Principles of Rehabilitation in Geriatric Emergency Medicine

© Springer International Publishing Switzerland 2018
Christian Nickel, Abdelouahab Bellou and Simon Conroy (eds.)Geriatric Emergency Medicine

24. Principles of Rehabilitation in Geriatric Emergency Medicine

Ebby Sigmund 

Occupational Therapy Department, Castle Douglas Hospital, Academy Street, Castle Douglas, DG7 1EE, UK



Ebby Sigmund

24.1 Rehabilitation in the Development of Geriatric Medicine

Rehabilitation can be defined as to restore someone to health or normal life. The origin of the word literally means to ‘make fit again’.

Until the late nineteenth and early twentieth centuries, older people who were ill were usually cared for in an unskilled manner with little or no thought to the possibility of recovery. Their care was low priority and not highly regarded as a role for physicians.

Early pioneers of geriatric medicine recognised the importance of rehabilitation and implemented it as a core part of their revolutionary methods. In the UK Marjory Warren (1897–1960) was one of the first medical practitioners to introduce a systematic approach that included rehabilitation in addition to medical assessment and treatment. Her method vastly improved outcomes for older patients and led to many being discharged home. Interest in rehabilitation and the holistic needs of older patients led to early interdisciplinary collaborations, such as Dr. Exton-Smith’s work with nurse Doreen Norton. Many of these early pioneers published widely and were inspirational teachers so that the previously unpopular area of medicine for older people began to attract doctors of the highest quality [1, 2]. Their vision raised standards and expectations and emphasised the importance of what we now recognise as a holistic approach, interdisciplinary working and inclusion of active rehabilitation in the treatment and care of older people. This was instrumental in the development of geriatric medicine into the unique and fascinating speciality it is today.

24.2 The International Classification of Functioning, Disability and Health (ICF)

The World Health Organization (WHO) defines health as ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’ (Constitution of the [3]). Rehabilitation is viewed as a process that aims to enable individuals to remain at or return home, live independently and participate in wider occupations such as education, work, social and civic life.

The WHO produced the ICF [4] as a framework for measuring and defining health and disability issues for individuals and across populations. This free, international resource is used in many European countries. It provides a common language and conceptual basis for the measurement of disability. It is used across health, social care and education systems and can be applied at many levels from clinical practice to research and policy development. Many national and local rehabilitation guidelines draw on its concepts.

The ICF uses a biopsychosocial model. It views an individual’s functioning as a dynamic process involving the interaction between their health condition, personal and environmental factors. It takes into account the individual’s subjective view of their situation, focussing on the impact of a condition on daily life, rather than the disease itself.

The ICF consists of two parts:

  • Functioning and disability—subdivided into two components:

    • Body functions and body structures

    • Activities and participation

  • Contextual factors—subdivided into two components:

    • Environmental factors

    • Personal factors

The ICF and supporting resources are available in several languages and can be accessed and browsed online.

24.3 World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0)

The WHODAS 2.0 is a tool for generic assessment of health and disability grounded in the conceptual framework of the ICF. It consists of six domains:

  • Cognition

  • Mobility

  • Self-care

  • Interacting with people

  • Life activities

  • Participation (community)

WHODAS 2.0 offers a simpler 12-item version (estimated 5 min to complete) and a more complex 36-item version (estimated 20 min to complete).

The common language provided by these tools supports a holistic, interdisciplinary approach and places an emphasis on person-centred care. All of these factors contribute to better outcomes for patients in geriatric emergency medicine [5].

24.4 Vulnerability to Poorer Outcomes in Older People Admitted to Emergency Care

The changing population demographic of the developed world means that many more people live into late old age. The oldest old, those over 85, are ten times more likely than 20–40-year-olds to have an emergency admission to hospital. They also have the longest length of stay and the highest readmission rates and are most likely to require long-term care upon leaving hospital [6]. The oldest old are more likely to suffer some form of patient safety incident in hospital [7], thus potentially incurring further injury or loss of function.

Many older people, particularly in the oldest old group, have frailty. Frailty is related to ageing and the gradual loss of the in-built reserves of multiple body systems [8, 9]. Older people are less able to withstand the onset of a new illness or apparently minor event, especially if combined with pre-existing physical frailty and/or multiple co-morbidities, sensory impairments, cognitive impairments or acute confusion. On an emergency admission, they may present with non-specific symptoms or issues such as immobility or falls that can mask a serious underlying medical problem. All these issues occurring in the context of the unfamiliar and confusing environment of an emergency unit contribute to increasing older people’s vulnerability to poor outcomes following an emergency admission to hospital.

These issues are covered in more detail elsewhere in the curriculum so we will concentrate on looking at what this means for rehabilitation.

24.5 The Importance of a Rehabilitation Approach in Geriatric Emergency Medicine

The ageing population is often viewed as a problem for society. It should be remembered that many older people remain fit and active well into old age [10] and contribute to society in many ways—economically and in terms of volunteering, unpaid care provision and many civic and community roles [11].

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May 1, 2018 | Posted by in Uncategorized | Comments Off on Principles of Rehabilitation in Geriatric Emergency Medicine

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