Overview of geriatric rehabilitation: Patient assessment and common indications for rehabilitation
- Helen Hoenig, MD, MPH
Helen Hoenig, MD, MPH
- Professor of Medicine/Geriatrics
- Duke University School of Medicine
- Chief - Physical Medicine and Rehabilitation Service
- Durham VA Medical Center
- Cathleen Colon-Emeric, MD
Cathleen Colon-Emeric, MD
- Associate Professor of Medicine
- Duke University Medical Center
Disability, or limitation in the ability to carry out basic functional activities, becomes increasingly common with advancing age; nearly one in four United States Medicare beneficiaries report at least one health-related disability . Crude rates of disability are rising around the globe with over 700 million years lived with disability (YLDs) in 2010 compared with 583 million in 1990; however, after adjusting for population growth rates of YLDs per 100,000, people have remained largely constant over time, but rise steadily with age . While there is considerable heterogeneity across countries in the dominant causes of disability, in general, the global disease burden has shifted from communicable to noncommunicable diseases, with many countries experiencing increases in age-related conditions and YLDs . The most common contributors to YLDs in 2010 included low back pain, major depressive disorder, iron deficiency anemia, neck pain, chronic obstructive pulmonary disease (COPD), anxiety disorders, migraine, diabetes, and falls .
The primary purpose of rehabilitation is to enable people to function at the highest possible level despite physical impairment. While rehabilitation may be provided to all age groups, the fastest growing population of persons requiring rehabilitation services is adults over 65 years of age.
This topic will discuss assessing patients for rehabilitation services and indications for rehabilitation. Issues regarding comprehensive geriatric assessment, disability assessment, and components and settings for rehabilitation are discussed separately. (See "Comprehensive geriatric assessment" and "Disability assessment and determination in the United States" and "Overview of geriatric rehabilitation: Program components and settings for rehabilitation".)
EPIDEMIOLOGY OF DISABILITY
Functional disabilities are commonly categorized as activities of daily living (ADL) (table 1) or instrumental activities of daily living (IADL) (table 2). ADLs include bathing, dressing, toileting, transferring, eating, and continence. IADLs include cooking, cleaning, shopping, transportation, finances, and medication management.
Disability has a tremendous impact on the quality of life of individuals and their caregivers . Disability also impacts health care utilization; increasing the number of ADL disabilities from zero to six results in a sevenfold increase in health care costs . Multiple chronic conditions are associated with increasing levels of disability, and the proportion of older adults in the United States reporting multiple chronic conditions is increasing over time, with 17.4 percent reporting four or more chronic conditions in 2008 compared with 11.7 percent in 1998, although, the proportion reporting an ADL or IADL disability has remained stable at approximately 25 percent over this period .
- Chan L, Beaver S, Maclehose RF, et al. Disability and health care costs in the Medicare population. Arch Phys Med Rehabil 2002; 83:1196.
- Vos T, Flaxman AD, Naghavi M, et al. Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012; 380:2163.
- Murray CJ, Vos T, Lozano R, et al. Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012; 380:2197.
- Gobbens RJ, van Assen MA, Luijkx KG, Schols JM. The predictive validity of the Tilburg Frailty Indicator: disability, health care utilization, and quality of life in a population at risk. Gerontologist 2012; 52:619.
- Hung WW, Ross JS, Boockvar KS, Siu AL. Recent trends in chronic disease, impairment and disability among older adults in the United States. BMC Geriatr 2011; 11:47.
- Gill TM, Gahbauer EA, Han L, Allore HG. Functional trajectories in older persons admitted to a nursing home with disability after an acute hospitalization. J Am Geriatr Soc 2009; 57:195.
- Hardy SE, Dubin JA, Holford TR, Gill TM. Transitions between states of disability and independence among older persons. Am J Epidemiol 2005; 161:575.
- Gill TM, Allore HG, Hardy SE, Guo Z. The dynamic nature of mobility disability in older persons. J Am Geriatr Soc 2006; 54:248.
- Gill TM, Gahbauer EA, Han L, Allore HG. Trajectories of disability in the last year of life. N Engl J Med 2010; 362:1173.
- www.who.int/classifications/icf/training/icfbeginnersguide.pdf (Accessed on April 16, 2015).
- Mainland B, Shulman K. Clock Drawing Test. In: Cognitive Screening Instruments, Larner AJ (Ed), Springer, London 2013. p.79.
- Froehlich TE, Robison JT, Inouye SK. Screening for dementia in the outpatient setting: the time and change test. J Am Geriatr Soc 1998; 46:1506.
- Podsiadlo D, Richardson S. The timed "Up & Go": a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc 1991; 39:142.
- Guralnik JM, Simonsick EM, Ferrucci L, et al. A short physical performance battery assessing lower extremity function: association with self-reported disability and prediction of mortality and nursing home admission. J Gerontol 1994; 49:M85.
- Tygesen H, Wettervik C, Wennerblom B. Intensive home-based exercise training in cardiac rehabilitation increases exercise capacity and heart rate variability. Int J Cardiol 2001; 79:175.
- Gordon NF, Gulanick M, Costa F, et al. Physical activity and exercise recommendations for stroke survivors: an American Heart Association scientific statement from the Council on Clinical Cardiology, Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention; the Council on Cardiovascular Nursing; the Council on Nutrition, Physical Activity, and Metabolism; and the Stroke Council. Stroke 2004; 35:1230.
- Nici L, Donner C, Wouters E, et al. American Thoracic Society/European Respiratory Society statement on pulmonary rehabilitation. Am J Respir Crit Care Med 2006; 173:1390.
- Liu SY, Lapane KL. Residential modifications and decline in physical function among community-dwelling older adults. Gerontologist 2009; 49:344.
- Iwarsson S. A long-term perspective on person-environment fit and ADL dependence among older Swedish adults. Gerontologist 2005; 45:327.
- Ryburn B, Wells Y, Foreman P. Enabling independence: restorative approaches to home care provision for frail older adults. Health Soc Care Community 2009; 17:225.
- Hung WW, Egol KA, Zuckerman JD, Siu AL. Hip fracture management: tailoring care for the older patient. JAMA 2012; 307:2185.
- Stroke Unit Trialists' Collaboration. Organised inpatient (stroke unit) care for stroke. Cochrane Database Syst Rev 2013; :CD000197.
- Pollock A, Farmer SE, Brady MC, et al. Interventions for improving upper limb function after stroke. Cochrane Database Syst Rev 2014; :CD010820.
- Duncan PW, Zorowitz R, Bates B, et al. Management of Adult Stroke Rehabilitation Care: a clinical practice guideline. Stroke 2005; 36:e100.
- Bates B, Choi JY, Duncan PW, et al. Veterans Affairs/Department of Defense Clinical Practice Guideline for the Management of Adult Stroke Rehabilitation Care: executive summary. Stroke 2005; 36:2049.
- Chumbler NR, Quigley P, Li X, et al. Effects of telerehabilitation on physical function and disability for stroke patients: a randomized, controlled trial. Stroke 2012; 43:2168.
- Laver KE, Schoene D, Crotty M, et al. Telerehabilitation services for stroke. Cochrane Database Syst Rev 2013; :CD010255.
- Bragge P, Chau M, Pitt VJ, et al. An overview of published research about the acute care and rehabilitation of traumatic brain injured and spinal cord injured patients. J Neurotrauma 2012; 29:1539.
- Tomlinson CL, Patel S, Meek C, et al. Physiotherapy intervention in Parkinson's disease: systematic review and meta-analysis. BMJ 2012; 345:e5004.
- Herd CP, Tomlinson CL, Deane KH, et al. Speech and language therapy versus placebo or no intervention for speech problems in Parkinson's disease. Cochrane Database Syst Rev 2012; :CD002812.
- Chudyk AM, Jutai JW, Petrella RJ, Speechley M. Systematic review of hip fracture rehabilitation practices in the elderly. Arch Phys Med Rehabil 2009; 90:246.
- Auais MA, Eilayyan O, Mayo NE. Extended exercise rehabilitation after hip fracture improves patients' physical function: a systematic review and meta-analysis. Phys Ther 2012; 92:1437.
- Latham NK, Harris BA, Bean JF, et al. Effect of a home-based exercise program on functional recovery following rehabilitation after hip fracture: a randomized clinical trial. JAMA 2014; 311:700.
- Mallinson T, Deutsch A, Bateman J, et al. Comparison of discharge functional status after rehabilitation in skilled nursing, home health, and medical rehabilitation settings for patients after hip fracture repair. Arch Phys Med Rehabil 2014; 95:209.
- Handoll HH, Cameron ID, Mak JC, Finnegan TP. Multidisciplinary rehabilitation for older people with hip fractures. Cochrane Database Syst Rev 2009; :CD007125.
- Morghen S, Gentile S, Ricci E, et al. Rehabilitation of older adults with hip fracture: cognitive function and walking abilities. J Am Geriatr Soc 2011; 59:1497.
- Vidán M, Serra JA, Moreno C, et al. Efficacy of a comprehensive geriatric intervention in older patients hospitalized for hip fracture: a randomized, controlled trial. J Am Geriatr Soc 2005; 53:1476.
- Gill SD, McBurney H. Does exercise reduce pain and improve physical function before hip or knee replacement surgery? A systematic review and meta-analysis of randomized controlled trials. Arch Phys Med Rehabil 2013; 94:164.
- Khan F, Ng L, Gonzalez S, et al. Multidisciplinary rehabilitation programmes following joint replacement at the hip and knee in chronic arthropathy. Cochrane Database Syst Rev 2008; :CD004957.
- Tian W, DeJong G, Horn SD, et al. Efficient rehabilitation care for joint replacement patients: skilled nursing facility or inpatient rehabilitation facility? Med Decis Making 2012; 32:176.
- Dejong G, Horn SD, Smout RJ, et al. Joint replacement rehabilitation outcomes on discharge from skilled nursing facilities and inpatient rehabilitation facilities. Arch Phys Med Rehabil 2009; 90:1284.
- Jette DU, Warren RL, Wirtalla C. The relation between therapy intensity and outcomes of rehabilitation in skilled nursing facilities. Arch Phys Med Rehabil 2005; 86:373.
- Bannuru RR, Schmid CH, Kent DM, et al. Comparative effectiveness of pharmacologic interventions for knee osteoarthritis: a systematic review and network meta-analysis. Ann Intern Med 2015; 162:46.
- Hochberg MC, Altman RD, April KT, et al. American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee. Arthritis Care Res (Hoboken) 2012; 64:465.
- Whitson HE, Whitaker D, Sanders LL, et al. Memory deficit associated with worse functional trajectories in older adults in low-vision rehabilitation for macular disease. J Am Geriatr Soc 2012; 60:2087.
- Clegg A, Young J, Iliffe S, et al. Frailty in elderly people. Lancet 2013; 381:752.
- Cesari M, Vellas B, Hsu FC, et al. A physical activity intervention to treat the frailty syndrome in older persons-results from the LIFE-P study. J Gerontol A Biol Sci Med Sci 2015; 70:216.
- Carli F, Charlebois P, Stein B, et al. Randomized clinical trial of prehabilitation in colorectal surgery. Br J Surg 2010; 97:1187.
- Li C, Carli F, Lee L, et al. Impact of a trimodal prehabilitation program on functional recovery after colorectal cancer surgery: a pilot study. Surg Endosc 2013; 27:1072.
- Singh F, Newton RU, Galvão DA, et al. A systematic review of pre-surgical exercise intervention studies with cancer patients. Surg Oncol 2013; 22:92.
- Kosse NM, Dutmer AL, Dasenbrock L, et al. Effectiveness and feasibility of early physical rehabilitation programs for geriatric hospitalized patients: a systematic review. BMC Geriatr 2013; 13:107.
- Van Craen K, Braes T, Wellens N, et al. The effectiveness of inpatient geriatric evaluation and management units: a systematic review and meta-analysis. J Am Geriatr Soc 2010; 58:83.
- EPIDEMIOLOGY OF DISABILITY
- APPROACH TO ASSESSING LATE-LIFE DISABILITY
- Characterize the disability
- Identify impairments
- Identify health conditions
- Identify contextual factors
- APPROACH TO THE MANAGEMENT OF LATE-LIFE DISABILITY
- Strategies to improve capacity
- Strategies to reduce demand
- Role of the interprofessional team
- REHABILITATION FOR SPECIFIC CONDITIONS
- - Stroke
- - Other neurologic conditions
- Spinal cord injury
- Musculoskeletal conditions
- - Hip fracture
- - Elective joint replacement
- - Knee arthritis
- PREVENTION OF LATE-LIFE DISABILITY
- Optimizing functional reserve
- Prevent common disability precipitants
- Early intervention
- SUMMARY AND RECOMMENDATIONS