F-35 Geriatric rehabilitation
Geriatricians were perhaps the first doctors to be interested in rehabilitation in the UK; Marjory Warren (1897-1960) instituted rehabilitation when made responsible for 714 chronically ill patients in 1935. Their engagement grew in the UK, both clinically and academically, because rehabilitation was not recognised as a healthcare speciality or service for many years. Geriatrics has recently become more medically focused, but rehabilitation remains vital. As the scope of rehabilitation in the UK has grown, it has inevitably also taken on responsibility for older adults, a marked contrast to the situation when I started in rehabilitation in 1980 when only patients aged between 16 and 65 years were considered eligible for rehabilitation. Rehabilitation of older adults requires particular types of expertise. One must be familiar with diseases across all organs because many patients have many active diseases. Many patients will be frail; though this concept is ill-defined, it is best considered a lack of reserves so that small changes may lead to dramatic consequences. Cognitive impairment and loneliness are two other common issues.
Table of Contents
Competency in geriatric rehabilitation
The rehabilitation expert will be “Able to assess rehabilitation needs, give rehabilitation advice about, and take rehabilitation responsibility for any older patient referred for rehabilitation.” Defining an age limit is complex, and one might better consider it concerning characteristics such as multimorbidity. One alternative approach is to say it relates primarily to people over 80 or younger people with multiple morbidities and additional biological, psychological, or social vulnerability and low reserves. A downloadable document gives details of the behaviours, knowledge, and skills associated with this competency.
Introduction
Rehabilitation emerged, in the UK at least, with parallel development of different single-issue services. Marjory Warren was the exception. The first services concerned traumatic injuries, burns, amputations, and ‘shell-shock’. The last was rapidly disbanded despite its vast importance. Other services were developed for spinal cord injuries, wheelchair provision, cardiac and pulmonary conditions, rheumatological conditions, back pain, etc. Almost all services concerned people, mainly men, of working age,
Associated characteristics of early services were that conditions had a sudden onset and a natural tendency to improve, or, looked at from another perspective, the patients adapted successfully to their condition. Rehabilitation is generally avoided for people aged over 65 years, with multiple diseases, or with progressive disorders.
Geriatric services became involved initially with stroke, a disease of older adults, and later hip fractures. However, they soon appreciated the value of concentrating on improving or maintaining function and optimising function in the face of decline with age, which, initially, was accepted as natural and inevitable.
The comprehensive geriatric assessment
Geriatric rehabilitation may have started in 1935, but by 1955, the need for it was fully recognised. In ‘An effective comprehensive program for geriatric patients’, Murray Ferderber and Gerard Hammill wrote, “If we, as physicians, can agree that sound medical care must include the triad of diagnosis, definitive treatment, and finally rehabilitation, the problems of the aging present themselves more clearly. This report is not meant to deal primarily with definitive care and diagnosis but rather with rehabilitation and its ramifications.”
By 1982, Laurence Rubenstein and colleagues published ‘The role of geriatric assessment units in caring for the elderly: an analytic review.” This paper reviewed many studies of comprehensive geriatric assessment, mainly undertaken in hospitals. The concept appears to have emerged in 1975. They concluded, “The published reports on GAUs and rehabilitation units, although mostly descriptive and nonexperimental in design, support the contention that major improvements can be made in health care for elderly persons.” They also called for robust evaluation.
Forty years later, we have acquired some evidence, including three Cochrane reviews. Graham Ellis and colleagues reviewed the research into “Comprehensive geriatric assessment for older adults admitted to hospital”. They found that patients receiving comprehensive assessments in the hospital were more likely to be alive and in their own homes at follow. This mirrors the extensive research into stroke units, showing both a biological benefit (more likely to survive) and a functional benefit (more likely to be at home and independent).
This benefit is supported by a second Cochrane review on “Comprehensive geriatric assessment for older people admitted to a surgical service,” which found benefits for patients with a hip fracture. However, there was insufficient evidence to be sure about other surgical admissions.
In contrast, Robert Briggs and colleagues did not find much effect from “Comprehensive Geriatric Assessment for community‐dwelling, high‐risk, frail, older people”; it did not impact mortality or admission to a care home, although it might reduce the risk of unplanned hospital admission.
These studies do not elucidate whether comprehensive assessment is effective if undertaken in a hospital by a visiting team or whether it is cost-effective.
In 1998, I reviewed the evidence on the effectiveness of assessment in rehabilitation and suggested that effectiveness likely depends crucially on the same team’s associated comprehensive rehabilitation input. Studies on isolated assessment without a link to intervention generally do not show benefit, which is unsurprising.
Frailty
Older adults are often considered to be frail, and frailty is frequently mentioned when discussing geriatric rehabilitation. However, as I have discussed in a post, frailty is an imprecision concept. As with many ideas, frailty is not a definite state; instead, there are degrees of frailty.
Frailty may also refer to various aspects of the biopsychosocial model of illness. Biological or, better termed, physiological frailty concerns how resilient the body is, and this will be closely linked to multimorbidity. Functional frailty concerns how much functional reserve someone has; while physiological reserves influence this, it is also influenced by emotional, cognitive, and other psychological factors. The third separate domain concerns social support and networks; a socially frail person has minimal support available. This will be associated with loneliness, which itself may increase ill-health.
Frailty usually means that the person has limited capacity to participate in more intense rehabilitation interventions. This does not mean they cannot benefit. Rehabilitation must be tailored to the person. In practical terms, it is often called slow-stream and may be conducted in a care home or the community.
Multi-morbidity
Multi-morbidity is ill-defined and poorly measured. Iris Szu-Szu and colleagues reviewed 566 studies and found that 206 (36%) did not define multi-morbidity, and 73 (13%) did not describe the conditions included. Therefore, all studies of multi-morbidity must be interpreted cautiously, and comparisons between studies should be avoided unless definitions are given.
Milagros Ruiz and colleagues investigated the concept of the “complex elderly”. They accepted that complexity was difficult to define, though they referred to the biopsychosocial model of illness and the use of the INTERMED to measure complexity. They studied data from nearly three million hospital admissions of adults aged over 65 years. They identified three clusters:
- “Group 1 (multi-morbidity ≤2), associated with cancer and/or metastasis;
- Group 2 (multi-morbidity of 3, 4 or 5), associated with chronic pulmonary disease, lung disease, rheumatism and osteoporosis; finally
- Group 3 with the highest level of multi-morbidity (≥6) and associated with heart failure, cerebrovascular accident, diabetes, hypertension and myocardial infarction.”
Monika Kastner and colleagues have reviewed interventions for older adults with multi-morbidity. The first was a systematic review and meta-analysis investigating the Effectiveness of interventions for managing multiple high-burden chronic diseases in older adults. They reported benefits from care coordination strategies with or without patient education. This refers to considering and adapting “how, when and where health care is organized and delivered, and who delivers health care.”
In a later publication based on the same work, they published a realist review on Underlying mechanisms of complex interventions addressing the care of older adults with multimorbidity. Their essential message was that optimal management required a system-level approach in which clinical management and patient self-management were placed in the context of the person, the provider, and the health and social care system. They observed that people are concerned with symptoms and quality of life, whereas providers focus on disease and its effect on morbidity and mortality.
Conclusion
Geriatric rehabilitation requires the same generic knowledge and skills needed in all rehabilitation. The rehabilitation clinician needs to be more aware of the broader aspects of a person’s illness, especially their limited ability to adapt to minor changes in their bodily or mental capability, function, or social support and their limited ability to exercise and practice new activities which will slow down the adaptation. Nonetheless, they can still benefit from rehabilitation. Second, the expert needs to consider all a person’s conditions and review all medical treatments and rehabilitation interventions to reduce management burden, risk, and complexity. Last, and crucially, the healthcare system must acknowledge the complexity of managing older adults with limited reserves and multiple conditions that require more time and resources to improve.
