Geriatric physiotherapy

In short

Geriatric physiotherapy is the assessment and management of movement, balance, strength and function in older adults (conventionally 60 years and above in India), where ageing changes, multiple diseases, polypharmacy and social circumstances interact. It matters because India's 60-plus population is roughly 10% now and is projected to be about 13-14% by 2031 (NSO *Elderly in India*), and because falls, fractures, immobility and frailty are the main preventable causes of dependence. It is examined in BPT clinical physiotherapy papers, in the geriatrics/community blocks, and in MPT entrance and recruitment tests; it is used daily in hospital geriatric and orthopaedic wards, ICU step-down, old age homes, home-care companies and corporate wellness. Employers test it through outcome measures and their cut-off scores, fall-risk reasoning and safe exercise prescription rather than through recall of anatomy.

Explained

Ageing physiology and its therapy consequences

• Muscle: loss of mass begins around 30 and accelerates after 60 (roughly 1-2% mass and 1.5-3% strength per year); type II (fast) fibres shrink most, so power falls faster than strength - and power, not strength, predicts stair climbing and fall recovery.
• Bone: oestrogen fall after menopause causes rapid bone loss; cortical thinning and trabecular loss give osteoporosis, so a minor fall becomes a hip or Colles fracture.
• Joints and soft tissue: cartilage thinning, reduced water content, stiffer collagen, shorter resting muscle length → loss of range, slower, shorter-stride gait.
• Cardiorespiratory: maximum heart rate falls (≈220 − age), stroke volume reserve and VO₂max fall ~1% per year; lung elastic recoil and chest-wall compliance fall, residual volume rises → slower warm-up, longer recovery, less reserve.
• Nervous system and senses: slower reaction and conduction, reduced proprioception and vibration sense, presbyopia, cataract, presbycusis, vestibular hair-cell loss → balance depends more on vision, so dim light and bifocals are real fall risks.
• Homeostasis: poor thermoregulation, blunted thirst, orthostatic hypotension, delayed glucose handling - hence hydration breaks, slow position change and seated rest in Indian summer sessions.
• Normal ageing versus disease: slowing, mild stiffness and reduced reserve are ageing; pain, falls, confusion and sudden functional loss are disease and must be investigated, never accepted as "old age".

Geriatric assessment and outcome measures

• Comprehensive Geriatric Assessment (CGA): multidisciplinary evaluation of medical, functional, cognitive, nutritional, psychological, social and environmental domains - physiotherapy owns the mobility/balance/function part.
• History: presenting problem, fall history (number, place, mechanism, injury), polypharmacy (count drugs; sedatives, antihypertensives, diuretics, hypoglycaemics raise fall risk), continence, footwear, vision, home layout, caregiver availability, previous activity level.
• Examination: posture, ROM, manual muscle testing, handgrip dynamometry, sensation, tone, lying-to-standing BP (fall ≥20 mmHg systolic or ≥10 mmHg diastolic = orthostatic hypotension), gait pattern, aid used, skin over pressure areas.
• Core measures and cut-offs:
  • Timed Up and Go (TUG): stand from chair, walk 3 m, turn, return, sit. ≥13.5 s indicates increased fall risk in community elders; >20-30 s suggests dependence in mobility.
  • Berg Balance Scale (BBS): 14 items, 0-4 each, total 56; <45 associated with fall risk, <20 usually wheelchair-bound.
  • Tinetti POMA: balance 16 + gait 12 = 28; <19 high fall risk, 19-23 moderate.
  • Gait speed (4 m or 10 m): <0.8 m/s = slow/limited community ambulation, <0.6 m/s marks high risk of adverse outcomes; ≥1.0 m/s near-normal.
  • Short Physical Performance Battery (SPPB): gait speed + 5-times sit-to-stand + balance stands, 0-12; ≤8 = mobility limitation.
  • Five-times sit-to-stand: >12 s abnormal in older adults; 30-second chair stand counts repetitions.
  • Functional Reach, single-leg stance (<10 s abnormal after 60), Dynamic Gait Index (<19/24 fall risk), ABC scale / FES-I for fear of falling.
  • 6-minute walk test (6MWT): submaximal endurance; compare with predicted distance.
  • Function and participation: Barthel Index (0-100), Katz ADL, Lawton IADL, FIM, Elderly Mobility Scale.
  • Cognition and mood: MMSE (/30, ≤24 suggests impairment; adjust for education and use a validated Hindi/regional version), MoCA, Geriatric Depression Scale (GDS-15, ≥5 screens positive).
  • Others: Mini Nutritional Assessment, Braden or Waterlow scale for pressure ulcer risk, Morse Fall Scale in wards, Numerical/Faces pain scale, FRAX for 10-year fracture probability.
• Goal setting: SMART, function-based and negotiated with patient and family; discharge destination and caregiver capacity shape the plan more than the impairment does.

Falls, balance and fracture prevention

• Epidemiology: about a quarter to a third of people over 65 fall each year; 5-10% of falls cause fracture. Indian community studies report prevalence broadly in the 14-50% range depending on setting - quote the local study rather than a single national figure.
• Intrinsic risk factors: muscle weakness (strongest modifiable factor), balance and gait deficit, previous falls, age, vision loss, arthritis, stroke, Parkinson's disease, peripheral neuropathy, orthostatic hypotension, cognitive impairment, incontinence, depression, fear of falling, vitamin D deficiency.
• Extrinsic factors (common Indian homes): Indian-style toilets and wet bathroom floors, high door thresholds, steep narrow staircases without handrails, loose mats, poor lighting, trailing wires, charpoy/low beds, chappals without back strap, climbing on stools.
• Multifactorial intervention (the evidence-based package): exercise + medication review + vision correction + home modification + vitamin D/calcium where deficient + footwear advice + education.
• Exercise that works: progressive resistance, high-challenge balance training (reduced base, altered surface, head turns, tandem/semi-tandem, reaching outside base), gait and dual-task training, Tai Chi, Otago Exercise Programme (lower-limb strength + balance + walking, 3 sessions/week with home progression). Dose matters: at least ~50 hours of balance-challenging exercise over the programme.
• Not recommended alone: walking programmes only, general flexibility only, brisk walking in people at high fracture risk.
• Teach the fall: sit-to-floor and floor-to-stand transfers, how to call for help, hip protectors in selected institutional cases.
• Osteoporosis: physiotherapy adds weight-bearing and resistance exercise (not forward flexion/trunk rotation loading in vertebral fracture), spinal extensor strengthening, posture correction, balance work, and avoidance of lifting with a flexed spine; T-score ≤ −2.5 = osteoporosis, −1 to −2.5 = osteopenia.
• Post-hip-fracture: early mobilisation within 24-48 h of surgery, weight bearing as the surgeon permits, hip precautions after hemiarthroplasty (no flexion >90°, no adduction past midline, no internal rotation for posterior approach), progressive gait retraining with walker to stick to independence.

Common conditions and physiotherapy management

• Osteoarthritis knee/hip: land-based exercise and education are first-line; quadriceps and hip abductor strengthening, aquatic therapy, weight reduction, TENS/thermotherapy as adjuncts, cane in the opposite hand.
• Stroke, Parkinson's disease, dementia: in older adults the emphasis is comorbidity, fatigue, fall risk, cueing and caregiver training rather than the neurological technique itself.
• COPD and post-pneumonia deconditioning: pulmonary rehabilitation, interval training, breathing control, airway clearance, energy conservation.
• Cardiac: phase-wise rehabilitation with lower starting intensity, longer warm-up and cool-down, RPE-guided progression.
• Diabetes: foot care and footwear check before any walking programme; neuropathy changes balance training to non-weight-bearing and seated progression; inspect feet every session.
• Immobility syndrome - the complications to prevent and their counters: contractures (positioning, ROM twice daily), pressure ulcers (2-hourly turning, pressure-relieving surfaces, skin inspection), DVT (ankle pumps, early mobilisation, compression as prescribed), chest infection (deep breathing, positioning, clearance), osteoporosis and sarcopenia (loading), constipation, orthostatic intolerance (tilt/graded sitting), delirium and depression (orientation, activity, daylight).
• Incontinence: pelvic floor muscle training, bladder diary, timed voiding, transfer practice to reach the toilet in time.
• Pain: screen for under-reporting and for dementia-related pain behaviour; prefer activity-based and physical modalities given polypharmacy.
• Palliative and end-of-life care: positioning, breathlessness management, lymphoedema care, transfers for comfort and dignity; goals become symptom relief, not restoration.
• Aids and appliances: stick (length = greater trochanter to floor, elbow ~20-30° flexion), walker, rollator, axillary vs elbow crutches, wheelchair prescription, raised toilet seat, commode chair, grab bars, bed rails, AFO; prescribe, fit and *train*, then review - an unreviewed aid becomes a hazard.

Exercise prescription for older adults

• FITT-VP framework: Frequency, Intensity, Time, Type, Volume, Progression - written and progressed, not improvised.
• WHO 2020 guidelines for 65+: 150-300 min/week moderate (or 75-150 min vigorous) aerobic activity; muscle strengthening ≥2 days/week; multicomponent balance and strength training ≥3 days/week for fall prevention; limit sedentary time; do what you can if conditions limit you.
• Aerobic: walking, cycle ergometer, aquatic exercise; intensity by Borg RPE 11-13 on the 6-20 scale (or 3-4 on 0-10), or 40-60% heart-rate reserve; talk test is the practical bedside check.
• Resistance: 8-10 major muscle groups, 1-3 sets of 8-15 repetitions at 60-80% 1RM, 2-3 non-consecutive days/week; start at 40-50% 1RM in the frail and deconditioned; power training (fast concentric phase, light-moderate load) for fall-relevant function.
• Balance: progress by narrowing base, removing hand support, compliant surface, eyes closed, head movement, dual task - always within arm's reach of a solid support.
• Flexibility: static stretches 30-60 s, 2 days/week minimum; avoid ballistic stretching and end-range cervical rotation.
• Safety: absolute contraindications include unstable angina, uncontrolled arrhythmia, decompensated heart failure, acute DVT, resting systolic >200 or diastolic >110 mmHg, acute systemic illness, symptomatic severe aortic stenosis; stop for chest pain, dizziness, dyspnoea out of proportion, pallor, SpO₂ <88-90%, new confusion.
• Monitoring: pre/post BP, HR, SpO₂, RPE, pain; check for beta-blockers (HR targets invalid - use RPE), hypoglycaemia in insulin users, and Valsalva during resistance work.
• Frailty (Fried phenotype): weight loss, exhaustion, weakness, slow gait, low activity - 3 or more = frail, 1-2 = pre-frail; Clinical Frailty Scale 1-9. Management: progressive resistance exercise + protein-adequate nutrition + medication review; frailty is a reason to train, not to withhold training.
• Sarcopenia (AWGS 2019, used for Asians): low grip strength (<28 kg men, <18 kg women) or low 5-times sit-to-stand (≥12 s) plus low muscle mass = sarcopenia; add slow gait (<1.0 m/s) for severe sarcopenia. EWGSOP2 uses grip <27 kg men, <16 kg women.
• Dementia: short simple instructions, one step at a time, demonstration and tactile cueing, same therapist and time of day, familiar environment, errorless learning, avoid arguing with the patient, manage sundowning by scheduling activity earlier.

Indian context: law, programmes and practice

• NCAHP Act, 2021 (National Commission for Allied and Healthcare Professions) recognises physiotherapy as an allied/healthcare profession with a national commission, professional councils and state registers; registration, scope of practice and a code of ethics flow from it. The Indian Association of Physiotherapists (IAP) is the professional body.
• National Programme for Health Care of the Elderly (NPHCE), MoHFW: geriatric OPD/wards at district hospitals, Regional Geriatric Centres and National Centres for Ageing - a major employer of geriatric physiotherapists; rehabilitation services are an explicit component.
• Maintenance and Welfare of Parents and Senior Citizens Act, 2007: obligation of children/relatives to maintain parents, maintenance tribunals, provision for old age homes and medical care of senior citizens; amendments have been proposed and the position may have changed - check the current text before quoting detail.
• Rights of Persons with Disabilities Act, 2016: 21 specified disabilities, accessibility obligations, certification and benefits; relevant when ageing causes locomotor disability.
• Schemes: Rashtriya Vayoshri Yojana (free assistive devices - walkers, sticks, wheelchairs, hearing aids - for eligible senior citizens) under the AVYAY umbrella of the Ministry of Social Justice and Empowerment; Ayushman Bharat PM-JAY packages and health and wellness centres; Elderline 14567; Indira Gandhi National Old Age Pension under NSAP.
• Accessibility standards: National Building Code of India 2016, Part 3 and the Harmonised Guidelines and Standards for Universal Accessibility in India (2021) - ramp gradient not steeper than 1:12, handrails both sides, minimum 900 mm clear door width, anti-skid flooring, grab bars beside WC and in bathing area, lever taps. Home-visit advice should be written against these.
• Documentation and consent: informed consent (substitute decision-maker and family where capacity is impaired), SOAP notes, outcome measure at baseline and review, incident reporting for a fall during therapy, confidentiality.
• Ethics: screen for elder abuse and neglect; respect autonomy over family pressure; do not over-treat with passive modalities when exercise is indicated; infection control and hand hygiene in institutional care.

Key points

• Geriatric physiotherapy - function-led management of movement problems in older adults, framed by comorbidity, polypharmacy and social context.
• Sarcopenia - age-related loss of muscle mass with low strength or performance; AWGS grip cut-offs 28 kg (men) / 18 kg (women).
• Frailty - reduced physiological reserve; Fried phenotype 3 of 5 criteria, or Clinical Frailty Scale ≥5.
• TUG ≥13.5 s - increased fall risk; the single fastest screen in an OPD.
• Berg Balance Scale <45/56 - fall risk; Tinetti POMA <19/28 - high risk.
• Gait speed <0.8 m/s - limited community mobility; <0.6 m/s a strong predictor of adverse outcome.
• SPPB ≤8/12 - mobility limitation; combines gait, chair stands and balance.
• Multifactorial fall prevention - exercise plus medication review, vision, home safety, footwear and vitamin D beats any single measure.
• Balance training must be challenging - reduced support and altered surface, at least ~50 hours total dose.
• Power loss exceeds strength loss - include fast-concentric, light-load power work.
• WHO 65+ - 150-300 min/week aerobic, strengthening ≥2 days, multicomponent balance ≥3 days.
• Orthostatic hypotension - systolic drop ≥20 or diastolic ≥10 mmHg on standing; a common, treatable fall cause.
• Immobility syndrome - contracture, pressure ulcer, DVT, chest infection, bone loss, constipation, delirium: prevention is positioning plus early mobilisation.
• Hip precautions (posterior approach) - no flexion beyond 90°, no adduction past midline, no internal rotation.
• T-score ≤ −2.5 - osteoporosis; avoid loaded spinal flexion and rotation after vertebral fracture.
• Dementia-friendly teaching - one-step commands, demonstration, consistent therapist and timing, errorless learning.
• NPHCE and NCAHP Act 2021 - the service structure and the statutory basis of practice in India.
• Beta-blockers invalidate HR targets - prescribe and monitor by Borg RPE instead.

Formulas and examples

Example 1 - aerobic target for a 68-year-old, resting HR 72 bpm, not on beta-blockers.

• HRmax = 220 − 68 = 152 bpm; HRR = 152 − 72 = 80 bpm.
• 40% intensity: 72 + 0.40×80 = 72 + 32 = 104 bpm; 60%: 72 + 0.60×80 = 72 + 48 = 120 bpm.
• Prescription: treadmill or corridor walking at 104-120 bpm, Borg 11-13, 10 min × 3 bouts building to 30 min continuous, 5 days/week. If a beta-blocker is started, drop HR targets and use RPE 11-13 only.

Example 2 - fall-risk screen, 74-year-old woman with two falls in 6 months.

• TUG = 16.2 s (≥13.5 s → increased fall risk); BBS = 41/56 (<45 → at risk).
• 4-metre walk in 6.2 s → gait speed = 4/6.2 = 0.65 m/s (below 0.8 → limited community ambulation).
• Five-times sit-to-stand = 18 s (>12 s → lower-limb weakness); single-leg stance 4 s.
• Plan: Otago-type programme 3 days/week - ankle/hip/knee progressive resistance with 1 kg cuff weights, tandem and semi-tandem stands with counter support, sit-to-stand sets, 20 min walking; GP referral for medication review and vitamin D; bathroom grab bars and anti-skid mat; re-test TUG and BBS at 8 weeks.

Example 3 - 6MWT in a 70-year-old woman, height 155 cm, weight 62 kg, walked 310 m with two rests.

• Predicted = 2.11×155 − 2.29×62 − 5.78×70 + 667 = 327.05 − 141.98 − 404.60 + 667 = 447.5 m.
• Achieved 310/447.5 = 69% of predicted → significant exercise limitation.
• Average speed = 310/6 = 51.7 m/min → VO₂ ≈ 0.1×51.7 + 3.5 = 8.7 ml/kg/min = 8.7/3.5 ≈ 2.5 METs - barely enough for light housework (2-3 METs), which explains her reported dependence.
• A change of about 30 m is usually taken as the smallest clinically important improvement.

Example 4 - sarcopenia confirmation (AWGS 2019), 72-year-old man.

• Handgrip 24 kg (cut-off 28 kg) → low strength; gait speed 0.85 m/s (cut-off 1.0) → low performance.
• BIA appendicular muscle mass 18.5 kg, height 1.68 m → SMI = 18.5 / (1.68²) = 18.5/2.8224 = 6.56 kg/m² (cut-off 7.0) → low mass.
• All three present → severe sarcopenia. Prescribe progressive resistance training 3 days/week plus dietitian referral for protein intake.

Example 5 - starting load from a repetition test, and bone density.

• Patient manages 10 clean repetitions of seated knee extension with 8 kg. 1RM = 8 / (1.0278 − 0.0278×10) = 8 / (1.0278 − 0.278) = 8/0.7498 = 10.7 kg. Training at 70% 1RM ≈ 7.5 kg for 3 sets of 10; re-test every 2 weeks.
• DXA: BMD 0.680 g/cm², young-adult mean 0.942, SD 0.110 → T = (0.680 − 0.942)/0.110 = −2.38 → osteopenia (not yet osteoporosis). Weight-bearing and resistance exercise permitted; avoid loaded trunk flexion and rotation.

Example 6 - audit in an old age home. 40 residents followed for 6 months, 26 falls recorded. Person-years = 40 × 0.5 = 20 → rate = 26/20 = 1.3 falls per person-year - high, justifying a facility-wide multifactorial programme.

Where it is used

• Hospital geriatric, orthopaedic and medical wards: AIIMS and other Regional Geriatric Centres under NPHCE, post-hip-fracture and post-arthroplasty pathways, ICU step-down early mobilisation.
• Old age homes, retirement communities and assisted living: Ashiana, Antara, Columbia Pacific, church- and trust-run homes - group exercise classes, fall audits, staff training in transfers and positioning.
• Home healthcare companies: Portea, Nightingales, Care24, HCAH and hospital home-care arms - home-visit physiotherapy, home safety assessment, caregiver training, aid prescription.
• Rehabilitation and neuro-rehab centres and private OPD clinics: OA knee, post-stroke and Parkinson's elderly caseloads, osteoporosis exercise programmes.
• Community and public health: health and wellness centres, NGO day-care centres (HelpAge India), senior citizen camps, Rashtriya Vayoshri Yojana device distribution and fitting.
• Roles and allied work: geriatric physiotherapist, rehabilitation coordinator, MPT in geriatrics/community physiotherapy, clinical research in ageing (LASI-type cohorts), assistive-device and senior-living design consulting against NBC 2016 and the Harmonised Guidelines 2021.

Interview questions

• Q: Which single test would you use to screen fall risk in a busy OPD, and why? A: The Timed Up and Go - it needs only a chair, 3 m and a stopwatch, takes under a minute, and ≥13.5 s flags increased fall risk while also showing transfer, gait and turning quality.
• Q: Why does power training matter more than strength training in older adults? A: Type II fibres atrophy preferentially, so power declines faster than strength, and power is what recovers balance and climbs stairs; light-to-moderate loads moved fast target it.
• Q: A frail 85-year-old with Fried score 4 is referred. Is exercise safe? A: Yes - frailty is an indication, not a contraindication; progressive resistance exercise with adequate protein improves strength and function. Screen for unstable cardiac disease, start low, progress slowly and monitor BP, HR and RPE.
• Q: What are the three best outcome measures for a fall-prevention programme? A: TUG or gait speed for mobility, Berg Balance Scale or Tinetti POMA for balance, and a fall diary with FES-I for actual falls and fear of falling.
• Q: How does polypharmacy change your plan? A: Sedatives, antihypertensives, diuretics and hypoglycaemics cause dizziness, orthostatic hypotension and hypoglycaemia, so I check lying-to-standing BP, time sessions away from dose peaks, and refer for medication review as part of multifactorial fall prevention.
• Q: Which Indian home features most commonly cause falls, and what do you advise? A: Wet bathroom floors and Indian-style toilets, high thresholds, unlit stairs without handrails, loose mats and backless chappals - advise anti-skid flooring, grab bars and raised toilet seat, threshold ramps, night lighting, handrails both sides and secure footwear.
• Q: Your patient had a posterior-approach hemiarthroplasty. What do you avoid? A: Hip flexion beyond 90°, adduction past midline and internal rotation - so no low chairs, no crossing legs and no sitting on the floor; weight bearing as the surgeon allows, with walker-to-stick progression.
• Q: Patient is on atenolol. How do you set aerobic intensity? A: Heart-rate formulas are invalid, so I prescribe by Borg RPE 11-13 on the 6-20 scale with the talk test, and monitor BP, symptoms and SpO₂.
• Q: How do you treat a patient with moderate dementia who refuses exercise? A: Use short single-step instructions with demonstration, keep the same therapist, time and familiar setting, embed exercise in meaningful activity, involve the caregiver, and never argue - redirect and retry later rather than forcing.
• Q: Differentiate osteopenia and osteoporosis on DXA. A: T-score between −1 and −2.5 is osteopenia; ≤ −2.5 is osteoporosis, and osteoporosis with a fragility fracture is severe osteoporosis.
• Q: Which Act governs your registration as a physiotherapist in India? A: The National Commission for Allied and Healthcare Professions Act, 2021, which created the national commission, professional councils and state registers along with the code of ethics.
• Q: An 80-year-old on bed rest for 3 weeks is referred. What complications do you address first? A: Chest infection risk, DVT, pressure ulcers, contractures and orthostatic intolerance - so positioning and turning, ankle pumps and breathing exercises, graded sitting to standing, and early out-of-bed mobilisation the same day.

Common mistakes

• Quoting outcome measures without their cut-off scores, or using them once and never re-testing - the measure exists to show change.
• Attributing pain, falls, breathlessness or new confusion to "old age" instead of screening for disease, and so missing fracture, infection or delirium.
• Prescribing only walking or only flexibility for fall prevention; without challenging balance and resistance work the programme does not reduce falls.
• Keeping balance training too easy and too supported, or alternatively progressing with no hand support available - both are errors in opposite directions.
• Forgetting lying-to-standing blood pressure, and then blaming "weakness" for dizziness that is orthostatic hypotension.
• Using 220 − age heart-rate targets in patients on beta-blockers, or ignoring Valsalva and breath-holding during resistance exercise.
• Giving a walker or stick without measuring, fitting, training and reviewing it, and ignoring the family and home environment in goal setting.
• Writing adult doses and adult session lengths for a frail patient, instead of splitting bouts and progressing one FITT variable at a time.

Related topics

Musculoskeletal physiotherapy · Neurological physiotherapy · Cardiorespiratory physiotherapy · Community-based rehabilitation and public health physiotherapy · Exercise physiology and therapeutic exercise · Orthotics, prosthetics and assistive devices