Note: Rehabilitation [lat. rehabilitare = to restore] | geriatrics [greek γέρωνgerōn, “old” and ἰατρεία “medical science” = teachings of the diseases of aging people]

Geriatrics: Definition

Geriatrics, or geriatric medicine, is related to internal medicine, psychiatry, neurology, and orthopedics. In 1989, WHO defined geriatrics as a field of medicine 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 for geriatric patients.

The Geriatric Patient

There are different estimates regarding the appropriate age of a geriatric patient; however, the definition usually includes people above 70 years old. In typical geriatric cases, multiple illnesses (multimorbidity) must be present, of which at least 2 are illnesses requiring treatment. Moreover, the impact of these illnesses is taken into account. Immobility and cognitive disorders are possible morbidities. Others include:

  • Incontinence
  • Anxiety disorders
  • Depression
  • Chronic pain
  • General frailness
  • Strong restriction of sensory capabilities, such as hearing and visual disorders

Any limitations that may endanger the patient are also important, and social problems should also be taken into account. Acute care and rehabilitative treatments can take place simultaneously.

Clinical Geriatrics

Illnesses to be considered in the geriatric population include fractures near the hip joint, hip and knee surgeries with total endoprostheses, as well as amputations triggered by peripheral arterial occlusive disease, or diabetes-induced vascular disease. Thus, a multidisciplinary team is required to carry out a patient assessment.

Depending on the requirements, entire diagnostics and treatment teams may also be involved. This includes measures of care, physiotherapy, 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 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 homes, and the ability to cope with a self-designed daily routine. 

Contextual factors

Contextual factors include all information concerning the background of the patient. This includes all environmental factors and personal factors, as long as they affect the physical, mental, or emotional constitution of the affected person. Environmental factors refer to the way the patient organizes his/her 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 crucial. 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 comprise support from social circles, relatives, and caregivers. These include accessible facilities that can provide additional care, and possibly, even additional measures for rehabilitation, including aids that are available to the patient or that need to be acquired to enable the patient cope with everyday life. It also applies to resources, which enable or improve communication, and reconstructions may also be required in the home.

If positive contextual factors exist, they can have a positive impact on existing impairments, and this has a positive effect on rehabilitation. Therefore, it is necessary to examine which positive contextual factors may be involved in the treatment; this refers to the resource context of rehabilitation. Contrarily, negative contextual factors can negatively influence the course of rehabilitation.

Note: According to ICIDH / ICF (International Classification of Functioning, Disability, and Health), contextual factors interact with illness and its consequences.

Requirements for Rehabilitation

Rehabilitation can be performed as an outpatient or inpatient process. For inpatient rehabilitation, the facility must specialize in inpatient 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 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, such patients must be able to participate in rehabilitation, and the goals of the rehabilitation must be realistic.

The geriatric rehabilitation is subject to certain conditions, all of which must be fulfilled. This includes ensuring that vital parameters are stable and that existing comorbidities and anticipated complications can be treated by the institution’s staff.

In addition, the patients’ circulatory function and mental and physical capacity must be stable so they can actively participate in therapy, which should take place several times a day. Similarly, exclusion criteria also exist; if even one exclusion criterion is met, rehabilitation is ruled out.

One of these criteria is patient refusal. Another exclusion criterion is insufficient patient resilience, which can arise after several surgeries, e.g. fracture treatment. Some accompanying illnesses or complications can also preclude geriatric rehabilitation, for example, the tendency to run away, disorientation, and severe limitations in the ability to see or hear.

Moreover, bedsores can preclude a patient from rehabilitation measures. An existing problem with an amputation stump is also considered an exclusion criterion, in addition to depression or acute mania.

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 regarding 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 patients to institutions with which they have contractual connections. If the cost of the selected facility is higher than that of a facility recommended by the health insurance, the patient must pay the difference.

Note: In order to be admitted for rehabilitation, all requirements must be met. If even one exclusion criterion applies, rehabilitation is excluded. 

Development of a geriatric rehabilitation plan

First, the physician focuses on the patient’s medical history. This is followed by a thorough physical examination and various tests depending on the medical history. The tests assess 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.

Inpatient treatments usually last around 3 weeks, and their aim is to restore the patient’s health as much as possible in order to improve the quality of life and allow independent living.

Common treatment methods for inpatient rehabilitation

In the fields of orthopedics, neurology, psychosomatic medicine, psychiatry, cardiology, and internal medicine, patients are provided with comprehensive care. Various specialties are available depending on the facility, including neurology, cardiovascular medicine, or diabetic medicine. However, some facilities are specialized in several areas, such as pain-trauma therapy, radiation therapy, and nutrition, etc. Specialization is also necessary to meet the high costs of tests and treatments.

Geriatric Rehabilitation

Geriatric outpatient rehabilitation takes a holistic approach into account. Here, the requirement for commencing rehabilitation is multimorbidity with at least 2 illnesses that require 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 to be basic human needs. This means that health limitations, which make it impossible for the patient to pursue hobbies or other activities, are not necessarily criteria for outpatient rehabilitation.

Benefits of outpatient geriatric rehabilitation

Usually, inpatient geriatric rehabilitation is preferred to outpatient rehabilitation. 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 mostly means that they are able to stay in their familiar environment.

However, in outpatient treatment, the patient is not treated at home. Rather, they must visit the facility. Usually, support is usually available for this, since it can be assumed that the affected person cannot manage the journey alone. This type of geriatric rehabilitation is also an optional interim solution between hospitalization and transition to normal daily life. It is also suitable for preventing deterioration. Therapy is spread over the whole day, which means the patient remains at the clinic throughout the day.

The patient’s condition and the general treatment goals are crucial for the scope of the arrangement. Patients suitable for this type of arrangement are generally mobile and can cope at home while not being treated as inpatients. Application for reimbursement by the health insurance company is also required for outpatient rehabilitation and is made by the treating physician or hospital. Patients usually eat breakfast and dinner at home, while snacks in-between meals are served at the clinic.

The general practitioner is in charge of prescribing medications. Treatments are in accordance with those available at inpatient facilities.

Note: Outpatient geriatric rehabilitation is suitable for patients who are mobile and can manage their lives at home.

A possible issue may be the lack of suitable nearby clinics. In this case, the doctor should advise the patient. The commute should not exceed 1 hour as the patient’s capacity may be limited and there is a risk of deterioration despite a good prognosis. Evidence 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 is completed.

For older seniors, geriatric rehabilitation can be notably challenging. In particular, people who have lost their partners are at risk of becoming sick and losing their ability to live independently. Patients over 75 years old with strong physical and mental constitutions, who may be able to undergo geriatric rehabilitation, are not common.

Regarding geriatric care, relatives often worsen the situation and prevent patients from making their own decisions or force them into uncomfortable arrangements. Empathy is required for geriatric patients and this must be communicated to relatives and caregivers.

Reminder: The goal is to give patients back their capacity for independent living.

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