REHABILITATION

Rehabilitation is one of the basic elements of comprehensive geriatric care. Rehabilitation is indicated when someone is not functioning at their full potential. It involves an assessment of the underlying causes of activity limitation, treatment of the primary impairment to the extent possible, prevention of further disability, and interventions to promote adaptation of the person to their disability. The goal of geriatric rehabilitation is to maximize functional independence.

Rehabilitation in general, and geriatric rehabilitation in particular, is provided by an interdisciplinary team. The basic team consists of one (or more) occupational therapist, physiotherapist, physician, rehabilitation nurse, and social worker. Other disciplines that can be involved either as part of the core team, or on a consultation basis, include dietetics, pharmacy, psychology, recreational therapy, or speech-language pathology. A team that works well together, and whose members have an understanding of and respect for each other’s contributions and strengths, is integral to a successful rehabilitation program.

Assessment

Assessment begins with establishing the patient’s suitability for a rehabilitation program. In order to benefit from a geriatric rehabilitation program, the patient must be medically stable and have a minimum of endurance to undergo at least an hour per day of therapy. Patients must be motivated to participate actively in the program, and must have sufficient cognitive function to be able to learn simple tasks with repetition. They must require the expertise of at least two different rehabilitation disciplines.

The World Health Organization has defined several terms to facilitate communication. These include impairments, which are problems in body function or structure (e.g., an arthritic joint or a stroke). Activity limitations are difficulties an individual has in performance of activities (e.g., being unable to walk safely on stairs). Participation restrictions are problems an individual may have concerning involvement in life situations (e.g., being housebound because the only access requires using stairs, and there is no ramp or elevator in place). The rehabilitation team addresses activity limitations and participation restrictions associated with specific impairments.

It is important to get a good picture of the patient’s weaknesses and strengths in the spheres of mobility, self-care (bathing, dressing), continence, cognition, mood, and social situation. There are many different outcome measurements that are used to record and follow level of function. It is important to be aware of the patient’s previous level of function in order to set appropriate goals. Priority is given to the goals of the patient and family members.

Intervention

Intervention begins with prevention of further injury. This means preventing the complications that can arise from bedrest following the initial problem (stroke, hip fracture, medical illness). If older people are left convalescing too long, they become at risk for infections, pressure ulcers, and muscle atrophy. Early mobilization is essential. Risk factors for future falls, fractures, or strokes are identified and addressed, if possible, to try to prevent any further impairment.

The physiotherapist (PT) can design an exercise program to increase flexibility, strength, balance, and endurance. PT’s evaluate and train the patient in getting up from sitting, walking, stepping over curbs and going up stairs, using walking aids as necessary. The occupational therapist’s (OT) emphasis is on self-care skills, including bathing, dressing, and eating. They also focus on instrumental activities of daily living, such as cooking, housekeeping, using the telephone, and money management. The OT assists with education, training, compensatory skills, and adaptive equipment. The social worker plays a crucial role in discharge planning and as the primary communicator between the rehabilitation team and the family. Rehabilitation nurses encourage independence by providing physical or verbal assistance. They monitor skin care, bowel and bladder management, and provide guidance about medications.

Discharge planning begins as soon as the patient’s condition stabilizes and the likely functional outcome becomes clear. A home visit by a PT or OT may be useful to determine accessibility of the home environment and appropriate home modifications. Important considerations are the amount of support available (which can be a problem when the spouse is also frail and elderly) and the extent of care needs. Family meetings with representatives from the rehabilitation team, as well as community care providers, are often necessary to set up needed home help prior to discharge.

Stroke rehabilitation

Rehabilitation following a stroke should begin as soon as possible, to avoid the complications of immobility and to allow for maximal functional gains. Most functional recovery occurs within the first two to six months following a stroke, and early prediction of outcome is useful to set appropriate goals, facilitate discharge planning, and anticipate the need for home adjustments and supports. Muscle strengthening and general conditioning can reduce impairment and disability. Task-oriented exercise may be more meaningful to elderly patients and can contribute to motor recovery and gait retraining. Many stroke survivors have persistent activity limitation of the affected arm. Immobilization of the unaffected arm combined with intensive training of the affected one is occasionally used to improve arm function. Another approach involves facilitation of appropriate movement patterns in the affected arm. Depression is common after stroke and, unless treated, can interfere with recovery. Swallowing dysfunction should be looked for by an OT or speech-language pathologist.

Hip fracture rehabilitation

Falls and hip fractures are unfortunately common in frail elderly patients, and hip fracture rehabilitation is an important concern. Breaking a hip can result in nursing home placement or even death. An important predictor of being able to return home is pre-fracture mobility. Ongoing communication with the orthopedic surgeon is important to establish hip precautions, to avoid dislocation of an artificial joint, and for guidance on when the patient can begin to bear his full weight on the operated leg. Older patients may be unable to cooperate with partial weight-bearing restrictions, because of poor balance, weakness, or cognitive impairment. Although pain must be adequately treated, it is important to avoid overmedication and delirium in frail older adults. Fear of falling can become a limiting factor, and confidence must be addressed. Strengthening exercises (sometimes including treadmill gait retraining), balance training, and walking aids are standard components of hip fracture rehabilitation. Therapy can continue on an outpatient basis.

Inpatient rehabilitation can take place on the acute care unit (medical or surgical) or on specialized geriatric rehabilitation wards. If the patient is well enough to go home, outpatient rehabilitation can be facility-based or home-based. In some areas, geriatric day hospitals offer an intermediate solution to frail patients who have returned to the community. The types of geriatric services available vary depending on local preference, economics, and cultural attitudes toward the elderly. Particularly as the population ages, resources may not keep pace with needs. Outcome in geriatric rehabilitation very often depends upon the type and degree of social support available to the patient.

SUSAN FRETER

See also BALANCE AND MOBILITY; GERIATRIC MEDICINE; HIP FRACTURE; OCCUPATIONAL THERAPY; PHYSICAL THERAPY; STROKE; WALKING AIDS; WHEELCHAIRS.

BIBLIOGRAPHY

BARER, D. ‘‘Rehabilitation.’’ In Geriatric Medicine and Gerontology, 5th ed. Edited by J. C. Brocklehurst. London: Harcourt Brace, 1998. Pages 1521–1550.

BRUMMEL-SMITH, K. Clinics in Geriatric Medicine: Geriatric Rehabilitation. Philadelphia, Pa.: W. B. Saunders Co., 1993.

LÖKK, J. ‘‘Geriatric Rehabilitation Revisited.’’ Aging Clinical and Experimental Research 11 (1999): 353–361.

STEINBERG, F. U., and DEAN, B. Z. ‘‘Physiatric Therapeutics: Geriatric Rehabilitation.’’ Archives of Physical Medicine and Rehabilitation 71 (1990): S278–S280.

TAUB, E.; USWATTE, G.; and PIDIKITI, R. ‘‘Constraint-Induced Movement Therapy: A New Family of Techniques with Broad Application to Physical Rehabilitation—A Clinical Review.’’ Journal of Rehabilitation Research and Development 36 (1999): 237–251.

WEBER, D. C.; FLEMING, K. C.; and EVANS, J. M. ‘‘Rehabilitation of Geriatric Patients.’’ Mayo Clinic Proceedings 70 (1995): 1198–1204.

World Health Organization. ICIDH-2: International Classification of Functioning and Disability. Beta-2 draft. Geneva: World Health Organization, 1999. www.who.int/icidh

ZUCKERMAN, J. D.; FABIAN, D. R.; AHARANOFF, G.; KOVAL, K. J.; and FRANKEL, V. H. ‘‘Enhancing Independence in the Older Hip Fracture Patient.’’ Geriatrics 48 (1993): 76–81.