Introduction to geriatric rehabilitation

Elaine Y L Tsui 崔綺玲, Rosie T T Young 楊紫芝

HK Pract 2005;27:339-343

Summary

Many elderly are left with residual disability after hospitalization. Not all of them are candidates for geriatric rehabilitation. Yet, admitting the right candidate into a geriatric rehabilitation programme to reduce their disability is rewarding. This article introduces the family physician to the definition, effectiveness, clinical process of geriatric rehabilitation and who are the right candidates for geriatric rehabilitation.

摘要

許多長者出院後仍有一定的殘障，雖然並非所有病人都適合長者康復治療，但選擇適當的患者進行復康療程， 可以很有效地減輕他們殘障和不便。本文向家庭醫生介紹長者康復治療的寶貴效益，臨床經驗以及選擇病人的條件。

Introduction

The population of Hong Kong is ageing. The demand by the elderly for health care is great. People older than 65 years of age make up 11.4% of the total population yet they account for 50% of hospital admission in the Hospital Authority. Many elderly are left with residual disability after hospital admission. Geriatric rehabilitation can reduce their disability and can improve their quality of life.

Definition of geriatric rehabilitation

Geriatric rehabilitation is defined as functional assessment with realistic goal setting for the elderly through multidisciplinary team care and adjustment of therapy and interventions to prevent, reverse, or minimize disability.¹

Forms of geriatric rehabilitation

Geriatric rehabilitation is also known as comprehensive geriatric assessment. It is practiced in five programme types. They are (1) hospital geriatric evaluation and management unit (designated inpatient unit for comprehensive geriatric assessment and rehabilitation; (2) inpatient geriatrics consultation service (comprehensive geriatric assessment provided on a consultative basis to hospital patients in non-designated units); (3) home assessment service (in-home comprehensive geriatric assessment for community dwelling elderly person; (4) hospital home assessment service (in-home comprehensive geriatric assessment for patient recently discharged from hospital); and (5) outpatient assessment service (comprehensive geriatric assessment provided in an outpatient setting).

Comprehensive geriatric assessment is more effective with the following four characteristics: (1) exclusion of subjects with good health or functional status; (2) exclusion of subjects with poor prognosis; (3) control over implementation of medical recommendations; and (4) provision of long-term ambulatory intervention follow up.^2,3

The effectiveness of geriatric rehabilitation

The Marjorie Warren experiment

Geriatric rehabilitation was proven to be effective 50 years ago in England by Dr Marjorie Warren. Dr Warren was a pioneer of geriatric medicine. She was given responsibility for the West Middlesex County Hospital with several hundred chronic ill elderly. She developed a highly successful process of care: rehabilitation. What she had done is summarized in Table 1.⁴

Many studies have been done to prove that geriatric rehabilitation is effective since then. The result was summarized in the paper - "Comprehensive geriatric assessment: a meta-analysis of controlled trials" (Stuck, The Lancet 23 October 1993). The author did a meta-analysis on 28 controlled trials comprising 4959 subjects allocated to one of five types of comprehensive geriatric assessment type and 4912 controls. The result at six month of geriatric rehabilitation was compared with alternative care. The odd ratios for living at home, reduced mortality, improved physical function and improved cognitive function were 1.8, 0.68, 1.63 and 2.0 respectively.

The reasons for geriatric rehabilitation to be effective are:

1) Vulnerability of the elderly to functional decline.

The elderly are marginally functional because of multiple and chronic illnesses cumulatively erode organ reserve. Decompensation especially in mobility and self-care skill occur with minor superimposed or acute complication of disease process e.g. influenza, urinary track infection and chest infection.

2) Multiple degenerative diseases are common.

They are general osteoarthritis, chronic respiratory failure, ischaemic heart disease with heart failure, peripheral vascular disease, osteoporosis with hip fracture, and stroke. They are not cured with surgery or medical therapy. The elderly are left with residual disability so that rehabilitation can improve their function and quality of life.

3) Adverse effect of hospitalization.

One of the adverse effects of hospitalization is deconditioning. Deconditioning is due to: i) the elderly and family's expectation that the elderly to be totally taken care of after hospital admission; ii) the staff is too busy to supervise the elderly to care for themselves. Bed rest and totally taken care of in all aspect of activities of daily living result in bed rest during hospitalization with deconditoning.¹

Deconditioning

Deconditioning is defined as multiple changes in physiology induced by physical inactivity and reversed through physical activity. The changes associated with deconditioning are i) decreased maximum oxygen uptake; ii) shortened time to fatigue during submaximal work; iii) decreased muscle strength; iv) decreased in reaction time, balance and flexibility. Deconditioning is reversible through muscle strengthening resistance training programme and exercise programme (exercise for flexibility, aerobic endurance). The clinical significance of deconditioning are i) causing functional loss due to muscle weakness; ii) complicating functional loss of underlying disease. The causes of deconditioning are i) acute inactivity with bed rest during hospitalization; ii) chronic inactivity with sedentary lifestyle. Treatments are i) therapeutic exercise; ii) maintaining exercise habit by group exercise with social interaction and support.¹

The clinical process of rehabilitation

The key process (The Rs) of rehabilitation is listed in Table 2.⁴

The "hard" rehabilitation is made up of drugs, physiotherapy, occupational therapy, speech therapy, adaptation and appliances. The "soft" rehabilitation is made up of advising, education, counselling, encouragement and listening.

The core team members of rehabilitation team

The doctor provides medical care. The nurse provides patient care and patient and family teaching. The physiotherapist provides assessment and treatment for mobility problem. The occupational therapist provides training in activities of daily living, appliances and assistive device. The social worker assesses and mobilizes family and community resource.

Rehabilitation programme of therapeutic exercise

The prescription is based on current functional limitation, realistic goal setting, pre-morbid functioning, anticipated improvement in medical status, physical status, patient's participation and condition of proposed care giver after discharge. Formal therapy technique is incorporated into functional task. Examples are improving range of motion with dressing training and remediating perceptual problem during eating.

When patient is left with residual disabilities, aids and appliances are provided to improve function. New techniques will be taught to patient to achieve old tasks. Using one hand technique to achieve activities of daily living is an example.¹

Doctor's role in geriatric rehabilitation

The doctor's role are i) reassessment of medical status; ii) avoiding adverse drug effect; iii) managing common complication.¹

Reassessment of medical status

Admission of the elderly into the rehabilitation ward provides an opportunity to assess their medical status: a) confirming the accuracy of the referral diagnosis; b) evaluating previously unrecognized conditions; c) reviewing medication for continuing appropriateness.

Avoiding adverse drug effect

The key causes of adverse drug reaction are i) polypharmacy; ii) noncompliance; iii) increased susceptibility to adverse reaction; iv)altered pharmacokinetics; and v) altered receptor sensitivities.¹ The first two factors are treatable.

Polypharmacy is a term difficult to define. The causes of polypharmacy are multiple diseases with prescriptions from multiple specialties, self medication with nonprescription drugs like cough and cold preparation, vitamins, antacids and laxatives. To minimize polypharmacy, no medication should be used without an indication. If side effect of drug occurs, the drug should be changed rather than adding on other medications. Hospitalization provides continuous observation to discontinue questionable medications especially for digitalis, NSAID, and psychotropic medications.

Studies of compliance have shown that the more medications a patient takes, and the longer he or she is asked to take them, the more likely he or she will be to make important errors in administration or to decide to stop taking the medication. Thus individuals with multiple chronic illnesses taking multiple medications on a chronic basis are those least likely to comply with the full therapeutic regimen. This is typical of elderly with multiple chronic diseases. A reasonable regimen is less than six drugs per day, the number of doses less than 12, and the schedule is less than three times a day.⁵

The other causes of noncompliance are side effect of drugs, complicated regimen, and patient's belief that the drug is unnecessary. The consequences of noncompliance are post-discharge deterioration due to drug omission and drug toxicity after admission with drug supervised.

Optimal prescribing principles for the elderly are:

1) Review medication regularly.

Identify an indication for each medication and discontinue medications without any indication.
Assess whether any current medications are contributing to symptoms or signs of illness.

2) Before adding a new medication.

Maximize the use of non-pharmacological means.
Prescribe at the lowest effective dose.
Evaluate for potential drug interactions or allergies.

3) Educate the patient or caregiver on the medication.

Indication, proper administration technique, expected therapeutic effect, side effect potential.⁶

Managing common complication

The following complications are common with the onset of disability. This is because they are common in the elderly and worsened or induced by the onset of disability. They are urinary incontinence, sleep disorder, anxiety, depression, and pain. They should be looked for and treated in the usual way.

Factors affecting rehabilitation outcome

After the right candidate (patient without good health or functional status and without poor prognosis) is chosen for geriatric rehabilitation, the poor prognostic indicators are advanced age, inability to understand commands, dementia, urinary incontinence, pressure ulcers and visuospatial deficits. The most important prognostic factor among all these is severe dementia.

The role of geriatric day hospital

Geriatric day hospital provides medical assessment, nursing care, physiotherapy, occupational therapy and medical social service for patient who can be supported in the community. It is a good place to continue rehabilitation for patient in geriatric rehabilitation programme when they are medically stable. For patient with good social support, their personal need and activities of daily living are supported by carer, they can be discharged to geriatric day hospital when their medical condition is stable. Attendance in geriatric day hospital provides a smooth transition from hospital to home. The advantage of geriatric day hospital support are i) improving patients quality of life by returning home early ii) releasing hospital bed for other patient in need.

Conclusion

This article summarizes the rationale behind geriatric rehabilitation, the process of rehabilitation and the contribution of doctor in i) reassessment of medical status; ii) avoiding adverse drug effects; iii) managing common complications in the rehabilitation process.

Key messages

1. Geriatric rehabilitation was proven to be effective.
2. The right candidate has to be chosen for geriatric rehabilitation if the maximum benefit is to be obtained from it.
3. The role of geriatrician are i) reassessment of medical status ii) avoiding adverse drug effect and iii) managing common complication.