Table of Contents
Note: Rehabilitation [lat. rehabilitare = to restore] | geriatrics [greek γέρωνgerōn, “old” and ἰατρεία “medical science” = teachings of the diseases of aging people]
Geriatrics, or geriatric medicine, comprises internal medicine, psychiatry, neurology and orthopedics. Since 1989, the WHO defines geriatrics as a medical branch that addresses health in old age. This includes diagnostics and holistic therapies tailored to the needs of aging people. Both outpatient and inpatient treatments are available.
The Geriatric Patient
To qualify as a geriatric patient, the aging person has to have a biologically older age. There are different estimates for this; however, usually this includes people who are more than 70 years old. Additionally, in typical geriatric cases, multiple illnesses (multimorbidity) must be present, of which at least two are illnesses requiring treatment. However, the impact of these is also taken into account. In addition to immobility, these can be cognitive thinking disorders. Other possible consequences include:
- Anxiety disorders
- Chronic pain
- General frailness
- Strong restriction of sensory capabilities, such as hearing and visual disorders
It also applies to any limitations that may endanger the patient. Social problems are also taken into account. Acute care and rehabilitative treatments can take place simultaneously.
Illnesses or implications include fractures near the hip joint, surgery on hips and knees with total-endoprostheses, as well as amputations which are triggered by peripheral arterial occlusive disease, or diabetes-induced vascular disease. Thus, in order to carry out a patient assessment, a team comprised of various disciplines is required.
Depending on the actions required, entire diagnostics and treatment teams may also be involved. This includes measures of care, physiotherapy, movement therapy, occupational therapy and speech therapy, as is required with swallowing disorders, for example. In addition, it may be necessary to include neuropsychological and psychotherapeutic methods, as well as a social counseling.
Patients should be independent for as long as possible. This involves autonomous food intake, the ability to dress and undress by themselves, the ability to move around their own home, and the ability to cope with their own structured daily routine.
Contextual factors include all information concerning the personal background of the patient. This includes all environmental factors, as well as personal factors, as long as they affect the physical, mental or emotional constitution of the affected person. Environmental factors refer to the way the person organizes their life. These are physical, social and attitudinal factors, and include the support the patient receives, and their values and convictions.
Personal factors mainly comprise all essential facts concerning the person, such as age, level of education and profession. Furthermore, habits play an important role, as do life experiences and character. The patient’s upbringing and conflict behavior are also of importance. Finally, general health issues and physical fitness, as well as lifestyle, play important roles in the assessment of a patient.
Physical and social environmental factors i.e. support from their social circle, relatives and also caregivers. These include accessible facilities that can provide additional care, and possibly even further measures for rehabilitation, including aids that are available to the patient, or that need to be acquired in order for the patient to be able to cope with everyday life.
It also applies to resources, which enable or improve communication. Potentially, reconstruction measures may be required in their home.
If positive context factors exist, they can have a positive impact on existing impairments, which has a positive effect on rehabilitation; therefore, it is necessary to examine which positive context factors may be involved in the treatment. In this context, we talk of resource context of rehabilitation. Respectively, negative contextual factors can have a disturbing influence on the course of rehabilitation.
Requirements for Rehabilitation
Rehabilitation can be performed as an outpatient or inpatient. For inpatient rehabilitation, the facility must specialize in this type of treatment. Mobile rehabilitations are also possible. Certain requirements must be met for this option. The supervising team must also have special knowledge. The conditions are stipulated by the MDS (Medical Service of the Central Federal Association of Health Insurance): By definition, the patient must be a geriatric patient in order to meet the requirements for rehabilitation. In addition, they must be able to participate in the rehabilitation. The goals of the rehabilitation must be realistic.
The geriatric rehabilitation capacity is subject to certain conditions, all of which must be fulfilled. This includes ensuring that vital parameters are stable and that existing comorbidities or consequential damages, as well as the associated anticipated complications, can be treated by the institution’s staff.
In addition, the patient’s circulation must be stable, as well as their mental and physical capacity, so they can participate in therapy every day, which, furthermore, should take place several times a day. Similarly, exclusion criteria also exist – if only one criterion is met, rehabilitation is ruled out.
One of these is the patient’s consent, which is mandatory. Another exclusion criterion is the patient not being sufficiently resilient, which can be the case after several surgeries, e.g. in the treatment of fractures. Some accompanying illnesses or complications can also exclude geriatric rehabilitation: the tendency to run away, disorientation, and severe limitations in the ability to see or hear.
Moreover, bedsores can exclude a patient from rehabilitation measures. An existing problem with an amputation stump is also considered an exclusion criterion, as well as severe cases of depression, or acute mania symptoms.
Depending on the type of rehabilitation, fecal incontinence may also be an issue. The objectives of rehabilitation must be relevant for everyday life and a positive rehabilitation prognosis must exist. The legal provisions must be checked in the respective jurisdiction. Requests for geriatric rehabilitation can be made by a hospital or physicians. The justification for requiring rehabilitation has to be submitted to the patient’s health insurance.
The patient can choose the facilities themselves. Health insurance companies are also available as points of contact – they usually refer to institutions with which they have contractual connections. Should the cost of the selected facility be higher than at a facility recommended by the health insurance, the patient must pay the difference.
Development of a Geriatric Rehabilitation Plan
First, the physician focuses on the patient’s medical history. This is followed by a thorough physical examination, e.g. various tests depending on the medical history. The tests concern the patient’s physical, cognitive, emotional and social condition. Subsequently, the treatment is determined. Therapies can be adjusted during the course of rehabilitation. To this effect, regular meetings and examinations are held in order to document the treatment’s success. In this context, medication is also discussed. Inpatient treatments usually last around three weeks, and their aim is to restore the patient’s health as much as possible in order to improve their quality of life and allow them to live mostly independent.
Common Treatment Methods for Inpatient Rehabilitation
In the areas of orthopedics, neurology, psychosomatic medicine, psychiatry, cardiology and internal medicine, patients are provided with comprehensive care. Depending on the facility, various specialties are possible, such as neurology, cardiovascular or diabetes. However, there are also facilities that have specialized in several areas, such as pain-trauma therapy, radiation therapy and nutrition, etc. Specialization is also necessary to meet the high costs of examination procedures and therapeutic treatments.
Geriatric outpatient rehabilitation also takes a holistic approach into account. Here, too, the requirement is multimorbidity with at least two illnesses requiring treatment. An illness requires treatment if the resulting medical problems have to be closely monitored by doctors during rehabilitation, and if they need to be considered in the therapy. However, it is irrelevant whether the same department is concerned or whether another doctor has to be consulted. Furthermore, outpatient rehabilitation is only approved if the health disorders affect the patient’s day-to-day independence; however, these only include activities that are considered basic human needs. This, therefore, means that health limitations, which make it impossible for the patient to pursue hobbies or other activities, are not necessarily affected.
Benefits of Outpatient Geriatric Rehabilitation
Usually, inpatient geriatric rehabilitation is given preference. The patient stays at the facility and receives intensive care and treatment 5 or 6 days per week. However, demand is also increasing for outpatient methods, which have their own advantages. For older patients, it mainly means that they are able to stay in their familiar environment.
However, outpatient treatment does not mean that the patient is treated at home. Rather, they must visit the facility. Usually, support is available for this, since it can be assumed that the affected person cannot manage the journey alone. The clinic usually takes care of this. This type of geriatric rehabilitation is also an optional interim solution between hospitalization and transition to normal daily life. It is also suitable, however, as a measure to prevent deterioration. The therapeutic treatments are spread over the whole day, which means the patient remains at the clinic throughout the day.
Of course, the patient’s condition and general treatment goal are crucial for the scope of the arrangement. Patients suitable for this type of arrangement are generally mobile and can cope at home while they are not treated as inpatients or full inpatients. Nevertheless, it is intended for patients older than 65. Application for reimbursement by the health insurance company is also required for outpatient rehabilitation and is made by the treating physician or hospital. In everyday life, the patients eat breakfast and dinner at home. Snacks in between meals are served at the clinic.
The general practitioner is in charge of prescribing medication in this case. Therapeutic treatments are in accordance with those available at inpatient facilities.
A possible issue may be the lack of suitable clinics nearby. In this case, the doctor is asked to advise the patient. The commute should not exceed one hour, as the patient’s capacity is limited, otherwise, there is a risk of the condition deteriorating despite good prognosis, due to overloading the patient. A supporting argument for this is evidence that suggests that a patient’s condition may improve, over 20 days, to the extent that lasting positive effects remain. In addition, it is possible to offer outpatient treatment after inpatient treatment has been completed.
For seniors of this age, geriatric rehabilitation can be a great challenge. In particular, people who have lost their partner and are now at risk of becoming so sick that they lose their independence, face unusual challenges. Courageous patients over 75, who face the challenge boldly and accept the available offer, are not the norm; even relatives are not necessarily much help. They often make seniors feel subjected to the situation and unable to make their own decisions, or force them into a situation that scares them. At this point, empathy is required.
Reminder: The goal is to give the patient their independence back.
The correct answers are below the references.
1. Geriatric rehabilitation is aimed at:
- Patients over 50.
- Patients over 60.
- Patients with multimorbidity, age is not relevant.
- Patients who require intensive care.
- Patients who are overburdened with their home lives.
2. Outpatient geriatric rehabilitation…
- …has fewer requirements to fulfill
- …is also suitable for younger patients
- …is only suitable for mobile patients
- …is preparation for inpatient treatment
- …is aftercare
3. Requirements for geriatric rehabilitation:
- The patient has to fulfill at least 3 conditions.
- The patient may not fulfill more than one exclusion criterion.
- The patient must be at least 75 years old.
- The patient must have received prior treatment at a hospital.
- The patient must fulfill all criteria and must not fulfill any exclusion criteria.