Occupational therapists work with therapeutic use of everyday life activities to participate in the home, school, work, and community settings, addressing physical, cognitive, psychosocial, and other aspects of performance that affect health, well-being, and quality of life. These professionals include:

Physical therapists examine functional limitation, disability, or other health-related conditions to determine a diagnosis, prognosis, and intervention in order to alleviate impairment through use of exercise, manual therapies, adaptive measures, and modalities. These professionals include:

A physician (M.D., D.O.) with graduate medical education in Physical Medicine and Rehabilitation. Their educational focus is on function and independence in treating nerve, bone, and muscle injuries and illness. They are interdisciplinary team leaders, considering a broad range of medical, socioeconomic, neuropsychological, and cultural factors and barriers that affect a patient’s ability to recover and function independently. There are subspecialty designations in Traumatic Brain Injury (TBI), Spinal Cord Injury (SCI), Electrodiagnostics (EMG) and Neuromuscular Medicine, Pain Medicine, Palliative Care, and Sports Medicine. Not all physiatrists participate in acute/subacute inpatient rehabilitation, as many maintain pure outpatient, procedural-based practices. Practitioners who typically interface with hospital-based teams are in general rehabilitation and are available on a consultative basis.

Medical social workers have an in-depth understanding of the resources available to the patient based upon available funding, area (e.g., county) of residence, and related factors. They communicate those options to the patient and the team. They are frequently expert communicators who gather environmental and contextual information, explain the barriers and challenges to patients and their caregivers, and confirm the final discharge plan.

These individuals have a graduate-level degree with clinical certification to treat patients with speech, swallowing, and cognitive deficits through use of therapeutic exercises, adaptive strategies, and devices.

Cognitive deficits in the aging population typically involve memory, orientation, and/or judgment [10, 11]. Memory deficits can result from primary progressive diseases, such as Alzheimer disease, or cumulative processes, such as small vessel brain disease or multiple traumatic or anoxic events. Cognitive declines are magnified with each additional injury to the head. A communication challenge to families and caregivers is to convey the idea that while the patient may seem to be independent performing routine daily activities, they may have had a decline in cognition for many years. It is important to note that short-term memory is primarily affected, while long-term memory is maintained, even with dementia.

Unfortunately, with impairment of short-term memory, new tasks taught to enforce safety in mobility may only be learned through repetition and supervision. The rehabilitation team frequently engages in scheduled tasks that are in keeping with the patient’s baseline activities and teaches safe strategies to avoid future injuries. It is not uncommon that patients perform better upon discharge home, as familiar environments can provide reminders for activities and precautions.

One of the hallmarks of aging is the phenomenon of falling [13–16]. The rising incidence of idiopathic falls in the elderly is still a medical enigma and is likely multifactorial. Not uncommonly, older people fall while performing routine activities, such as getting to the bathroom or transferring while bathing. Prevention of falls includes assessing the home for loose rugs, items close to the ground (e.g., grandchildren toys, pets) that may not be seen easily in dim lighting or with a decline in vision, and smooth flooring that can lead to slippery surfaces when wet, such as tile or wood floors.

Trauma in the aging population typically occurs at lower speeds and heights. Falls from standing due to decreased balance can cause multiple fractures due to loss of bone density. Hip fractures are associated mortality rates of 50 % over 1 year. Degenerative spondylosis increases with age and contributes to a number of conditions associated with increased risk for falling. Cervical myelopathy due to stenosis or vertebral fractures can contribute to falling and result in spinal cord injury. Central cord syndrome is common and can occur with minimal injury. Atrophy of brain mass potentiates tears of bridging veins in the subdural space, which leads to further decline in mentation that can then contribute to falling. Prevention of falls and known contributing factors can help to prevent related injuries.

Prior to discharge, it behooves the clinical team to discuss with patients some of the abovementioned barriers. As quality benchmarks are predicated on decreasing readmissions to the hospital, it becomes essential to limit the ways that patients might incur further injuries in their home through prevention and preemptive preparation. Currently, the literature is equivocal on Tai Chi and other exercises for fall prevention, although it is largely accepted that the patient who stays the most active and mindful is typically less prone to fall. For patients with frequent falls, balance and proprioceptive therapies might be suggested [17, 18]. There are PTs who specialize in this complex process and can be of tremendous benefit to the patient and their families.

Another phenomenon that is more prevalent with advancing age is that of urinary urgency. For men, prostatic hypertrophy and/or malignancy can lead to incomplete bladder emptying with the subjective sensation of urgency and frequency. For women, especially those who have had children and/or gynecological surgery, the integrity of the perineum and external sphincters may have been disrupted, leading to stress and urge incontinence [19, 20]. Additionally, many aging patients are on diuretics and other medications that alter ability to hold or excrete urine. Careful consideration to the time of day when those medications are taken will also improve duration of uninterrupted sleep at night. For example, it is not uncommon for furosemide to be prescribed as multiple doses each day. Knowing that its pharmacokinetics occurs within 6 h, the last dose each day should be taken at least 6 h before bedtime to promote good sleep hygiene. It should not be surprising that with declining dexterity in clothing management and nocturnal frequency are factors that make the bathroom one of the more dangerous rooms in the home for the elderly.

When approaching a patient with continence issues, it is important to identify whether the patient has a spastic bladder, detrusor atony, sphincter incompetency/dysynergia, or outlet obstruction. This can be identified during the inpatient setting by performing bladder scans to determine the bladder volume index and/or post-void residuals. If bladder volumes are consistently low with frequency, then the patient may benefit from an anticholinergic medication. If the bladder volumes are high post-void, it may be that the patient needs to decompress the bladder for a time and use medications that either promotes detrusor tone (e.g., bethanechol) or maintains an open sphincter to allow complete emptying (e.g., tamsulosin). A urology consult should be obtained for the patient with an enlarged prostate or intrapelvic organ prolapse. For most patients, performing bladder scans is a noninvasive way to identify and potentially treat continence problems for the aging patient.

Timed voiding is an easy way for many patients and their caregivers to manage continence. One simple way to avoid incontinence is to offer the aging patient regular times for elimination such as upon awakening, after each meal, and at bedtime. This allows for the opportunity to void and evacuate at least four times a day and is concurrent with activities already requiring supervision, set up, or assistance.

Aging is associated with a loss of subcutaneous adipose tissue. This in combination with certain medications that are commonly prescribed for the geriatric patient with concomitant cardiopulmonary disease such as anticoagulants and inhaled steroids increases the risk for skin breakdown, particularly in the sedentary patient [21]. Additionally, incontinence and widespread use of impermeable briefs trap moisture against the skin over bony prominences such as the sacrum and ischial tuberosities leading to an increased incidence of decubitus ulcers. Timed voiding, as described above, is one way to limit the use of briefs by allowing regular micturition and evacuation. For those patients with limited cognition and mobility, a condom or indwelling catheter may be considered, although these are associated with higher risks of urinary tract infections, which can also exacerbate preexisting cognitive dysfunction. It is important to counsel the patient and caregivers on the importance of checking the skin and minimizing the use of impermeable briefs when possible.

As mentioned earlier, more and more children are opting to move away from their parents in the course of seeking educational and employment opportunities. Thus, it is not uncommon that the aging patient lives without siblings and/or children in the same community. Even when children do reside in the same neighborhood, they are not available for constant supervision or assistance of their parents. Americans are living longer because of improved medical care, but it does not necessarily mean that their quality of life or independence is preserved. Independent and assisted living communities have become more commonplace to address this sense of isolation. These facilities are not without substantial cost, however. It is not uncommon for independent living apartments to cost thousands of dollars in monthly rent. The cost escalates with additional services. To avoid leaving their home, friends and neighbors or even extended families that have remained in the area assist the elderly with ADL. However, varying levels of commitment from these individuals over the long term should be expected and clarified by a team representative.

A word should be mentioned about bereavement as a chronic condition. It is not uncommon for the aging patient to experience a slow erosion of their social support, including that from their spouse. Depression can adversely affect one’s motivation and willingness to participate. There may be a profound desire to not continue living, and efforts should be made to address the psychological barriers to successful rehabilitation. These conditions are commonly magnified by decreased metabolic and endocrine function. If psychiatry or neuropsychology services are available, consultation can be beneficial both to address the psychological issues and identify potential endocrine and/or neurophysiological contributors to the depression and dysthymia.