and reality check, is the likely differences between the current cohort of older adults (on which current research is based) and the next generation of older adults. Much of the current evidence is based on studies that emerged from landmark investigations completed 20 to 40 years ago. The older adult of prior years is not the same older adult we anticipate in the next 20 years. Baby boomers are approaching old age with a different perspective and set of experiences with physical activity and exercise than prior generations of older adults. Medical science has decreased the impact of many chronic health conditions and increased the likelihood of other conditions associated with a longer life span. Good evidence Reasonably consistent findings from several high-quality definitive studies of clinical applicability. Unlikely that further research will change the recommendation in any important way. Fair evidence Reasonably consistent findings from several moderate-quality studies (initial studies evaluating foundational concepts) or one definitive study of clinical applicability. Although there is support for the recommendation, there is a reasonable possibility that further research will modify the recommendation in some important way. Weak evidence Reasonably consistent findings from primarily foundational studies with findings not yet rigorously tested on relevant patient groups. It is quite likely that further research will modify the recommendation in some important way. Inconclusive evidence There is insufficient or markedly conflicting evidence that does not allow a recommendation to be made for or against the intervention. BOX 1-4 One Framework for Assigning Strength to Recommendations Emerging from a Systematic Review
CHAPTER 1 Geriatric Physical Therapy in the 21st Century PATIENT-CLIENT PREFERENCES AND MOTIVATIONS f en moi s physical appea Patient-client preference and motivation is the third A80 information stream making up evidence-based(evidence- aho not be described as old by those around her,whereas The the expertis ms hared and b als and in likely to be perceived and tions.Patient autonomy is grounded in the principle that Age bias,a negative perception of older adults based their re. ency for he set in a met provi be oward ol of 43 than younger adults to make decisions about their health toward younger people.The subtle negative attitudes and rehabilitation.The reality of clinical practice is that inte wid ty of c more obvious and ir atient a (and familv/caretakers.as appr poo ropriate)have all pertinent make therapy-related health care t rm: on s share 0 racteristics in a study ld the nd th nch tial risks.benefits.and harms amount of effort and tient receiving rehabilitation postamputation.Howeve compliance associated with the various options;and the multiple variations of this core scenario were presented likely prognosis. The uld ha d patient to expres or fe 11 has heard them accurarely and without bias.Thegoals (2)depressed,or (3)nor and preferences of the older adult patient may be very rom what physical therapis csaia eve t physical therapy is creatively addressing the tient' the scenario describing an old patient demonstra using appropriate evidence,clinical skills,and more negative attitudes than those responding to the available resources. scenario d n th care setting. THE INFLUENCE OF AGEISM 06e and less The perception of someone as being old or geriatric is making a human connection with the patient.2 Age been identified as a reason for undertreating older ent rew bas nd tha groups lation h which a as old.However,the age of the survey Typically,physical therapists are drawn to the profes Kespondents un by a strong desire to help peopl n a very tangib <n ine low potential for imp beginning of old age;and those older than age 64 years Stereotypes about older adults inaccurately he e typic age ed and perma noncompl ant an identified by medical n others Many interactions with physical thera ing individuals as old. at very vulnerable points in an older adult's life.For
14 CHAPTER 1 Geriatric Physical Therapy in the 21st Century PATIENT-CLIENT PREFERENCES AND MOTIVATIONS Patient-client preference and motivation is the third information stream making up evidence-based (evidenceinformed) practice. The scientific evidence and the expertise of the practitioner are combined with the preferences and motivations of the patient to reach a shared and informed decision about goals and interventions. Patient autonomy is grounded in the principle that patients have the right to make their own decisions about their health care. There is a tendency for health care providers to behave paternalistically toward older adult patients, assuming these patients are less capable than younger adults to make decisions about their health and rehabilitation. The reality of clinical practice is that physical therapists encounter a wide variety of decisionmaking capabilities in their older adult patients. Physical therapists have a responsibility to ensure their patients (and family/caretakers, as appropriate) have all pertinent information needed to make therapy-related health care decisions, and that this information is shared in a manner that is understandable to the patient and free of clinician bias. The patient should understand the potential risks, benefits, and harms; amount of effort and compliance associated with the various options; and the likely prognosis. Patients should have the opportunity to express their preferences and be satisfied that the practitioner has heard them accurately and without bias. The goals and preferences of the older adult patient may be very different from what the physical therapist assumes (or believe they would want for themselves under similar circumstances). Part of the “art” of physical therapy is creatively addressing the patient’s goals using appropriate evidence, clinical skills, and available resources. THE INFLUENCE OF AGEISM The perception of someone as being old or geriatric is a social construct that can differ greatly among cultures and social groups. A recent Pew Foundation survey23 found that, on average, a representative sample of the U.S. population perceives age 68 years as the age at which a person crosses the threshold to be classified as old. However, the age of the survey respondent influenced perceptions: Respondents under the age of 30 years identified old age as starting at 60 years; those between 30 and 64 years indicated 70 years as the beginning of old age; and those older than age 64 years indicated that old age starts at 74 years. The age of 65 years, which is the typical age when individuals in the United States become eligible for Medicare, is probably the most common age identified by medical researchers and social policy advocates when categorizing individuals as old. In reality, perceiving a specific individual as old is often more associated with the person’s physical appearance and health status than his or her chronological age. An 80-year-old who is independent, fit, and healthy may not be described as old by those around her, whereas a 60-year-old who is unfit, has multiple chronic health problems, and needs help with daily activities that are physically challenging is likely to be perceived and described as old. Age bias, a negative perception of older adults based on their age alone, is endemic in Western culture, including health care settings.24 Kite and Johnson,25 in a metaanalysis of 43 studies on age bias, concluded that attitudes toward older people are more negative than toward younger people. The subtle negative attitudes toward older adults that are often identified among health care practitioners become more obvious and influential when old age is combined with a perception of the patient as having low motivation, poor compliance, or poor prognosis. Rybarczyk et al25a considered age plus other patient characteristics in a study of bias in nearly 1000 rehabilitation professionals, including physical therapists. One core clinical scenario was developed representing a patient receiving rehabilitation postamputation. However, multiple variations of this core scenario were presented. The identically involved patient was either young or old and further divided into male or female. The young or old patient was (1) ideally motivated and cooperative with rehabilitation, (2) depressed, or (3) noncompliant. The study found little age bias when the ideally motivated old patient was compared to the ideally motivated young patient. However, when two noncompliant or depressed patients were compared, those responding to the scenario describing an old patient demonstrated more negative attitudes than those responding to the scenario describing a young patient. In the hectic and often stressful acute care setting, nurses admit that older patients are often marginalized with their needs given lower priority, and less time spent making a human connection with the patient.26 Age bias has been identified as a reason for undertreating older adults with cancer based on unsupported assumptions that treatments are unsafe for the older adult, or at times, despite evidence supporting the use of the intervention for older adults.24,27,28 Typically, physical therapists are drawn to the profession by a strong desire to help people in a very tangible and interactive way, often expressing low interest in patients they perceive as having low potential for improvement.29,30 Stereotypes about older adults inaccurately suggest that, as a group, older adults have low potential for improvement, are unmotivated, noncompliant and set in their ways, confused, and permanently dependent on others. Many interactions with physical therapists occur at very vulnerable points in an older adult’s life. For
CHAPTER 1 Geriatric Physical Therapy in the 21st Century 15 enificant ilness:in a skilled nursing facility for reha- ation of the patient's goals,and objective (unbiased)as bilitation after hip fracture or knee replacement;or in sessment and communication of the likely efforts required back udepartment during a disabline oking to meet those goals will help reduce stereotyping. making SUMMARY The key principles underlying contemporary geriatric rehabilitation.It is true that some older physica therapy practice describe d in this ppery be particularly challer given prior functional mitted to c and ready t leveheindividua tomkoec e they want to place their efforts in the stanti energy reserves their paticnts enging tim of op older patients,appropriately aggressive physical therapy therapists et ageist stereotypes inl among th underestimate rior functional ability of individuals and phasizin the clinical relevance of the material in this book REFERENCES Hausdorff et al in a study examining the influer To enhance this text and add value for the reader all of ageist messages on older adults.found s references are included on the comnanion Evolve site ferences in gait arameters (gait speed and swing time)in &ommnirydwelhngolderadwlhseposedoanegatg that accompanies this text book.The reader can view the reference source and ing a er gener
CHAPTER 1 Geriatric Physical Therapy in the 21st Century 15 example, it is common to first evaluate an older adult in the midst of an acute hospitalization from a sudden and significant illness; in a skilled nursing facility for rehabilitation after hip fracture or knee replacement; or in the outpatient department during a disabling bout of back pain. When formulating a prognosis and making recommendations for the aggressiveness of interventions, it is easy to fall back on stereotypes suggesting old patients have low potential for improvement and low motivation for rehabilitation. It is true that some older adults enter physical therapy very low on the slippery slope of aging (frailty and failure stages). Rehabilitation may be particularly challenging given prior functional level, requiring the individual to make conscious decisions about where they want to place their efforts in the presence of substantially limited energy reserves; in which case goals not achievable through physical rehabilitation may guide their decisions. However, for most older patients, appropriately aggressive physical therapy can substantially affect functional ability and quality of life. Physical therapists who let ageist stereotypes influence their judgment are likely to make assumptions that underestimate prior functional ability of individuals and future potential for improvement. Do not let stereotypes cloud judgment about the capacity of older adults and the benefit to be achieved by appropriately aggressive rehabilitation. Hausdorff et al.,31 in a study examining the influence of ageist messages on older adults, found significant differences in gait parameters (gait speed and swing time) in community-dwelling older adults exposed to negative versus positive reinforcement of age stereotypes during a 30-minute interaction. In the clinical environment, most patients will look to the professional for guidance in the likely outcome of various therapies. Thorough consideration of the patient’s goals, and objective (unbiased) assessment and communication of the likely efforts required to meet those goals will help reduce stereotyping. SUMMARY The key principles underlying contemporary geriatric physical therapy practice described in this chapter are woven throughout the remainder of this book. The need is great and opportunities abound for talented physical therapists committed to optimal aging and ready to apply best evidence, fully develop their clinical expertise, and work collaboratively with their patients and other health care providers. It is a challenging time full of opportunity to be a geriatrically focused physical therapist. However, whether as a geriatrically focused physical therapist or simply a physical therapist who frequently/ occasionally treats older patients, the number and complexity of the older adult patients among the caseload of all physical therapists will increase in the decades to come, emphasizing the clinical relevance of the material in this book. REFERENCES To enhance this text and add value for the reader, all references are included on the companion Evolve site that accompanies this text book. The reader can view the reference source and access it online whenever possible. There are a total of 31 cited references and other general references for this chapter
CHAPTER 2 Implications of an Aging Population for Rehabilitation: Demography,Mortality,and Morbidity of Older Adults Andrew A.Guccione,PT,PhD,DPT,FAPTA or oler er oy d) en beyond phy during the past 60 years as a social problem of vast num- aging society whose members span a continuum across lth,infirmity,and death. h Thee of the n to their families and their communities:a g the data below Much of what wen th United States know in gerontology and geriatrics has been derived from two speci orts.The first coh ort was born h The purpose of this chapter is to review the sociode- arrived in America.Thus the initial m ence of mographic characteristics of older adults in American gerontological research in the 1970s is based largely on and vitality into ind that son is population of ol so,we determined ong be active and healthy,or as sick and frail,are neither in- correct nor contradictory,but more appropriately ond cohort,whose experiences define our current-day applied to only some segments of a heterogeneous rld wars and the Great Dep ion.Thus.whey or clients,each of us has ohysical,psychologi al.and we choose to explicate ag g and the status of n be ca older adults,be it their physical h ealth or social well- hto groups indi we mus o appreciate that wh at we unc are more likely to experience a p articular health the case necessarily what will be the norm in the future.As the adults of the post-World War II "baby boom begin to retire in 2011,we can expect that ge. progress in per pective, even some alter theories and geriatric to know the prevalence of a pnd-21st findings that (i.e.the number of cases of that condition in a popula- emerge from scientific study of this third and markedly tion)and its incidence(the number of new cases of a distinct cohort. 16 Copyright 2012.2000,1993 by Mosby,Inc.,an affiliate of Elsevier Inc
16 What are the implications of an increase in the number of older persons in American society, particularly as it affects rehabilitation specialists such as physical therapists? Some have portrayed the “graying” of America during the past 60 years as a social problem of vast numbers of resource-guzzling older adults who threaten to strip the health care system of its scarce resources. Others have portrayed this same group as a rich resource to their families and their communities: a group still very much engaged in life as healthy, active older adults. Is it possible that these two contrasting representations of America’s older persons refer to the same set of individuals? The purpose of this chapter is to review the sociodemographic characteristics of older adults in American society, then relate these factors to mortality and morbidity in this population. In doing so, we shall find that conflicting portrayals of older persons as active and healthy, or as sick and frail, are neither incorrect nor contradictory, but more appropriately applied to only some segments of a heterogeneous population. Although physical therapists implement interventions in a plan of care designed for individual patients or clients, each of us has physical, psychological, and social characteristics by which we can be categorized into groups. Knowing that individuals with certain characteristics—for example, being a particular age or sex—are more likely to experience a particular health problem can assist physical therapists in anticipating some clinical presentations, placing an individual’s progress in perspective, and even sometimes altering outcomes through preventive measures. It is also useful to know the prevalence of a particular condition (i.e., the number of cases of that condition in a population) and its incidence (the number of new cases of a condition in a population within a specified time period). Taken beyond examination of a single person, physical therapists can use this information to plan and develop services that will meet the needs of an aging society whose members span a continuum across health, infirmity, and death. There is one critical caveat to any of the inferences about aging or older persons that may be drawn from the data below. Much of what we in the United States know in gerontology and geriatrics has been derived from two specific cohorts. The first cohort was born near the end of the 19th century, many of them impoverished child immigrants or born into families recently arrived in America. Thus the initial emergence of gerontological research in the 1970s is based largely on these individuals whose early health and vitality into adulthood were determined long before the medical advances and economic prosperity that marked the “American Century.” Their children comprise the second cohort, whose experiences define our current-day understanding of aging. Geriatric and gerontological research in this group is also contextually situated in the defining events of the first half of the 20th century: two world wars and the Great Depression. Thus, whenever we choose to explicate aging and the status of older adults, be it their physical health or social wellbeing, we must also appreciate that what we understand is based on what either has been or is currently the case, not necessarily what will be the norm in the future. As the adults of the post–World War II “baby boom” begin to retire in 2011, we can expect that gerontological theories and geriatric practice—geriatric physical therapy included—will change markedly by mid–21st century to accommodate new findings that emerge from scientific study of this third and markedly distinct cohort. C H A P T E R 2 Implications of an Aging Population for Rehabilitation: Demography, Mortality, and Morbidity of Older Adults Andrew A. Guccione, PT, PhD, DPT, FAPTA Copyright © 2012, 2000, 1993 by Mosby, Inc., an affiliate of Elsevier Inc