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, comprises internal medicine, psychiatry, neurology, and orthopedics. Since 1989, 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 be of a biologically older age. There are different estimates for this; however, this usually includes people above 70 years old. Additionally, in typical geriatric cases, multiple illnesses (multimorbidity) must be present, of which at least 2 are illnesses requiring treatment. However, the impact of these is also taken into account. In addition to immobility, these can be cognitive disorders. Other possible consequences include:

  • Incontinence
  • Anxiety disorders
  • Depression
  • 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.

Clinical Geriatrics

Illnesses or implications 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, in order to carry out a patient assessment, a multidisciplinary team is required.

Depending on the requirements, 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 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

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 comprise 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, reconstructions may be required in their home.

If positive contextual 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 about the resource context of rehabilitation. Respectively, negative contextual factors can have a disturbing influence on 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, they must be able to participate in 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 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 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. 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. 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 to 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, 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 3 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 independently.

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. Depending on the facility, various specialties are possible, such as neurology, cardiovascular, or diabetic. 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 Rehabilitation

Geriatric outpatient rehabilitation also takes a holistic approach into account. Here, too, the requirement is multimorbidity with at least 2 illnesses requiring treatment. 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 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 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. Therapy is spread over the whole day, which means the patient remains at the clinic throughout the day.

The patient’s condition and 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 they are not treated as inpatients or full inpatients. Nevertheless, it is intended for patients older than 65 years. 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, 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.

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

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 1 hour, as the patient’s capacity is limited, otherwise, there is a risk of the condition deteriorating despite a good prognosis, due to overloading the patient. 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 older seniors, 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. Patients over 75 with stronger physical and mental constitutions, who may be able to accept geriatric rehabilitation, are not the norm; even relatives are not necessarily much help. Relatives often worsen the situation and prevent seniors from making their own decisions or force them into uncomfortable arrangements. Empathy is required for geriatric patients and this must be communicated to the patients’ relatives and caregivers.

Reminder: The goal is to give patients back their independence.

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