The British Geriatrics Society represent a speciality that, in the UK at least, delivers more rehabilitation than named expert rehabilitation services. Historically, services for specific disabling conditions, such as spinal cord injuries, burns, amputations, and the need for a wheelchair developed as needed, usually in response to war injuries. The first services focused on disability rather than a specific condition were designed for people with long-term disabilities. This development occurred in 1935, more than five years before the word rehabilitation was first used in a healthcare context (1940). In 1947, Trevor Howell, a general practitioner, founded the Medical Society for the Care of the Elderly with others. The skills held by the founding doctors included rehabilitation, management of incontinence, and assessment of elderly patients at home. In 1959, the original Society became the British Geriatrics Society (BGS). The Society’s core concern is with the care of the elderly. Nonetheless, rehabilitation is a significant area of practice and expertise. Specific areas of rehabilitation expertise include orthogeriatrics, old age psychiatry, and managing frailty.
Interest in rehabilitation
I will first establish that the British Geriatric Society has a significant interest and expertise in rehabilitation. While people working in the speciality will know this and take it for granted, others may not realise it. There is a risk that the public, commissioners, other healthcare specialities and even people working in elderly care services may relegate rehabilitation to the position of an add-on “if we have the time and resource”.
The UK curriculum for Geriatric Medicine is being finalised, but its current draft is unlikely to change much. You can find it here. There are seven high-level training outcomes/ from the speciality training programme that, in effect, define the speciality:
- Performing a comprehensive assessment of an older person, including mood and cognition, gait, nutrition and fitness for surgery in an in-patient, out-patient and community setting.
- This is similar to the first rehabilitation medicine capability: “ Able to formulate a full rehabilitation analysis of any clinical problem presented, to include both disease-related and disability-related factors.
- Managing complex common presentations in older people, including falls, delirium, dementia, movement disorders, incontinence, immobility, tissue viability, and stroke in an in-patient, out-patient and community setting
- This is similar to the Rehabilitation Medicine capability: “Able to diagnose and manage existing and new medical problems in a rehabilitation context”
- Managing older people living with frailty in a hyper-acute (front door), in-patient, outpatient and community setting.
- There is no direct equivalent, but this is really a subset of capability two above.
- Managing and leading rehabilitation services for older people, including stroke.
- This is an explicit rehabilitation capability.
- Managing community liaison and practice.
- This is a direct equivalent of the Rehabilitation Medicine capability: “Able to work in any setting, across organisational boundaries and in closecollaboration with other specialist teams.”
- Managing liaison with other specialties, including surgery, orthopaedics, critical care, oncology, old age psychiatry.
- This is also a direct equivalent of the Rehabilitation Medicine capability immediately above.
- Evaluating performance and developing and leading services with special reference to older people.
- There is no equivalent within Rehabilitation medicine curriculum, because we saw in as part of Generic Capabilities one and three: “Able to function successfully within NHS organisational and management systems.” and “Is focused on patient safety and delivers effective quality improvement in patient care.”
This review of the training curriculum shows that the speciality of geriatrics and thus the British Geriatric Society are interested in, undertake and have expertise in rehabilitation.
Rehabilitation and Geriatrics.
The British Geriatric Society does not have a long-term special interest group for rehabilitation, probably because rehabilitation is an integral part of elderly care. Unfortunately, this may lead both geriatricians and healthcare, politicians, commissioners and the public to forget that rehabilitation is a core, specific and separate area of knowledge and skills.
The failure explicitly to acknowledge the importance of rehabilitation within the geriatric practice is a risk to the speciality, who may lose resources considered unnecessary for their ‘core business’ as perceived by others. It is also a risk to rehabilitation because the same groups may not recognise that elderly care services provide rehabilitation and so not realise how much resource is devoted to rehabilitation.
Research by geriatricians has provided much of the evidence supporting rehabilitation. Conversely, research by rehabilitation experts has provided much evidence to support geriatric care. The two services overlap so much that they are indistinguishable when considering rehabilitation.
Geriatricians were the first to stress that visual and auditory impairment is common in older people and must always be looked for and managed. They necessarily link to rehabilitation services for impaired hearing and vision. Immobility is common in older people, and geriatric services also use assistive technology rehabilitation services.
Geriatricians and named rehabilitation services will often see similar patients. For many conditions, a patient may receive rehabilitation from a designated expert rehabilitation service, an elderly-care rehabilitation service, non-specific community services, or no service. There are no features to distinguish which patients will be seen in what service. Usually, it is a matter of chance, or local preferences and referral routes, or geography. For example, and person of 85, previous very fit and active, who has a complex stroke may well be seen in an expert rehabilitation service when a person aged 70 years with a similar stroke, who is also frail, would usually be seen by a geriatric service.
It is likely that Covid patients may be seen in any one of a panoply of services: cardio-pulmonary rehabilitation, expert name rehabilitation services, paediatric services, neurological services, psychiatric services and geriatric services. Indeed, the British Geriatric Society has set up a short-term, ‘task and finish’ rehabilitation group specifically to consider rehabilitation after Covid in the elderly population. (here)
Individual patients may be seen in a geriatric service and a named rehabilitation service simultaneously or sequentially, being transferred from one to the other.
Some personal reflections
I think that services explicitly identified as rehabilitation services have much to learn from geriatric services.
In the late 1960s, geriatric services were in a similar situation to the position of rehabilitation medicine now: a small speciality with few consultants, not recognised as being of value, under-resourced, limited evidence base. The road to success involved becoming integrated into acute medical care teams. Over time geriatricians demonstrated their value. Initially, the value primarily followed on from their pursuit of rehabilitation. Now geriatricians are so integrated that they participate in general medical take. This involvement in acute care may have reduced the time and other resources available for rehabilitation. Nonetheless, we should learn from geriatricians that one road to success is attending ward rounds run by acute care physicians.
Geriatric services in some areas also have close working links with nursing homes and are expected to see and advise on the needs of people in long-term care. As part of this, hospital-based geriatricians are also involved in other community services and may visit patients at home less frequently than was once the case. It is relatively rare for rehabilitation services to be involved with nursing homes. Some home visits do occur, but most community rehabilitation services are run separately from hospital services, and few have a fully multi-professional service. For example, approximately 70% of community rehabilitation teams have no medical input, and over 50% have no input from nursing, clinical psychology, speech and language therapy or dietetics. (here)
It seems probable that elderly care services would be a good source of ideas about and experience of the different service organisation and delivery types. The clinical and management problems faced by geriatricians are probably similar to those faced by most rehabilitation services. Sharing our mutual expertise and experience would almost certainly benefit both parties. Trainees in rehabilitation would learn much from an attachment to their local geriatric service. The reverse is also likely to be true.
Conclusions
There is considerable overlap between geriatric medical practice and rehabilitation medical practice, but at present, we do not use this overlap to improve our services. There are opportunities for shared learning about service organisation, rehabilitation processes and interventions, and the management of specific clinical situations. We can also share many educational and training resources. As an area of particular expertise in the UK, rehabilitation has many progenitors, such as rheumatology, neurology, spinal cord injury services, and prosthetic services. However, geriatric practice was probably a significant albeit unrecognised parent. The British Geriatrics Society would be a vital member of any rehabilitation community.