A patient recovering from a fall wanted to attend her grandson's wedding in five months. Ross Davis, PT, MPT, MBA, rehabilitation director for Atlanta-based Gentiva Home Healthcare, worked with her to break that goal into manageable steps. "She needed to have the dynamic balance to ambulate 500 feet, for example, and to stand for 30 minutes," he said. "So we based all our treatments and established goals toward making that a successful experience."

Meaningful goals are one way physical therapists can help motivate their elderly patients who may be demoralized by the health challenges that come with an aging body.

Fran Fleishman, OTR/L, MS, CHT, who practices at Hudson Valley Hand Physical Therapy and Occupational Therapy in Hawthorne, N.Y., said a good way to set goals is to talk about what patients could do previous to their injury or illness, compared to what they can do now. "We do a perceived disability scale that brings their issue into the real world. This helps them clearly see things they currently cannot do, which can help with setting goals. I assure them that when they fill the scale out at their one-month evaluation, there will be measurable improvement."

Attainable goals

Establishing attainable goals is key, said Judy Wiskoski, PT, MSHA, therapist at Holy Redeemer Hospital in Meadowbrook, Pa. "What I have found to be the biggest motivation is assuring them that they will return to some better level of function, assuming they're capable of that," Wiskoski said. "If we set a small goal, the patient can attain it quickly and see progress, and I can point out that progress."

Wiskoski puts short-term goals in writing, along with a time frame. After a knee replacement, for example, a short-term goal may be walking 30 feet with minimal assistance in three days.

When patients can't or won't come up with a goal, Wiskoski talks about what they should be able to do, based on her experience with others. She continually evaluates progress and moves the goal out.

It is easy for a clinician to create goals that address a patient's impairments, or goals for simple functional activities that are important, Davis said, such as safely getting from bedroom to bathroom. But compliance and motivation for participation in therapy have been shown to be much greater if patients set goals themselves, he said.

"I may come up with a dozen goals for things I'd like them to do, but it doesn't matter if the patient doesn't care," Davis said. "I want [them] to tell me what [they] want to do. Then I can contour a treatment program geared to the patient's bigger goal, such as getting to that wedding."

While there are differences between intrinsic and extrensic motivations, Davis pointed out that the latter can turn into the former if a patient sees benefits. "If someone wants to lose 10 pounds and puts $5 in a jar for every pound they lose, at the end they will have $50 to buy something," he said. "But they will also realize that they feel a heck of a lot better, and then that motivates them to keep going."

Social interaction

When several patients are present at the same time, they can give each other support and encouragement, Fleishman said. Sometimes, a patient will voice concerns to the other patients rather than to her, and those other patients tell that person how well the exercises work, she noted.

"People are motivated when they see other people being successful, or feel that other people want them to be successful," Davis said. "Anyone who chooses to come to an event in an assisted living facility, for example, has the opportunity to inspire someone else. People are willing to participate if someone shows they care."

Wiskoski also encourages patients in inpatient settings to attend as many recreational activities as possible. This gives them an opportunity to bond with others, perhaps those who are in the same position.

Establishing a rapport with patients is important, Wiskoski said "I ask questions like, 'What is the biggest change you've seen in your life?' Then I talk with them about that." Given that rapport, she said, patients tend to believe her when she tells them they can do something.

Can-do mindset

Rebecca Barton, OTR, DHS, associate professor at the University of Indianapolis School of Occupational Therapy, said patients who feel they have control over their treatment tend to do better. "I think it helps to have a collaborative relationship, to help them feel responsible for their own progress, rather than an authoritarian type of relationship," Barton said.

It can be difficult to motivate patients who are not unhappy with where they are, Fleishman said. "People in home care who have all their needs met by family or caregivers may not believe they need to do things differently. I believe there has to be an inner need for change, or some dissatisfaction on the part of the patient, in order for them to be engaged in the rehabilitation process."

Patients must believe their efforts will be successful, according to therapists. "If people believe that they can be successful," Davis said, "they have a much higher chance of participating in the activity."

Therapists can help patients recognize their successes. "We can give them exercises that we know they will be successful at," Davis said. "Then, because they have been successful, they're more likely to try the next thing, even if it's more challenging. That leads to increased participation and increased compliance."

Because the geriatric population generally is not familiar with virtual reality games such as Wii, these therapists don't use them. Music and dance, on the other hand, are effective tools for motivating these patients to move.

"Motivation is a complex animal," Davis said. "What specific thing motivates one person may not apply to the next. But it's fun to look for ways to consistently motivate patients." •

Melissa Gaskill is a freelance writer.