By Donna Cifuni, PT, DPT, LSVT
Physical Therapist
NY Long Island

Here’s a scenario clinicians see all too often when their services come to an end.

John is an 85-year-old male with a history of falls and decreased lower extremity strength. John was receiving PT and OT services 4x/week from January – March of 2021 with a primary focus on balance and gait training. John had shown improvement over his course of treatment with an improved BERG score from 38/56 to 50/56, indicating a decreased falls risk. Since March, John’s caregivers admitted that John has not been consistent with his Home Exercise Program (HEP) and has had 4 falls over the last 3 months.

A patient makes tremendous progress with their physical and occupational therapy service and then a new referral comes in 3 months later with a notable decline. Why is this happening and how can clinicians prevent decline after our care wraps up?

Timing of HEP Education Makes A Difference

Carryover with a Home Exercise Program (HEP) leads to greater outcomes when it is provided early and can then be reviewed and progressed throughout the plan of care. For patients with cognitive impairment, early caregiver education on the HEP will also be integral to patient progress.

Home Exercise Programs should include exercises that are individual to the patient and their motivation levels. One study found that a group of patients over 65 years old were less likely to perform an exercise program that include 8 exercises as opposed to 2 exercises, for example.

Once the HEP is individualized for the patient, it is important for the clinician to follow up on compliance. A useful tool to gauge patient carryover is a weekly accountability calendar. This can be provided to the patient or caregiver and checked frequently by the therapist and reviewed to ensure that patient is performing their daily exercises. Patients and caregivers are more likely to “do their homework” if they know you will be checking in on their progress.

An earlier-provided HEP also presents an opportunity for expansion or growth. A patient who initially presents with weakness in bilateral lower extremities may be provided with a HEP that includes seated exercises. However, as this patient gets stronger and progresses to standing exercises with their PT or OT, they can now be provided with a more challenging HEP.

For older adults who have been exercising regularly, like with physical and occupational therapy, studies have shown up to a 25% muscle loss after injury and periods of inactivity over a two-week period. Educating patients on the risk of decline after discharge if they do not follow their exercise program may motivate these patients to participate more with their HEP.

Once a patient/caregiver makes a routine of performing their HEP when PT or OT is not present, it will be easier for this patient to continue with their HEP following discharge. Extra accountability calendars can be provided for patients to use when they conclude skilled services in an effort to keep up with their routine.

Home Safety Is Key to Reducing Falls

When inquiring about John’s falls, the caregiver noted that he tripped over his area rug when walking in his living room.

One of the main benefits to treating a patient in their home is being able to observe the environment in which they live. Patients can be educated on home modifications that will reduce their risk for falls.

A Home Safety Assessment can also be performed early in the plan of care to ensure that patients are as safe as possible when service ends to further reduce future injury.

A Vitals and Symptoms Journal Can Decrease Risk of Hospitalization

John reports occasional dizziness that requires him to sit down due to a feeling of unsteadiness.

Low blood pressure is a common cause of falls as well as reported feelings of dizziness or lightheadedness. Patients on multiple medications (polypharmacy) are placed at an increased risk for falls.

Some patients may also experience orthostatic hypotension—a drop in blood pressure when changing positions that is caused by the failure of blood vessels to constrict when the body becomes upright. Patients should be educated to take their time when changing positions from supine to sitting or sitting to standing. A patient who sits up, for example, should be educated to sit for a moment to allow their blood vessels to adjust to the change in position. Encouraging the patient to monitor their blood pressure before and after changing positions will also give the patient time to rest and to ensure their pressure is regulated before proceeding to stand and walk. This can reduce their risk of blood pressure dropping too quickly, and thus can reduce dizziness or risk for falls.

Patients can purchase electronic blood pressure monitors as well as pulse oximeters to keep track of their daily vitals. If the patient or caregiver notices any changes in blood pressure, heart rate, or oxygen percentage level, they should be informed to contact the patient’s primary physician to discuss the findings.

Other Options Available After Skilled Therapy

John’s caregiver reports they feel they will not be able to commit to John’s exercise program after discharge, but John has not shown progress on his goals in 2 weeks and would be appropriate for discharge at this time.

Some patients or caregivers may feel they are not ready to stop having someone there as a motivator during their exercise program. In this case, FOX’s physical and occupational therapists can offer private pay as an option. Private pay may be indicated when a patient is no longer eligible for skilled care but feels they may still find value in working with a clinician who provides assistance with exercises, balance activities, or ambulation compliance.

If the primary focus for a patient is to maintain their home exercise program, FOX also provides exercise physiologists for an out-of-pocket cost. Exercise physiologists can run through a patient’s home exercise program and maintain the patient’s current level of function.

Providing Community Resources for Patients Can Reduce a Sedentary Lifestyle

Many towns have community centers that offer recreational programs for older adults. The aim of these programs is to keep the patient engaged in the community. Some of these community centers or local libraries may also provide exercise classes such as Tai Chi or Chair Yoga to keep patients active. Some towns will also provide transportation via buses for older adults which can be found on the local town’s websites.

Silver Sneakers is another great program that offers in-person or online exercise classes for older adults. Many gyms and local malls participate with the Silver Sneakers program for exercise classes or walking programs.

More mobile patients can also join local walking clubs within their community which can create a network of friends and motivators to continue moving.

With Help From Clinicians, Patients Can Continue to Show Progress

With a combination of safety measures to reduce the risk for injury, education on HEP compliance, and resources for other exercise programs for patients, FOX can fight aging and promote aging in place.

At John’s three-month follow-up call, his caregiver states that he has been doing wonderfully! They have been performing his HEP 5 days a week. He has also been attending virtual Tai Chi classes. He has not had any falls since discharge.