CHAPTER 16 REHABILITATION
Practice of Geriatrics
CHAPTER 16 REHABILITATION
Helen M. Hoenig, M.D.
The Disablement Process
Rehabilitation Assessment (Approach, Specific Tests, and Examinations)
Sites and Reimbursement for Rehabilitation
Rehabilitation for Specific Diseases
Rehabilitation is a restorative process that aims to maximize a patient’s functional abilities through the treatment of impairments, disabilities, and handicapping circumstances. This process can occur through many different interventions, and it can be carried out by a variety of people and in a wide variety of settings. This chapter provides a conceptual framework for the use of rehabilitation and for development of a rehabilitation plan that is suitable for geriatric patients. In particular, this conceptual framework helps to provide an understanding of the determinants of functional dependence and independence in the geriatric population and of the role of specific rehabilitative interventions. The most commonly used interventions will be described and their use outlined for the conditions seen most frequently in the geriatric population.
Approximately one in every seven Americans has a disabling condition that interferes with his or her life activities. Annual disability-related costs total more than $170 billion.1 Disabilities are disproportionately represented among the elderly and lower socioeconomic populations.1 Rehabilitation is the primary means of treating disability; its goals are independence in daily living skills and independent functioning in the community.
The success of rehabilitative treatment depends largely on patient participation. Therefore, an agreement between the patient and the provider on the goals of treatment is particularly important. Patients and health care providers sometimes disagree with each other about treatment because they have different beliefs about the origin of disease and how it should be treated and about what constitutes wellness. All of us, patients and providers alike, subconsciously or consciously have a conceptual model of the causes of health and ill health. This model determines the person’s approach to coping with illness and influences the goals of health care. The pertinence to rehabilitation lies in the effect of the model on the strategies chosen to cope with chronic illness and during the recovery period after acute illness. People with chronic arthritic pain may be reluctant to engage in regular exercise because they believe that the best treatment for pain is rest. After a heart attack some patients may be fearful about resuming vocational or avocational activities. Similarly, some patients may be reluctant to forgo personal assistance with self-care to achieve greater independence if they come from a family milieu in which a primary means of expressing love is caretaking during illness, especially if assistance with self-care is their only source of caring touch. By the same token, the physician’s underlying conceptual model of the illness in question drives the interventions he or she may select to treat the illness. As with other medical diseases, the sophistication of our understanding of the disablement process, i.e., our conceptual model of disability, determines both the diagnostic and therapeutic approaches to the treatment of disability. It is important, therefore, to understand our own models of disease and illness and how they may conflict with those of our patients. The next section will focus on conceptual models of disability.
THE DISABLEMENT PROCESS
We will begin by reviewing two traditional models of health and illness. The first is the biomedical model, and the other is the quality-of-life model. The biomedical model is the model most familiar to physicians and to many health care providers. The focus of this model is on the “etiologic agents and processes that affect biologic, physiologic, and clinical outcomes. It focuses on understanding causation and is derived from biology, biochemistry, and physiology.”2 This model is the basis for many of the advances in medicine that have occurred during the last 100 years and is most useful for unicausal processes. The quality-of-life model, on the other hand, focuses on “function and well-being. It is most useful for understanding complex behaviors and is derived from the fields of social science, psychology, and economics.”2 Because functional disability is a complex behavior caused by biologic, physiologic, psychological, economic, and social factors, effective treatment requires a combination of the two models.
Several attempts have been made to meld these two conceptual models.1,2,3 and 4 For example, function or behavior can be considered as the product of biologic factors, environmental factors, and psychological factors3 (Fig. 16-1). Losses in any of these three areas can cause a decrement in function. For example, someone who has been able to live independently in the community after a stroke through the use of paid personal assistance may no longer be able to maintain himself in the community if he suffers a loss of income. Similarly, someone with paraplegia who has been able to manage wheelchair mobility and transfers independently may no longer be able to function this way if she develops degenerative arthritic disease of the shoulders.
Figure 16-1 Conceptual model of disablement process.
The World Health Organization (WHO) adopted a conceptual framework for disability in 1980.4 The WHO model has been criticized, primarily because of measurement and semantic issues in regard to disability and handicap. In 1991 the Institute of Medicine published a revision of the WHO model that takes into account some of these concerns.1 However, the WHO model remains the most widely accepted one and will be used throughout this chapter.
In the WHO model, disease is defined as “an intrinsic pathology or disorder that gives rise to changes in the structure or function of the body. Pathologic changes may or may not be evident clinically.”4 Disease, if sufficiently severe, may result in an impairment. Impairment is defined as a “loss or abnormality of structure or function at the organ system level. At this stage, an affected individual becomes aware of the pathology or, in behavioral terms, becomes aware that he or she is unhealthy.”4 So, for example, a person who has had untreated hypertension for a long time may have a stroke. If an impairment is severe enough or if other facilitating factors are present, the impairment may become manifest as a disability. Disability is a “restriction or lack of ability to perform an activity in a normal manner or a disturbance in the performance of daily tasks. Disabilities are the functional consequences of impairments.”4 Thus, a stroke may or may not be severe enough to interfere with walking.
Finally, depending on societal circumstances, a disability may become manifest as a handicap. Specifically, a handicap is a “disadvantage due to impairment or disability that limits or prevents fulfillment of a role that is normal (depending on age, sex, and social and cultural factors) for the affected individual. The nature and severity of a handicap are determined in large part by the interaction of the person with his or her social and environmental surroundings and the adjustments made by society to it.”4 Thus, for example, if the workplace and home environment are wheelchair accessible, vocational pursuits and independent function in the community may continue despite inability to walk after a stroke.
Disability can be unicausal or multicausal in origin. Multicausal disability is more common in the geriatric population. A number of factors can affect the disablement process (Fig. 16-2). These factors can be thought of as external to the individual (extrinsic factors) and internal to the individual (intrinsic factors).5 In general, intrinsic factors include such things as comorbid disease, disease severity, and comorbid impairments such as poor cognition. They include the patient’s education, culture, and motivation. Extrinsic factors include medical treatment, preventive health care, rehabilitative treatment (e.g., physical therapy), the physical environment, social supports, finances, and so on. Disability and impairment can themselves cause additional diseases and impairments. For example, a patient who is bed-bound because of a stroke may develop pressure sores. It is through a thorough understanding of these factors and their relationship to disability that we can reduce disability and handicap.
Figure 16-2 Conceptual model of disablement process and the role of specific factors in that process.
Since disability in the geriatric population is often multicausal, effective treatment usually requires consideration of the many underlying causes at work. One of the clearest examples of multiple causation is seen in the ability to ambulate after an amputation. Ambulation with a prosthesis significantly increases the work of walking; the higher the amputation, the greater the energy requirement. Typically, patients slow their gait speed to compensate for the increased work required. However, in the presence of significant heart or lung disease, a patient may not be able to meet the energy requirement for independent ambulation. Optimizing cardiac and lung function is a priority in these patients. In some patients with severe cardiopulmonary disease, particularly those with high-level or multiple amputations, independent ambulation may not be a realistic goal. Rehabilitation resources would then be better directed toward obtaining a wheelchair, teaching the patient safe transfer techniques, and ensuring that the patient’s environment is wheelchair accessible. Thus, the rehabilitation plan must consider all intrinsic and extrinsic factors that contribute to the disablement process. Figure 16-3 is an example of a rehabilitation plan for a specific patient that shows the typical complex interacting factors that often affect function in older patients.
Figure 16-3 Clinical assessment and management map of the results of a disability assessment. Each column heading indicates the type of information listed below it. For example, column one lists three diseases responsible for significant impairment in a person (cataract, stroke, and depression). Different types of management are needed for diseases, impairments, disabilities, and handicaps.
In the Disability column, walking is the key disability from which the patient’s other problems stem. If the patient’s mobility can be improved, many of the other problems can be improved.
In the Handicap column, the key issue is the patient’s ability to live independently (role functioning). Because of social and environmental circumstances, the patient’s difficulty with walking threatens to force him to move into a nursing home. However, nursing home placement may not be necessary if treatment of the patient’s disease, impairment, and disability is undertaken, along with other environmental modifications (e.g., moving to the first floor). Improvement in the remaining environmental stressor (e.g., spouse’s caregiver stress) can be expected as the patient becomes more mobile. (From Rubenstein LV: Using quality of life test for patient diagnosis or screening, or to evaluate treatment. In Spilker B [ed]: Quality of Life and Pharmacoeconomics in Clinical Trials. Philadelphia, Lippincott-Raven, 1996, pp. 363–374.)
Identification of the intrinsic causes of disability requires the diagnostic input of the physician about the underlying disease states; it is assisted by diagnostic input from rehabilitation therapists about coexisting impairments that may be contributing to the disablement process. Identification of the intrinsic causes of disability in a given patient (i.e., the diagnostic work-up) is aided by an understanding of the prevalence and impact of diseases and impairments seen generally in older people. Some diseases carry a greater likelihood of causing disability—that is, they have a high disabling impact. These include diseases such as hip fracture and stroke. Among older persons, a stroke doubles the odds of developing disability, and arthritis increases the likelihood of developing disability by 50%.6 More than 60% of persons suffering a hip fracture will incur a reduction in functional ability.7 On the other hand, hip fracture is a relatively rare occurrence compared with arthritis, so the overall impact of hip fracture on disability in the population as a whole is smaller than that of arthritis. Diseases that cause significant disability and also are highly prevalent in the older population include arthritis, cardiopulmonary disease, and eye disease.8
One can also characterize the effect of intrinsic impairments on the likelihood of developing functional disability. Specifically, in the geriatric population, lower extremity impairments such as difficulty in rising from a chair (which requires both strength and balance), limitations in upper extremity strength, visual or hearing impairments, and affective disorders all have been found to predict functional disability. Persons with none of these impairments have a 7% likelihood of developing functional dependence, whereas persons with three of these limitations have a 60% chance of developing functional dependence.9 Obesity and cognitive impairments are also significant risk factors, but the magnitude of their risk has not been well characterized.
Extrinsic factors can also affect the likelihood of disability in a given individual. Extrinsic factors include psychosocial factors that modify the likelihood or extent of disability and handicap as well as many of our traditional medical and rehabilitative interventions. Extrinsic factors can affect the disablement process at the disease level, the impairment level, the disability level, and the handicap level, and this is a useful way of thinking about treatment of disability.
At the disease level, preventive health care, like regular exercise, appears to prevent development of disability. For example, one recent study found that members of a running club developed disability more slowly than community controls. There were no differences in the two groups in the development of osteoarthritic changes, and the study adjusted for age, obesity, baseline function, and comorbid disease.10 Again at the disease level, medical and surgical care can affect function. For example, in patients with visual deficits due to cataracts, surgery was shown to improve performance of activities of daily living and timed manual performance.11 Similarly, use of anti-inflammatory medications can improve function by reducing pain and inflammation in patients with rheumatoid arthritis.
At the impairment level is the process that is classically thought of as rehabilitation. Rehabilitative interventions at this level are often directed toward improving strength and range of motion. For example, in one study, a resistive exercise program (which treats muscle weakness caused by deconditioning) significantly improved stair climbing and gait speed, and increased general physical activity in the very elderly.12 Impairment-related rehabilitation may also include specific equipment items such as hearing aids.
Classic rehabilitative techniques are also often used at the disability level. These techniques include interventions such as assistive devices and adaptive equipment that make functional tasks easier. Hart and colleagues showed that provision of assistive devices significantly reduced difficulty with activities of daily living and the time required for their performance.13
Finally, handicap level interventions include techniques such as patient and family education, for example, to alter beliefs about the sick role in patients with chronic illness. Such education may be needed so that people will return to an active lifestyle even if they still have physical symptoms of disease rather than staying in bed as if they were sick. Other handicap level interventions include reducing architectural barriers, increasing financial resources, and vocational retraining.
REHABILITATION ASSESSMENT (APPROACH, SPECIFIC TESTS, AND EXAMINATIONS)
Clinical assessment for rehabilitation14 begins by characterizing the disability or disabilities and then proceeds with the differential diagnosis accordingly. To characterize the disability one needs to determine (1) the severity of the disability (e.g., how far the patient can walk, the frequency of the falls, and how much help is required for bathing); (2) any compensatory techniques or adaptations the patient has made (e.g., use of a cane or a shower seat); and (3) any symptoms associated with the complaint (e.g., pain, shortness of breath, weakness, etc.). Pain and affective disorders commonly contribute to disability and should be specifically investigated. Complaints about pain should be evaluated for the location, quality, radiation, and timing of the pain. It is also important to question the patient about disabilities he or she may not have mentioned. For example, someone who presents with a chief complaint of falls is also likely to have difficulty in rising from the toilet and getting into and out of the tub.
Once the disability or disabilities have been characterized, the assessment should proceed to identification of the relevant causes, i.e., the differential diagnosis. In approaching a differential diagnosis of disability, it is best to start with the impairment level before specific disease diagnoses are considered—otherwise, the differential is overwhelmingly long. For example, more than 50 different diseases can cause difficulty with walking; however, there are only nine basic impairments that can primarily affect walking. Similarly, difficulty with self-feeding in a nursing home patient may be due to cognitive impairment, hand and arm weakness, impaired vision, swallowing difficulties, or abdominal pain. The differential diagnosis varies substantially according to which body system the clinician believes is the most likely culprit; however, the assessment is much more straightforward once the relevant body system has been identified. Thus, if the diagnostician can narrow down the causal factors at the impairment level, the work-up and treatment will be more manageable, in that most of the standard differential diagnoses taught in medical school relate specific impairments to possible underlying diseases.
Thus, the clinical assessment in patients with a new-onset disability should be directed first at defining the relevant impairments. As previously discussed, the likely culprits are lower and upper extremity impairments (e.g., weakness, contractures, incoordination), sensory deficits (e.g., reduced proprioception, visual deficits), obesity, impaired cognition, and affective disorders. Thus, the clinical examination should focus on these areas. Special attention should also be directed toward any specific complaints the patient may have mentioned (e.g., shortness of breath with exertion would prompt the diagnostician to perform a thorough cardiopulmonary examination).
If data from the history point to particular impairments, the physical examination targets those areas. Otherwise, the physical examination can begin in the traditional fashion with the head and neck. Examination of the head and neck should include a thorough assessment of vision, including visual acuity, visual fields, and nystagmus. Hearing can be examined with the whisper test. The oral examination should include inspection of the tongue for asymmetry and appreciation of any speech abnormalities (e.g., hypophonia is common in parkinsonism, and a scanning speech pattern should alert the diagnostician to possible cerebellar dysfunction). The clinician should also test for dysphagia by asking the patient to drink some water and observing for any cough or drooling (which would alert the clinician to the possibility of amyotrophic lateral sclerosis or other neurologic disease). Key tactile senses are light touch and position sense. A Romberg test provides a gross assessment of position sense.
The back and neck should be inspected for scoliosis, kyphosis, or other loss of range of motion (spinal stenosis is a fairly common cause of functional impairment in older patients). Functional range of motion for the upper extremity is tested by asking the patient to (1) clasp the hands behind the head; this tests external rotation and abduction of the shoulder as well as elbow flexion; (2) clasp the hands behind the back, which tests internal rotation of the shoulder. Limitations in upper extremity range of motion are likely to affect dressing, bathing, and housework.
Functional range of motion for the lower extremity is tested by asking the patient to (1) place the ankle on the opposite knee, which tests external rotation of the hip, hip flexion, and knee flexion. While the patient is in this position, examine the ankle to determine whether the patient has at least 90 degrees of dorsiflexion. (2) With the patient supine on the examination table, flex the knee of one leg to the chest. The patient should be able to keep the other leg flat on the examining table. This maneuver tests both hip and knee extension in the extended leg, and hip and knee flexion in the flexed leg. At this time the knee of the extended leg can be examined to confirm the presence of 180 degrees of hip and knee extension and to detect any varus or valgus deformity of the knee or any medial or collateral ligmentous laxity. With the foot of the flexed leg firmly on the examination table, the flexed knee can be examined for laxity of the anterior or posterior cruciate ligament. Hip, knee, and ankle range of motion are particularly pertinent to walking and mobility in the community because even a loss of 5 degrees of hip or knee extension can markedly increase the work of walking and may preclude functional ambulation. Loss of ankle range of motion to less than 90 degrees of dorsiflexion (e.g., during prolonged hospitalization) can adversely affect balance and can interfere with ambulation. Similarly, loss of hip and knee flexion makes rising from a chair much more difficult.
Strength in both the upper and lower extremities should be tested. Functional arm strength can be checked by asking the patient to put a heavy book on a shelf; functional pinch strength is assessed by asking the patient to grasp a piece of paper and then resist its removal. Useful screening tests for lower extremity strength include ability to stand on one foot (assistance with balance may be needed), the number of times a patient can stand from a sitting position (normal is five times without using the arms to assist), and the number of times the patient can rise on tiptoe (normal is five to ten times). If any abnormalities are found in either upper or lower extremity screening tests, manual muscle testing should be performed.
Coordination can be easily assessed by asking the patient to perform rapid alternating movement (e.g., toe taps) and/or the finger-nose-finger maneuver (which simultaneously checks functional vision, arm strength, and coordination). Static and dynamic sitting and standing balance are examined by asking the patient to assume independent seated and standing positions and then challenging him or her with a gentle push (be sure to be able to assist the patient to resume balance should it be necessary). A useful test of standing balance is the functional reach test (in which the patient reaches as far forward as he or she safely can while remaining in a standing position; see Duncan and colleagues15 for details). Finally, the examination should include an assessment of the patient’s gait (e.g., using the Tinetti gait and balance test or the Get Up and Go test).16,17 Last but not least, cognition and affect should be examined. Useful screening tests for these include the mini-mental state examination and the geriatric depression scale, although many others exist.15
At the end of the history and directed physical examination, the diagnostician should have a clear impression of the likely contributory impairments. If the case remains unclear, referral is indicated.18 Assuming that the causal impairments have been identified, the diagnostic work-up is then directed toward determining which underlying diseases are responsible according to standard medical procedure e.g., the differential diagnosis for monoarticular arthritis includes trauma, infection, gout, and so on, and the clinician would proceed with arthrocentesis). After the disablement process has been characterized according to causative diseases and impairments and any contributory intrinsic or extrinsic factors, an appropriate treatment plan can be developed.
The rehabilitation treatment plan is developed after the disablement process has been characterized, a process that includes identification of intrinsic and extrinsic factors. Interventions can then be specifically directed at the identified causal factors and can also be considered systematically according to the point in the disablement process where they may be effective—i.e., one should systematically review whether any useful interventions are possibly at the disease level, at the impairment level, and so on. By using the conceptual model of disability, the clinician can develop a rehabilitation plan that is specifically designed for the needs of the individual patient. Figure 16-3 is an example of the causal pathway of disability and appropriate related treatment interventions in a specific patient. In developing the treatment plan, consideration should be paid to both the suitability of a rehabilitative intervention and its timing in relation to other interventions (Table 16-1). Owing to the multicausal nature of geriatric disabilities, successful treatment often requires a multidisciplinary approach using the expertise of many professionals. The role and training of the individuals in the multidisciplinary rehabilitation team, and where and how their services can be obtained, are reviewed in the next two sections.
TABLE 16-1 GUIDELINES FOR GERIATRIC REHABILITATION
Who provides rehabilitation interventions?19 A number of different professionals can provide important rehabilitative interventions and may have to be included in the health care team for an individual patient. As outlined in the following paragraphs and as shown in Figure 16-4, these providers can be thought of in terms of their impact at different levels of the disablement process. There is a great deal of overlap and variability in the roles played by rehabilitation providers; the descriptions that follow are therefore generalities and may differ significantly among specific providers and facilities.
Figure 16-4 The role of different health care providers in the disablement process. For reasons of space and clarity, not all rehabilitation providers are depicted. Please see text for details.
Treatment provided by physicians largely acts at the disease or impairment level. For example, an internist may give a patient a cortisone injection to reduce inflammation caused by trochanteric bursitis. When the inflammation in the bursa is decreased, the patient experiences a reduction in impairment (reduced pain), a reduction in disability (improved gait), and a possible improvement in ability to maintain social roles through participation in leisure activities, (such as playing golf or hiking). Similarly, a surgeon may place an artificial knee in a patient with severe osteoarthritis. Physicians may also act as leaders of the rehabilitation team, particularly physiatrists, neurologists, orthopedists, and geriatricians. Physician referral is often required for the patient to gain access to rehabilitation providers, i.e., the physician acts as gate keeper. Thus, it is incumbent on the geriatric physician to be familiar with the role and function of specific rehabilitation providers. The actual rehabilitation services are traditionally delivered by physical, occupational, and speech and language therapists. Other personnel routinely involved with rehabilitation care include nursing personnel, social workers, and dietitians. In addition, some programs have kinesiotherapists, recreational therapists, vocational rehabilitation therapists, psychologists, psychiatrists, and prosthetists who may also contribute to the overall rehabilitation effort.
Physical therapy (PT) affects primarily the impairment and disability levels. Physical therapists work most specifically with the musculoskeletal and neurologic systems. They provide the following kinds of services: (1) evaluation of joint range of motion and muscle strength; (2) exercise training to increase range of motion, strength, endurance, and coordination; (3) evaluation of mobility (gait or wheelchair) and need for mobility aids and training in their use; (4) treatment with physical modalities, including heat, cold, ultrasound, massage, electrical stimulation, iontophoresis, and so on; and (5) home safety evaluation, sometimes in conjunction with occupational therapy.
Occupational therapy (OT) is largely directed at the disability and handicap levels, although OT hand therapy specialists also provide impairment level interventions. Occupational therapists (OTs) evaluate and train patients in self-care activities and activities of daily living. They recommend and train patients in the use of assistive devices and adaptive equipment for self-care. OTs also work with the cognitive aspects of independent living skills such as the handling of money, safety in the kitchen, and other issues requiring proper judgment. Compensatory techniques to adjust for sensory-perceptual or motor deficits are taught by OTs. They may address prevocational and leisure time issues with patients and their families. OTs and physical therapists (PTs) work together to maintain the patient’s range of motion and strength, especially in the upper extremities. OTs may also work in conjunction with speech therapists and nutritionists to help treat difficulties with self-feeding and dysphagia.
Speech therapists work mainly with patients with impairments and disabilities and secondarily with handicapping circumstances. They help patients with all aspects of communication, and they participate in the evaluation and management of patients with swallowing disorders. Because communication involves many components, the speech pathologists intervene at several levels, including evaluation of cognitive skill and aphasia in patients with cortical dysfunction. Management of patients with laryngectomy and other head and neck surgical procedures is also within the scope of the speech pathologist, as is evaluation of swallowing on radiographs, by endoscope, and at the bedside.
Nursing personnel have roles and functions that span the entire spectrum from disease to handicap. Some nurses have specialized training in rehabilitation. Nurses function in an important way in facilitating the patient’s independent performance of activities of daily living during daily care. They are an important source of information and education for caregivers and as such may act to reduce both disability and handicap. Nurses help patients manage self-medication, independent bowel and bladder activity, and prevention of secondary complications such as pressure ulcers, as well as provide medication, nutrition, and wound care.
Social workers direct their efforts primarily toward reducing handicapping circumstances. They perform tasks of evaluation, disposition counseling, and liaison with the community. They evaluate the patient’s social, physical, and financial home environment. They engage family, community, government, and other resources to assist patients in returning to an appropriate setting for their new level of function. Social workers also provide individual and family counseling. They make home visits and interact with entitlement providers such as Medicare on behalf of the patient.
Dietitians have the greatest impact at the impairment level by preventing or reducing nutritional deficiencies, which can retard recovery from a disability (e.g., reduction of muscle mass due to protein malnutrition reduces strength and exacerbates disability). Dietitians assess the patient’s nutritional status and suggest alterations in the patient’s diet to maximize nutrition. In conjunction with speech pathologists and occupational therapists, they may treat eating disorders, for example, by altering the consistency of the diet for patients with dysphagia.
Recreational therapists influence the patient at the level of handicap—that is, the ability to maintain social roles and carry on leisure activities. They facilitate the use of organized leisure activities and usually work with patients in group settings, emphasizing social interactions. Personal leisure activities such as hobbies and avocations are used by the recreational therapist to improve self-reliance and self-care. Such activities may help the patient adjust to a new disability. Recreational therapy can be helpful in achieving the goal of community reintegration.
Vocational counselors influence the level of handicap by helping patients return to the work environment. Patients may be able to return to their previous employment with adaptations, or they may be assessed for alternative employment. Vocational counselors usually see patients near the end of their inpatient rehabilitation stay or after discharge. Even in the geriatric setting, vocational counseling may be an important component of the rehabilitation process.
Psychologists are included on the rehabilitation team if testing is needed to assess the patient’s psychological or cognitive abilities or if there is a need for counseling. Psychiatrists may be consulted for assessment and pharmacologic treatment of patients with disorders such as depression or dementia, which can interfere with the rehabilitation process. Both psychologists and psychiatrists may be involved in providing counseling and psychotherapy to assist the patient in making adjustments to changes resulting from the new disability.
Prosthetists fabricate and fit braces and other orthotic devices, particularly those for the feet, lower limbs, and back. When an individually fitted orthotic device or splint is needed for the upper extremity, it is usually fabricated by the occupational therapist.
In different settings, other professionals may also participate in the rehabilitation process. In Department of Veterans Affairs hospitals, kinesiotherapists also known as corrective therapists) work alongside physical and occupational therapists. Kinesiotherapists emphasize long-term maintenance of fitness and conditioning. Music therapists and horticulture therapists can also provide useful services in the treatment of disabled elderly patients and can have beneficial effects on the quality of life of these patients.
SITES AND REIMBURSEMENT FOR REHABILITATION
Rehabilitation is usually reimbursed by one of three major sources. The site in which rehabilitation is offered may be affected by the available reimbursement. Most geriatric rehabilitation services have generally been reimbursed through Medicare; other sources include private insurance (which usually reimburses in a manner similar to that of Medicare), Medicaid, and the Department of Veterans Affairs.19 Changes in Medicare are expected as prospective payment for rehabilitation and ambulatory care is enacted, and this change may affect the use of rehabilitation services. Health maintenance organizations often use nursing homes for rehabilitation rather than rehabilitation hospitals for their covered patients.
The major sites in which rehabilitation services are currently offered include acute care hospitals, rehabilitation hospitals, skilled nursing care facilities, outpatient settings, and at home. There is some evidence that the site where rehabilitation services are provided can affect treatment outcomes for patients with strokes; however, such evidence is still limited. The following list is a summary of the kinds of rehabilitation services typically available in different settings and the goals typical of rehabilitation treatment in each setting.20
Acute care hospital. Generally, patients can receive only short-term therapy in this setting because of constraints on the length of stay. The intensity of therapy may vary widely according to staff availability and hospital policy. Typical goals of therapy in acute care hospitals may include diagnostic and prognostic evaluation (e.g., gait assessment, assessment of the patient’s functional abilities and home situation for discharge planning), patient and family education, and short-term therapeutic interventions to facilitate early discharge or improve recovery.
Inpatient rehabilitation hospital. Inpatient rehabilitation may be provided by freestanding hospitals or by distinct units of acute care hospitals. These hospitals are staffed by a full range of rehabilitation professionals, and an interdisciplinary team provides a comprehensive rehabilitation program for each patient. Hospital inpatient rehabilitation is generally more intense than rehabilitation offered in other settings and requires greater mental and physical effort from the patient.
Skilled nursing facilities. Rehabilitation programs in nursing facilities vary widely in the spectrum of services provided. Hospital-based nursing facilities are located in or adjacent to acute care hospitals. They provide rehabilitation services designed primarily for patients who have the potential to improve enough during 2 or 3 weeks of treatment to become candidates for inpatient, home, or outpatient rehabilitation. Programs in community-based nursing homes also vary. Some are nearly as comprehensive as inpatient rehabilitation hospital programs, whereas others are very limited in scope.
Outpatient rehabilitation programs. These programs are offered by both hospital outpatient departments and by freestanding outpatient facilities. They can provide either a comprehensive rehabilitation program (i.e., multidisciplinary rehabilitation treatment) or individual rehabilitation services i.e., services offered by a single provider type, for example, physical therapy). An advantage of outpatient programs is that they enable the patient to live at home while retaining access to an interdisciplinary program and to rehabilitation equipment. The patient also has opportunities to make social contacts and obtain peer support. Although they are frequently more intense, day hospital programs are otherwise similar to outpatient programs. The patient spends several hours, 3 to 5 days per week, in a typical day hospital program. Availability of transportation is a prerequisite for both outpatient and day hospital programs.
Home rehabilitation programs. These programs usually provide physical therapy, occupational therapy, and nursing services. Some of these programs also offer speech therapy and social work services. Programs are expanding their capabilities, and some now provide comprehensive services, including home visits by physicians and intense rehabilitation services. An advantage of home rehabilitation programs is that new skills are learned in the same environment where they will be applied. An additional advantage is that many patients function better in a familiar environment.
REHABILITATION FOR SPECIFIC DISEASES
The following section offers an overview of rehabilitation interventions for specific syndromes and conditions. These suggestions should be modified according to individual patient needs.
Rehabilitation is commonly used after an acute stroke. Depending on the specific impairments caused by the stroke, rehabilitative interventions may include physical therapy, occupational therapy, and speech therapy. For moderate to severe strokes, all members of the rehabilitation team may be involved. Rehabilitation after a stroke can be provided in any of the rehabilitation settings mentioned earlier. The choice of rehabilitation setting depends on the following factors: (1) the patient’s medical stability; (2) the patient’s physical endurance; (3) the degree of functional impairment; and (4) the kinds and amount of support available in the home. The Agency for Health Care Policy and Research (AHCPR) recently issued clinical practice guidelines for post-stroke rehabilitation, and they provide an excellent review of pertinent evaluation tools, scientific data supporting specific rehabilitation interventions for stroke, and recommendations for their use.20 Figure 16-5 depicts the treatment algorithm used by the AHCPR. Further information on cerebrovascular disease in older persons is found in Chapter 32.
Figure 16-5 Clinical flow diagram for stroke rehabilitation. (From Gresham GE, Duncan PW, Stason WB, et al: Post-stroke rehabilitation: Assessment, referral, and patient management. Clinical Practice Guideline. Quick Reference Guide for Clinicians No. 16. AHCPR Publication No. 95-0663. Rockville, MD, U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, 1995.)
Arthritic and Soft Tissue Musculoskeletal Disorders
Rehabilitation is often used in patients with musculoskeletal disorders. The most beneficial rehabilitation intervention varies with the underlying pathophysiology of the disorder and its location. Recent data indicate that walking and resistive knee-strengthening exercises are beneficial for patients with osteoarthritis of the knee.21 Exercise interventions may also be beneficial for arthritic disease of the shoulder. On the other hand, degenerative joint disease of the hip is better treated by reducing the weight borne across the joint through the use of a mobility aid (e.g., a cane) or by altering the activity (e.g., by using a raised toilet seat or shower seat). Chronic but not acute low back pain appears to respond to comprehensive exercise and rehabilitation interventions; however, there is little evidence of benefit from transcutaneous electrical nerve stimulation (TENS).22,23 Little is known about the efficacy of other modalities, although use of heat and cold can provide significant symptomatic relief.24 Corticosteroid injections can be beneficial in patients with inflammatory bursitis or tendonitis; however, the activities that led to the bursitis or tendonitis should be examined simultaneously and appropriate interventions made (e.g., use of a lift on the shoe if a leg length difference caused trochanteric bursitis, or range of motion exercise if tightness of the iliotibial band is present). Orthotics can be beneficial for arthritic problems of the feet, and input from an expert in podiatry can be most helpful. Splinting can provide significant relief from carpal tunnel syndrome and tenosynovitis of the thumb; similarly, padding may be beneficial in patients with ulnar nerve entrapment. Further information on musculoskeletal diseases in the elderly is found in Chapter 39.
Amputation of the lower extremity in older persons usually results from vascular insufficiency due either to diabetes mellitus or peripheral vascular disease. The level of the amputation is the major factor affecting the likely functional outcome. Preservation of the knee markedly increases the likelihood of functional ambulation. A below-knee amputee uses 40% to 60% more energy walking on level ground than does a non-amputee, and an above-knee amputee uses 90% to 120% more energy.25 Other factors affecting the patient’s probable functional outcome include diabetic retinopathy or neuropathy. Cardiac disease and cerebrovascular disease are also more common in older amputees and may interfere with functional outcomes. Preoperative consultation with a physiatrist, physical therapist, or prosthetist can be most beneficial.
Postoperative care is dictated in part by the patient’s functional goals. If functional ambulation is likely, great care must be taken with the stump to ensure that the stump will support use of a prosthesis. Careful attention must be paid to prevention of contractures. Use of a rigid removable dressing may permit earlier weight bearing, preventing development of deconditioning. If possible, the patient should be fitted with a prosthesis as soon as wound healing permits; a temporary prosthesis is sometimes used while the stump is maturing. The prosthesis should be selected in consultation with a physical therapist and a prosthetist. Pain can be a problem after amputation and may have multiple causes including neuromas, bone spurs, biomechanical pain, or phantom pain. Phantom pain differs from phantom sensations, which are quite common but not painful. Treatment of pain after amputation can be challenging and differs according to the cause; expert consultation is recommended. Cutson and Bongiorni recently reviewed rehabilitation of the elderly lower limb amputee.25
The goal of cardiac rehabilitation is to maximize patient outcome after a myocardial infarction. This goal can be achieved through patient education and graded exercises. Cardiac rehabilitation has been found to reduce mortality significantly at 1 year.26 It is not clear how much of this benefit is due to the educational component and how much is due to the exercise component. Cardiac rehabilitation may be most beneficial, particularly for reducing disability, among patients with underlying anxiety or depression. AHCPR has recently published clinical guidelines for the use of cardiac rehabilitation.28 Reimbursement for cardiac rehabilitation can be problematic.
Hip Fracture Rehabilitation
Rehabilitation is commonly used after an acute hip fracture. The goals are to restore functional ambulation and independent self-care. Early mobilization after the hip fracture has been repaired is desirable; otherwise, deconditioning and other bedrest-related complications can be a major cause of morbidity and mortality.27 Many older patients are unable to comply with “touch-down weight-bearing” or “non–weight-bearing” ambulation, particularly if they have cognitive deficits. These patients often do well with “weight-bearing as tolerated” or “partial weight-bearing” if adequate fracture stability has been achieved. Consultation with the orthopedic surgeon about the surgical technique that is most likely to permit early mobilization may be helpful. Most hip fracture rehabilitative treatment consists of physical therapy. The occupational therapist may help in assessing the patient’s need for adaptive equipment or methods used to achieve independent bathing and dressing. Rehabilitation typically begins in the acute care hospital. Rehabilitation may be continued after discharge from the acute care hospital by means of home health aides or subacute rehabilitation care in a nursing home.
Pulmonary rehabilitation is usually directed toward patients with chronic obstructive pulmonary disease (COPD). Typical components are patient education, including instruction in physical and respiratory care, psychosocial support, and supervised exercise training. Comparison of an educational program alone with a 2-month comprehensive rehabilitation program that included the aforementioned components showed significantly better exercise tolerance, fewer symptoms of breathlessness and fatigue, and trends toward better survival and shorter hospital stay in the comprehensive program.29 An extensive review of exercise training respiratory and endurance) for patients with COPD can be found in an article by Reid and Samrai.30 Reimbursement for pulmonary rehabilitation can be problematic.
This chapter has provided a comprehensive review of the concepts and principles underlying the use of rehabilitation services for older persons. Disablement is a complicated process, and its treatment is equally complicated. Rehabilitative interventions are noninvasive, have few complications, and have broad clinical acceptability, all of which make them appealing for use in treating disability among older persons. Although we still have much to learn about the optimal use of rehabilitation, the principles outlined in this chapter will help clinicians to select and apply the rehabilitation interventions most likely to be of benefit to their patients.
ACKNOWLEDGMENT This work was supported in part by the National Institutes of Health, National Institute on Aging, Geriatric Research and Training Centers, National Grant No. 1 P30 AG09463, and the Claude D. Pepper Older Americans Independence Center, Grant No. 5 P60 AG11268.
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