The Influence of Physical Therapists’ Beliefs and Attitudes About Ageing on Expectations About Outcomes in a Hypothetical Patient

Abstract

Background: The aim of this study was to analyze the influence of beliefs and attitudes of practicing physical therapists (PTs) about aging on their expectations concerning the behavior and outcomes of patients with orthopedic conditions. We hypothesized that some beliefs and attitudes would be related to expectations of worse outcomes in older patients compared to clinically identical younger patients. Methods: Seventy-one (71) practicing PTs with a mean age of 40 years (±10.44, range 24–67) were recruited via snowball sampling and asked to participate in a three-part online questionnaire. For part 1, participants were randomly assigned a hypothetical case involving either a 42-year-old or an 85-year-old patient s/p surgical repair of a femoral shaft fracture. Thirty-five (35) participants were randomly assigned to the young case group (YCG) and 37 to the old case group (OCG). Participants were asked questions related to their expectations concerning the patient’s clinical and functional potential, response and adherence to physical therapy, and patient responsibility for their own outcomes. For part 2, all participants completed the Kogan Attitude Toward Old People Scale consisting of 34 paired (positive/negative) statements. Part 3 consisted of subject demographics. Results: Participants in the YCG and the OCG were similar in age (41 vs. 40 years), PT experience (16.7 vs. 14.8 years), gender (82.9% vs. 86.5% female), and positive Kogan score (69.5 vs. 68.2). The groups differed in belief the patient would return to their prior level of function. YCG believed it was “extremely likely”, while the OCG believed it was “moderately likely”. In the OCG, greater likelihood that the patient would return to prior level of function was related to stronger belief that “Most ageing adults are really no different from anybody else” (r = 0.35). Conclusion: In general, physical therapist participants in this study agreed with positive attitudes and beliefs about aging adults as measured by total positive Kogan score. The only outcome expectation that appeared to be influenced by the age of hypothetical patient was return to prior level of function. Although some specific age-related beliefs were correlated to expectation of return to prior level of function, the positive Kogan score was not. It is possible that age related differences in expectations of return to prior level of function were influenced by clinical experience rehabilitating older patients rather than negative attitudes and beliefs about aging.

1. Introduction

Physical therapists (PTs), also known as physiotherapists, are licensed healthcare professionals who help patients improve mobility, manage pain, improve physical function and fitness, and recover from injuries or surgeries through personalized exercise programs, manual therapy, and patient education. PTs frequently encounter, treat, and manage the rehabilitative care of older adults. A recent systematic review by Omaña et al. reported outcomes related to attitudes and beliefs of PTs and PT students toward working with older adults (i.e., the potential for age bias) [1]. The results indicated that PT students demonstrated positive attitudes toward older adults, while PT clinicians had neutral to weak positive attitudes toward older adults. Both students and clinicians had low levels of knowledge on aging and low interest in working with older adults [1]. This review did not explore the potential impact of negative beliefs and attitudes about older people on expectations related to a patient’s potential to improve. Paradoxically, despite the frequency with which PT’s treat older adults, there is not a requirement for dedicated content in geriatrics in professional education programs in the US [2].

There are potentially many ways that physical therapists’ attitudes and beliefs about aging could influence the rehabilitation of older adults. Ambady et al. examined the link between non-verbal communication by health care providers and therapeutic efficacy [3]. The study analyzed PT’s behaviors via videotaped encounters as well as the patient perception of the PTs behaviors. The authors concluded that PT behaviors demonstrating distancing from and indifference toward older patients (e.g., not smiling; looking away from the patient) were related to more negative short-term and long-term cognitive and physical health outcomes [3]. A review conducted by Lamont et al. found that memory and cognitive performance was adversely affected by negative age stereotypes, and that these effects were stronger when induced by stereotype rather than by actual facts [4]. Furthermore, positive age stereotypes lead to improved performance [4]. This was also seen in a study conducted by Stephan et al., where older adults who were experimentally induced to feel younger showed a significant increase in grip strength [5]. Research has also shown a relationship between negative attitudes and beliefs about aging and dementia-related biomarkers [6]. In the Baltimore Longitudinal Study of Aging, participants exposed to more negative age stereotypes earlier in life had elevated biomarkers related to Alzheimer’s disease in a post-mortem brain autopsy. Specifically, individuals with more-negative age stereotypes earlier in life had significantly steeper hippocampal-volume loss and significantly greater accumulation of neurofibrillary tangles and amyloid plaques [6].

Negative attitudes and beliefs about aging or age bias can influence how people perceive and evaluate older adults’ abilities, worth, and roles in society, often shaping their responses on standardized questionnaires based on cultural norms or personal experiences with aging. Age bias often manifests in stereotypical views, such as perceiving older adults as frail, dependent, or less adaptable, or, conversely, idealizing them as wise and nurturing. These stereotypes can lead to ageism which may be defined as prejudice and discrimination directed at people based on their age [7]. According to a global systematic review, ageism has a negative impact on physical, mental, and social aspects of health, including worse patient outcomes, earlier death, accelerated cognitive impairment, and increased the economic burden on society [7]. Research suggests that where ageism is present, it impacts the quality, quantity, and type of care that older adults receive [8,9]. This suggests that ageism results in less intense, less aggressive, and less comprehensive care that produces poorer outcomes [10].

Despite the clear evidence that negative attitudes and beliefs about aging have consequential health effects [11,12], there is limited information on how PTs’ attitudes and beliefs about older adults might influence physical therapy management of this patient population Physical therapists’ expectations concerning patient outcomes are important in managing the rehabilitation of older patients. The primary aim of this study was to examine how physical therapists’ attitudes and beliefs about aging influence their expectations about patient outcomes.

2. Materials and Methods

This was a cross-sectional study of physical therapists currently practicing in the United States. A convenience sample of participants was recruited using email contact information provided by the American Physical Therapy Association (APTA) Geriatrics, Acute Care, and Neurology Academy listservs, and through social media. To be included in the study, participants had to be above 18 years of age and hold an active physical therapy license in the United States. The study was conducted nationwide between 30 April 2021, and 10 June 2021.

Survey design, construction and data collection was accomplished using Qualtrics^® (Qualtrics, Provo, UT, USA, 2021 Version,). The Checklist for Reporting Results of Internet E-Surveys (CHERRIES) was used to ensure the completeness of reporting in publication, and all required components are reported herein [13]. Because the survey did not collect identifiable information, was completed anonymously, could be exited at any time, and was not interventional, the University of Miami Institutional Review Board (IRB) (IRB ID: 20210285) determined that the study met the criteria described in the Federal Regulations 45 CFR 46.104 and approved the study protocol prior to data collection. No incentives or compensation was provided for participation. When participants accessed the survey, they were informed that the research study was being conducted to learn more about the influence of their beliefs in predicting prognosis and potential patient compliance. Participants had to affirm their consent before they were allowed to proceed with the survey. Participants completed the survey online and had no direct contact with the investigators. (Survey available in Supplemental Materials S1). Duplicate entries were prohibited from the same IP address. This rule was in place during the entire time the survey was open.

The study was conducted in three parts. For Part 1, participants were randomly assigned a gender-matched hypothetical case, created for the purposes of this study, involving either a 42-year-old or an 85-year-old patient status post-surgical repair of a femoral shaft fracture. The gender of the hypothetical case was matched to the gender identity of the survey taker to reduce the effects of any potential gender bias. All components of the case were identical for both groups: the 42-year-old case/younger case group (YCG) or the 85-year-old case/older case group (OCG) except for the patient’s age. Participants were then asked a series of seven (7) questions. Five were related to their beliefs concerning the patient’s prognosis, the patient’s personal responsibility for their care, likelihood of achieving prior level of function, adherence with PT, and adherence with home program. These items were scored on a numeric scale from 1 (extremely likely) to 7 (extremely unlikely). One question was about the impact of PT on quality of life which was scored on numeric rating scale 1 to 7 where 1 = not at all and 7 = a great deal. And one question was regarding their own personal belief about the patient’s potential for improvement scored on a scale from 1 (definitely yes) to 5 (definitely not). The questions asked were adapted from those published in a similar study from Khosla et al. regarding the influence of racial bias on the same constructs [14]. These questions are routinely considered by healthcare professionals in the process of clinical decision making when determining patient prognosis, potential for improvement and patient adherence.

In Part 2, participants were asked to complete the Kogan Attitude Toward Old People Scale. The Kogan Scale is a widely used scale among health care professionals and students in the health sciences to assess the attitudes toward aging adults. The Kogan scale has demonstrated good reliability and validity in measuring attitudes toward older people across professional groups and cultures [15,16,17,18,19,20,21]. The Kogan Scale is a 34-item self-report measure of attitudes toward older individuals. It addresses 17 concepts with negative and positive wording for each concept for a total of 34 paired items. The Kogan Scale statements are rated on six-point Likert scale of one (1 = strongly disagree) to six (6 = strongly agree) for positive statements and one (1 = strongly agree) to six (6 = strongly disagree) for negative statements; with a higher overall score indicating more favorable beliefs about older people, while a lower overall indicates less favorable beliefs about older people. Participants were unable to review and change answers once answer selections were submitted. Kogan item language was slightly modified by changing “old people” to “ageing adults”, a phrase the authors agreed was more common among healthcare providers in the United States.

Because of an apparent social desirability bias in the responses to the negatively worded items, we created a positive Kogan Score by adding the responses to the 17 positively worded Kogan items, dividing by the total possible points (102) for these items and multiplying by 100. Higher scores indicated stronger agreement with positive statements about older adults. We used Student’s t-tests and Mann–Whitney-U statistics to compare the responses of the participants assigned to the younger case group (YCG) and the older case group (OCG). Data were analyzed using SAS™ software (© 2021, SAS Institute Inc., Cary, NC, USA, version 9.4). We calculated Spearman correlations to examine the relationship between Kogan items and prognosis items.

Table 1. Positive Kogan scale items.

1.	It would probably be better if most ageing adults lived in residential units with younger people.
2.	Most ageing adults are really no different from anybody else; they’re as easy to understand as younger people.
3.	Most ageing adults are capable of new adjustments when the situation demands it.
4.	Most ageing adults would prefer to continue working as long as they possibly can rather than being dependent on anybody.
5.	Most ageing adults can generally be counted on to maintain a clean, attractive home.
6.	People grow wiser as they get older.
7.	Ageing adults should have power in business and politics.
8.	Most ageing adults are very relaxing to be with.
9.	One of the most interesting and entertaining qualities of ageing adults is their account of past experiences.
10.	Most ageing adults tend to keep to themselves and give advice only when asked.
11.	When you think about it, ageing adults have the same faults as anybody else.
12.	The number of ageing adults living in a neighborhood does not impact how nice the neighborhood is.
13.	It is evident that most ageing adults are very different from one another.
14.	Most ageing adults seem quite clean and neat in their personal appearance.
15.	Most ageing adults are cheerful, agreeable, and good humored.
16.	One seldom hears ageing adults complaining about the behavior of the younger generation.
17.	Most ageing adults need no more love and reassurance than younger people.
Positive Response Categories 1 = Strongly disagree 2 = Slightly disagree 3 = Disagree 4 = Agree 5 = Slightly Agree 6 = Strongly agree		Total Score Calculation Item scores added. Ratio calculated item total/total possible (102) Ratio multiplied by 100 Total scores can range between 17 and 100 Higher scores indicate less ageism

includes the 17 positively worded Kogan items (as modified).

Part 3 of the survey collected demographic information about participants including participant age, gender identity, year their PT degree was completed, where they practiced as a PT (geographic location/US state), APTA and APTA section or academy membership, race and ethnicity, country of birth, type of community where they were raised and where they currently reside (e.g., urban, suburban, rural).

3. Results

Of the 111 individuals who initiated the survey, 40 were excluded because they did not meet inclusion criteria or did not complete the survey, a completion rate of 64%. Data from 71 participants were used for the statistical analysis. Participant’s mean age was 40 years (sd = 10.44, range 24–67), with a mean of 15 years’ experience as a PT (sd = 11.03, range = 1–43). Eighty-six percent (86%) of the participants identified as female, and 86% were members of the APTA. Participants were 69% White/Caucasian. Thirty-five (35) of the participants were assigned to the YCG and 37 were assigned to the OCG. Participants in both the YCG and the OCG were similar in age, years of PT experience, gender, and ethnicity. The mean positive Kogan scores were similarly high for both groups. Agreeing with all the 17 positive Kogan items would produce a total score of 67, indicating that both groups generally agreed with positive statements about aging adults. A larger portion of the OCG than the YCG group were APTA members (91.95% vs. 79.4%), but this difference did not achieve statistical significance. (See

Table 2. Comparison of group characteristics (younger case group vs. older case group).

Variable	Younger Case Group N = 35 Mean (Std) Frequency (%)	Older Case Group N = 37 Mean (Std) Frequency (%)	p-Value
Age (in years)	41.0 (10.0)	40.2 (11.0)	p = 0.75
Years of experience as a physical therapist	16.7 (10.5)	14.8 (11.6)	p = 0.457
Positive Kogan score	69.5 (7.2)	68.2 (6.2)	p = 0.39
Female gender	29 (82.9%)	32 (86.5%)	p = 0.67
Member of the American Physical Therapy Association (yes)	27 (79.4%)	34 (91.95)	p = 0.131
White non-Hispanic	21 (65.65)	27 (75.0%)	p = 0.397

).

Median scores for the prognosis items were generally very positive for both groups. There was a difference between the YCG and the OCG in their belief in the likelihood that the patient would “return to their prior level of function”. The YCG believed it was “extremely likely”, while the OCG group believed it was only “moderately likely”, that the patient would “return to their prior level of function”. This finding was statistically significant (p = 0.007). See

Table 3. Comparing prognosis items for the younger case group and older case group.

Variable	Younger Case Median (Min-Max) N = 35	Older Case Median (Min-Max) N = 36	p-Value
* 1. How likely is it that the patient’s condition will improve	1.0 (1.0–2.0)	1.0 (1.0–3.0)	p = 0.10
* 2. How likely is it that the patient will return to their prior level of function	1.0 (1.0–2.0)	2.0 (1.0–3.0)	p = 0.007
# 3. To what extent can physical therapy affect their quality of life?	7.0 (4.0–7.0)	7.0 (4.0–7.0)	p = 0.46
@ 4. Do YOU actually believe the patient’s condition will improve?	1.0 (1.0–2.0)	1.0 (1.0–3.0)	p = 0.26
* 5. How likely is it that the patient will be compliant with therapy?	1.0 (1.0–3.0)	1.0 (1.0–4.0)	p = 0.37
* 6. How likely is it that the patient will be compliant with the prescribed home exercise program?	2.0 (1.0–3.0)	2.0 (1.0–4.0)	p = 0.08
* 7. How likely is it that this patient is personally responsible for improving in therapy?	1.0 (1.0–2.0)	1.0 (1.0–5.0)	p = 0.41

* 1 = Extremely likely, 2 = Moderately likely, 3 = Slightly likely, 4 = Neither likely nor unlikely, 5 = Slightly unlikely, 6 = Moderately unlikely, 7 = Extremely unlikely. # Numeric rating scale 1 to 7 where 1 = Not at all and 7 = A great deal. @ 1 = Definitely yes, 2 = Probably yes, 3 = Might or might not, 4 = Probably no, 5 = Definitely not.

.

The only prognosis item that differed between the YCG and OCG was “How likely is it that the patient will return to their prior level of function”. This item was not correlated with the positive Kogan score. (r = −0.07, p = 0.74). To better understand how age-related attitudes and beliefs related to expectations about return to prior level of function we examined the relationship between this prognosis variable and individual positive Kogan items separately for the younger and older cases.

Table 4. Correlation between Kogan Items and “How likely is it that the patient will return to their prior level of function?”.

Positive Kogan Items	Younger Case Correlation p-Value	Older Case Correlation p-Value
1. It would probably be better if most ageing adults lived in residential units with younger people.	r = −0.10 p = 0.58	r = 0.32 p = 0.05
2. Most ageing adults are really no different from anybody else; they’re as easy to understand as younger people.	r = −0.25 p = 0.15	r = −0.35 p = 0.03
7. Ageing adults should have power in business and politics.	r = −0.49 p = 0.003	r = 0.26 p = 0.12
10. Most ageing adults tend to keep to themselves and give advice only when asked.	r = 0.18 p = 0.30	r = −0.39 p = 0.02
12. The number of ageing adults living in a neighborhood does not impact how nice the neighborhood is.	r = −0.24 p = 0.17	r = −0.38 p = 0.02
15. Most ageing adults are cheerful, agreeable, and good humored.	r = −0.21 p = 0.23	r = 0.34 p = 0.046

Bold = moderate correlation. Grey fill = negative, moderate correlation. Kogan Items: Higher scores indicate stronger agreement. Higher scores indicate that the item is less likely.

reports all statistically significant correlations (see Table 4).

For the OCG, there were moderate negative correlations between the likelihood that the patient would return to prior level of function and Kogan items 2 (aging adults are really no different from anybody else), 10 (aging adults give advice only when asked), and 12 (the number of aging adults in a neighborhood does not impact how nice it is). This indicated that the more strongly participants agreed with these items the more likely they felt that the older case patient would return to their prior level of function. Interestingly, there were moderate positive correlations between the likelihood that the patient would return to prior level of function and Kogan items 1 (better if most aging adults lived in residential units with younger people) and 15 (aging adults are cheerful, agreeable, and good humored). This indicated that the more strongly participants agreed with these items, the less likely they felt that the older case patient would return to their prior level of function.

For the YCG, most positive Kogan items were not related to expectation that the younger case patient would return to the prior level of function. Only Kogan item 7 (Aging adults should have power in business and politics) was negatively correlated with the likelihood that the young case patient would return to prior level of function. The more strongly participants agreed with this item the more likely they were to believe the younger case would return to their prior level of function.

4. Discussion

Participants for this study were recruited primarily using contact information from APTA Geriatrics, Acute Care, and Neurology Academy listservs. Therefore, it is likely that most participants chose to practice in settings where they frequently treated older adults. The median prognosis items scores of the YCG and OCG only differed on one item “likelihood that the patient would return to their prior level of function”. It could be argued that these differences could be due to previous clinical experience rehabilitating 85-year-old patients with femur fractures rather than negative attitudes and beliefs about aging.

On average, total positive Kogan scores were relatively high however, scores ranged from 50 (hypothetically produced if a participant scored 3) to 86 (hypothetically produced if a participant scored 5 on all items). Although the total positive Kogan score was not related to the expectation that the patient would return to their prior level of function, stronger agreement with some positive Kogan items increased the likelihood of this outcome. In particular, there were relationships between agreeing with some positive descriptors of older adults such as “no different from anybody else”, and “give advice only when asked”, and the expectation that the older case patient would return their prior level of function. However, there were several Kogan items that did not follow this pattern. Disagreeing with the statement “Most ageing adults are cheerful, agreeable, and good humored”, was related to an increased expectations that the older patient was likely to return to their prior level of function.

Older patients may experience pain, fatigue, and discomfort during PT interventions. PTs often treat patients who are initially anxious and uncooperative but eventually achieve positive outcomes. This may be especially true for patients who have cognitive impairments or painful conditions. The clinical experiences of PTs who treat older adults probably influenced how they responded to items about expected patient outcomes as well as to individual Kogan items.

In our sample, age-based opinions and attitudes may be partially influenced by real world experience treating older patients. While some of these opinions and attitudes could be theoretically considered negative stereotypes, differences in the expected outcomes of two hypothetical patients who differed only in age may reflect clinical reality rather than negative attitudes and beliefs about aging. The differences in outcome expectations based on age would only be a problem if it resulted in inappropriately withholding or decreasing the intensity of PT interventions.

Finally, as suggested previously, the scarcity of geriatric-specific curricular content taught in entry-level PT educational programs in the US may have a significant impact on attitudes and beliefs about aging. This lack of content and/or exposure to older people during matriculation in PT training may perpetuate aging stereotypes and influence decisions about the rehabilitation of older patients. We strongly advocate that geriatric content be incorporated into entry-level competencies for all PTs.

This study has a number of limitations. Further studies with a larger, more diverse sample are needed. Most participants were members of the APTA, which is not reflective of the overall population of PTs. Beyond that, they were also predominantly affiliated with the Geriatric, Neurology, or Acute Care Academies of the APTA. As of 2019, approximately 68% of US PTs were not members of the APTA [22]. Additionally, our participants were 86% female, compared to 68% of all US PTs and 75% of PTs who are geriatric specialists [22]. Thus, results cannot be generalized to the entire US PT population. Data were not collected on the extent of education or level of knowledge in gerontology/geriatrics which could impact attitudes about aging. Future studies should also consider inclusion of physical therapist assistants as they are important members of the rehabilitation team, especially in settings that treat large numbers of aging adults. There is research that supports the notion that under-resourced care settings negatively influence attitudes towards older people, while other studies did not find any significant difference across settings [23,24]. Future studies should investigate the relationship between PT practice setting and typical conditions encounters and therapists’ attitudes toward aging adults. Despite the Kogan Scale’s well-established use among healthcare professionals, there are some reservations for its use including length of the scale, and its dated tone and use of language [16,23,24]. In a 2019 systematic review on existing aging scales, the Kogan scale was said to fulfill two out of the three dimensions of ageism which were ‘prejudice’ and ‘stereotypes’ but not ‘discrimination’ [24]. Ultimately, the Kogan scale was selected despite its somewhat outdated language due to its wide use in healthcare research, and its moderate to high reliability and validity demonstrated across multiple cultures and healthcare professionals. Additionally, the results could partially be driven by respondents giving answers they thought were most acceptable. While we previously acknowledged the risk of social desirability bias and attempted to minimize or reduce its likelihood in our analysis, it is possible this bias impacted results.

5. Conclusions

In summary, this study found that the physical therapist participants in this study generally agreed with positive statements about aging as measured by Kogan score. Only the expectation that the patient would return to their prior level of function was better for the YCG than the OCG. Although some specific beliefs were related to returning to prior level of function, it is possible that difference in outcome expectations may be due to clinical experience rehabilitating older patients rather than negative attitude and beliefs about aging.