The purpose of rehabilitation is to restore some or all of a person’s physical and mental capabilities that have been lost as a result of disease, injury, or illness and to help achieve the highest possible level of function, independence, and quality of life. The techniques and modalities used to achieve these goals are numerous and typically do not differ for younger versus older persons. However, rehabilitation outcomes and approaches are frequently different for the older adult. For example, most young adults experience a single acute event that results in disability. Older adults are more likely to have multiple comorbid conditions that, over time, result in disability. Even if the older persons have acute events, like a hip fracture or a stroke, their underlying comorbid conditions may impact on the outcomes of rehabilitation. Older patients may also have subclinical physical or cognitive comorbidities, which become evident when challenged by a new disability. For example, mild cognitive impairment may be first recognized during rehabilitation after a hip fracture, when the patient has difficulty learning how to use a new assistive device.

Goals of rehabilitation for older adults usually focus on recovery of self-care ability and mobility, while for younger persons reentering the work force or returning to school may be the goal. In general, recovery for older adults requires a longer period of time to achieve, and functional outcomes are usually worse when compared with younger adults. It is important to discuss rehabilitation goals with all patients and focus therapy toward achieving those goals. For example, older persons may have been avid golfers or fishermen, and return to this activity may be important for their quality of life. Rehabilitation efforts and goals of care may also be impacted by a person’s values and beliefs about exercise and social roles. For example, if a patient has never cooked and does not believe that this is an important task to learn, taking the patient to the kitchen to learn how to prepare a meal may be viewed as a useless task. Participation by the patient and family in the development of the goals of rehabilitation is critical to achieve a successful outcome.

Disability is common in older persons and can have a significant impact on function and quality of life. In order to better understand the process of disablement, a variety of theoretical models have been explored and are presented below.

History of the Disability Framework

In an attempt to provide a framework for the discussion of the consequences of disease and injury, Nagi developed the first disablement model in the 1960s (Figure 29-1). The model uses four related yet distinct phenomena considered by Nagi to be the basis of rehabilitation and include active pathology, impairment, functional limitation, and disability. Active pathology was described as a disruption in the normal cellular function and the body’s efforts to regain a normal state. Impairment, which usually results from active pathology, referred to an abnormality or loss at the tissue or organ level. Functional limitation described restrictions at the individual level, while disability described a physical or mental limitation in a social context. Nagi’s view of disability was a product of the interaction between individuals and their environment. Importantly, individuals could have similar functional impairments that result in different patterns of disability, depending on the environment in which they function.

In 1980, the World Health Organization’s (WHO) International Classification of Impairments, Disabilities, and Handicaps (ICIDH) was developed in Europe. Like Nagi’s disablement model, the ICIDH characterized three distinct concepts related to disease and health conditions: impairments, disabilities, and handicaps. While the ICIDH was developed to classify function and disability, it failed to receive endorsement by the World Health Assembly. A major criticism of these early disablement models was that these presented the response to disease or illness as a static process with a linear progression through the disablement process. It was recognized that the interaction between disease and disability is more complex, particularly for older persons. Recognition of this complexity led to significant dialogue within the rehabilitation community and to a major revision of the ICIDH.

In 2001, the WHO released the International Classification of Functioning, Disability and Health (ICF) (Figure 29-2), which attempted to incorporate, from a biological, personal, and social perspective, a biopsychosocial view of health. The ICF characterizes decreases in function as the consequence of a dynamic interaction between various health conditions and contextual factors. Health conditions are described as diseases, disorders, injuries, or aging. Contextual factors are divided into two categories: environmental factors and personal factors. Environmental factors include the physical, social, and attitudinal environment in which people live. These might include individual environment like furniture placement in the home or societal environment like policies regarding access to buildings. Personal factors are characteristics of the individual, which are not part of the health condition or illness. These might include gender, fitness, or coping styles. Listed across the center of the model are the three domains of human function: body functions and structures, activities, and participation. Body functions and structures are the physiologic functions and the anatomical parts of the body. The execution of a task or action by a person is an activity, while participation is the application to a real-life activity. For each of these three domains of human function, there are several levels on which the function can be experienced. These include functioning at the level of the body or body parts and the level of the whole person and the whole person in their environment. Disability is defined as any decline at any of these levels.

Using the ICF model, we could describe an older woman who has a history of osteoarthritis of the knees and hypertension who presents to rehabilitation after a hip fracture. She lives alone in a second-floor apartment and has a daughter who lives at a distance 6 hours away. The patient has a large circle of friends and regularly attends social gatherings at the local senior center. Figure 29-3 demonstrates how this patient’s problems might be placed in the ICF model, with the goal of generating hypotheses about the best treatment options. Important issues include not only improving the patient’s strength and walking ability but also addressing where she will live after discharge and how to keep her active in her community. Understanding the relationships between the different components and addressing them is the key to a successful rehabilitation.

It is believed by many that the ICF framework has the potential to provide a standard disablement language, which could facilitate dialogue across disciplines. The ICF model attempts to reflect the interactions between different components of health and avoids the linear view of previous models. This framework also looks beyond disease and mortality to focus on how people live with their disabling conditions.

Goals of Evaluation

An important goal of evaluation is to identify the cause of the disability for which rehabilitation is required. While there is frequently a final common pathway for many disabilities, the cause may impact on treatment and outcomes. For example, a person’s walking difficulty could be caused by osteoarthritis of the knee or a meniscal tear. For the patient with osteoarthritis, an exercise program focused on strengthening the musculature around the knee has been demonstrated to decrease pain and improve the ability to walk. For the patient with a meniscal tear, surgical intervention may be a better option. Evaluation prior to rehabilitation is also important to identify comorbidities that may directly or indirectly affect rehabilitation outcomes. While the older person may have osteoarthritis causing limited walking ability, they may also have poor cardiac or pulmonary function that further limit walking ability. Another goal of evaluation is to determine the best site for rehabilitation to occur. Several settings are available, including an inpatient rehabilitation facility, a subacute nursing home, or a home. The appropriate setting is usually determined through evaluation of the disability and comorbid conditions that may affect rehabilitation. The next section outlines the evaluation process and focuses on creation of an individual treatment plan that addresses the patient’s unique disabilities.

Disability-Oriented History and Physical Examination

During the initial evaluation, the history and physical examination can help characterize the disability and lead the clinician toward the most effective types of treatment. Determining if the functional decline occurred suddenly or has taken a more slowly progressive course may be very helpful in determining the cause of the disability. Symptoms associated with a given activity may also help narrow the cause to a specific organ system. For example, while the impairment may be difficulty in walking, the limitation could be caused by shortness of breath or pain with weight bearing. Differentiating the causal pathway, in this case pulmonary versus musculoskeletal, helps to refine the workup required and assists the provider in targeting the appropriate therapy. Functional status and residence prior to the illness or injury may also help guide expectations of rehabilitation.

Table 29-1 lists several brief screening maneuvers, which can be done in the physician’s office when evaluating a patient for disability. These assessment tools can be used to quickly assess baseline functional status as well as monitor progress during rehabilitation. If these screening tests are positive, additional testing should be performed, as the screening tests are often not as accurate as more detailed maneuvers. A variety of standardized measures are available to further test function during basic and instrumental activities of daily living.

For example, lifting a heavy book overhead tests shoulder range of motion and strength. If a person is unable to achieve this task, additional range of motion and muscle testing should be done to isolate the cause of the difficulty.

Many of the screening tests listed have normative values and have been well validated for the geriatric population. The short physical performance battery includes three of the screening tests gait speed, timed chair stands and static balance with worse scores being associated with falls, nursing home placement, and mortality. The University of Alabama at Birmingham (UAB) Study of Aging Life-Space Assessment is a validated instrument that measures a person’s mobility in the home and community during the month preceding the assessment. Importantly, the Study of Aging Life-Space Assessment goes beyond measuring the individual’s ability to perform specific tasks by assessing the person’s actual pattern of mobility, which may help identify factors other than physical impairment, such as emotional or socioeconomic factors, which might be limiting mobility.

In addition to the history and physical examination, an evaluation should include assessments of cognition, motivation, depression, social support, and financial resources, as these factors can have a significant impact on rehabilitation outcomes. A variety of validated assessment tools can be used to screen for cognition and depression, such as the Geriatric Depression Scale or the mini mental state examination. Assessment of current methods utilized by the patient for coping with disability, including use of assistive devices, level of assistance needed, and any limitation of activities, should also be explored.

Determining Rehabilitation Potential

Many factors influence the choice of who would benefit from rehabilitation and the success of those rehabilitation efforts. Assessment for rehabilitation potential needs to be done when the acute medical illness has resolved. A patient with a hip fracture and concurrent delirium may do poorly on initial assessment but, once the delirium clears, may progress nicely with rehabilitation. At times, the medical condition will need to be treated concurrently with rehabilitation efforts. After a prolonged ICU stay, a patient may have significant orthostatic hypotension, which will resolve as they regain the upright position during rehabilitation. Table 29-2 lists a variety of acute medical illnesses that might delay referral to rehabilitation until these are resolved.

Other determinants of rehabilitation benefit include motivation, cognition, and prior functional status. Comorbid illness may have a significant effect on rehabilitation efforts and may even cause a change in rehabilitation approaches. For example, a patient with chronic obstructive pulmonary disease (COPD) on home oxygen who falls and fractures a hip may not be able to tolerate more than 5 minutes of therapy at one time. The rehabilitation approach might be changed to include frequent walks of short duration by therapy and nursing, as opposed to an hour-long therapy session twice a day. Table 29-3 lists a variety of factors that might influence either the use of rehabilitation or the goals of the rehabilitation. In some cases, like terminal illness with a short life expectancy, the goals of care may need to be addressed with the patient and family, and palliative care may be a more appropriate option. For other factors, like lack of motivation, well-defined patient-centered goals that are easily measured may help overcome this potential obstacle.

After careful evaluation, including a disability-oriented history and physical examination, assessment of factors that may impact on rehabilitation outcomes, and the development of goals with the team, including the patient and the family, we are ready for the final step prior to initiation of rehabilitation, choosing the site for rehabilitation. Determining the optimal setting in which rehabilitation should occur is based on many of the factors previously evaluated, as well as patient preference.

The Organization of Rehabilitation

Settings for Care

A variety of settings are available, both inpatient and community based, in which to receive rehabilitation services. It is important for the provider to understand the range of available settings and the advantages and disadvantages of each setting. While the provider may be responsible for helping match the patient to the optimal setting, insurance and cost also play a role. Rehabilitation services are available through Medicare Part A on a time-limited basis. Patients must demonstrate that they are making progress with rehabilitation in order to qualify for services.

Inpatient rehabilitation is offered in rehabilitation centers and Medicare-skilled nursing facilities. In order to qualify as a Medicare-certified inpatient rehabilitation hospital, a certain percentage of all admitted patients must have at least one of 13 conditions, which include diagnoses like stroke, burns, and neurological disorders. Patients must be managed by an interdisciplinary team of skilled nurses and therapists, be seen daily by a physician, and have 24-hour rehabilitation nursing care. Rehabilitation is intensive with patients receiving a minimum of 3 hours of therapy daily. As the rehabilitation center offers 24-hour-a-day medical care, patients in need of close medical supervision during therapy can receive it. However, the patient must be able to tolerate the intensity of therapy provided, which may be difficult for the older patient.

Like the rehabilitation center, Medicare-approved skilled nursing facilities must provide 24-hour nursing care. While physicians must be available 24 hours a day, they are just supervising care and can visit the patients less frequently. Multidisciplinary care may not occur, although therapy services, dietary, pharmacy, and social services are available. There are no requirements for intensity or duration of therapy sessions, or any required case mix. This setting allows for a slower rehabilitation pace, which may be necessary for some older patients with multiple comorbid diseases. The availability of 24-hour nursing care is also a benefit for persons who are unable to care for themselves or who do not have caregivers at home.

Home health benefits for rehabilitation are also available through Medicare to patients who are defined as “homebound.” This includes patients for whom leaving the home is difficult or who require help of another person to get out of the home. Part-time nursing and therapy services are available if prescribed by a physician, and these services must be recertified every 60 days. While the intensity of the rehabilitation is less and the nursing services are part time, many patients prefer rehabilitating in their own home. If the patient has the necessary support system, this can be an excellent option.

While a number of studies have examined the effect of the rehabilitation setting on outcomes, the results remain unclear. For patients with hip fracture, the setting of care does not appear to have an impact on outcomes. After a stroke, patients who are treated in inpatient rehabilitation hospitals or special stroke units are more likely to be discharged to home and with improved function. Ultimately, factors such as patient prognosis, level of medical and nursing care needed, and intensity of therapy the patient can tolerate will help determine the optimal setting for rehabilitation.

Rehabilitation Providers

An interdisciplinary team is often required to meet the complex rehabilitation needs of older patients. While team members have defined roles and functions, there is considerable overlap in the services provided. For example, while the physical therapist may focus on transfer and gait training, the occupational therapist may also encourage practice of transfers while performing self-care skills. In addition, there are different levels of education and licensure required for different providers. Table 29-4 outlines the types of rehabilitation providers and their usual methods of evaluation and treatment.

Key members of this interdisciplinary team are the patient and the family. An important component of chronic disease management is patient self-management, and patients must be active participants in the decision-making process. The team is responsible for establishing goals, in collaboration with the patient and the family, and developing a treatment plan to achieve those goals. In addition to teaching the patient, a key component of rehabilitation is training the caregiver or family. Specifically, caregivers must be taught how to assist with exercise programs ambulation and ADLs. The caregiver may need to know how to use adaptive equipment or even how to transfer the patient safely, if the patient is not independent with this task. Communication among all team members, including the patient and their family, is critical for success.

Process of Care: Rehabilitation Interventions

A variety of interventions are available to treat physical impairments and disability. The selection of intervention strategy is determined by the results of the assessment. All interventions should either directly or indirectly lead to an improvement in function and/or quality of life. Major categories of interventions include (1) exercise/physical activity; (2) modalities including thermal agents, electrotherapy, and phototherapy; (3) adaptive aids such as walkers, canes, and devices to improve activities of daily living; and (4) orthotics (splints and braces) and prosthetics (artificial limbs).

Exercise/Physical Activity

General Principles of Exercise