GOALS OF REHABILITATION

Goals of rehabilitation Rehabilitation reduces or reverses impairment, disability, or handicap caused by disease. More precisely, it enables the individual to achieve their fullest possible physical, mental and social capability by: Comprehensive (usually multidisciplinary) assessment (of problems and also the patient’s strengths and resources) - must cover all aspects of the patient’s current, former, and probable future, situation Goal setting (frail older people have reduced functional reserve so that they may be fully independent when well, but unable to perform the IADL when stressed by illness, injury, or environmental factors. The period of recovery from the stressors must be taken into account in rehabilitation goal-setting) Careful progress monitoring Surveillance and preventative care Specific therapies Assessment of nursing needs Selective feedback to the patient to reinforce positive attitudes Discussion, explanation, education of family/caregivers Discharge planning Long-term goal setting and review. Rehabilitation enables the individual to achieve their fullest possible physical, mental and social capability. Important parts of the process are full assessment, goal-setting, and feedback Goals may be: Full activity after a severe illness Maximum achievable after a damaging illness As much independence as possible when continuing impairment is unavoidable. Physical rehabilitation may reduce impairments e.g. exercise to improve muscle strength. Social care, including social rehabilitation (which may be undertaken by the patient’s family after instruction), may help the patient develop practical strategies to reduce the effects of a disability. Therefore rehabilitation is concerned with: Re-ablement Resettlement Readjustment Role fulfillment The realization of potential in every sphere of life. Handicap, disability and impairment - the three targets of rehabilitation TARGET WHO DEFINITION MANAGEMENT? Impairment Any loss or abnormality of psychological, physiological or anatomic structure or function Medical and surgical treatment usually concentrates on reducing impairments Disability Any restriction or lack (due to an impairment) of the ability to perform an activity in the manner or within the range considered normal for a human being Most clinical (especially hospital-based) rehabilitation tends to focus on disability Handicap A disadvantage resulting from an impairment or disability, that limits or prevents the fulfillment of a role appropriate to a person’s age, sex, social and cultural circumstances The dictionary definition of rehabilitation emphasizes the social dimension (handicap) Rehabilitation team The roles and sites of intervention by the rehabilitation team (from the AGS) DISCIPLINE PRIMARY FOCUS TASKS Physical therapist Impairment, functional limitation Evaluation of joint range of motion Exercise training to increase range of motion, strength, endurance, and coordination Evaluation of mobility and need for mobility aids Treatment with physical modalities (heat, cold, ultrasound, massage, electrical stimulation) Occupational therapist Functional limitation, disability, handicap Evaluation and training in self-care activities and activities of daily living Evaluation and training in cognitive activities of independent living skills (handling money, safety in the kitchen) Evaluation of home safety Speech therapist Impairment, disability Evaluation and training in all aspects of communication Therapy for swallowing disorders Nursing personnel Disease-to-handicap continuum Facilitation of independence with activities of daily living Education of patient and family Social worker Handicap Evaluation, disposition, and liaison with the community Counseling Dietitian Impairment Assessment of nutritional status and adjustment of diet to maximize nutrition Recreational therapist Disability, handicap Assistance with maintaining social roles The relative importance of each team member and the actual need for involvement of the family, friends or carer varies with country. International variations in settings for long-term care Australia Nursing homes, hostels, home care Canada Chronic care or rehabilitation hospitals, nursing homes, home care China Hospitals, other institutions, home care (informal) England Hospitals, nursing homes, residential homes, home care France Hospitals, nursing homes, residential care, home care Germany Hospitals, nursing homes, residential care, home nursing care United States Rehabilitation hospitals, nursing homes, home nursing care Setting The older frail patient may be hard to mobilize again once they have spent event a few days of total inactivity because of an acute illness. Thus rehabilitation is as much an acute specialty as a long term one. Rehabilitation in the acute care setting is generally limited because of limit on lengths of stay. Initial therapy goals include: Diagnosis of disabilities Prevention of complications of bed rest Initiation of treatment plans, including early mobilization and range-of-motion exercises. Rehabilitation may occur in specialized centers dedicated to rehabilitation: Staffed by the full gamut of the rehabilitation professionals Include 24-hour physician coverage Develops an individualized program of intense rehabilitation that usually involves a minimum of 3 hours per day of therapy The team meets at least once a week to evaluate progress and to amend the care plan. Nursing homes also offer less intense treatments and thus may manage patients not eligible for treatment in specialized centers. Many hospitals and outpatient clinics provide various levels of rehabilitation services with the range between: Services provided by only one member of the interdisciplinary team (e.g. physical therapist) Comprehensive care, preventive services, and maintenance therapies. Day hospitals are an example of this kind of care: The patients spend from 3 to 5 days a week in a facility that provides skilled nursing care and rehabilitation services These settings offer the advantage that the patient continues to live at home. A full array of rehabilitation services may also be offered in the home: Interventions tailored to the environment in which they need to be used Limited by cost constraints. Rehabilitation is as much an acute specialty as a long term one Standardized instruments for assessment Some standardized clinical instruments and measurement scales in older people (from Brocklehurst, p 1523) PROPERTY ASSESSED RECOMMENDED SCALE DOMAIN OF INTEREST COMMENTS Basic activities of daily living Barthel Index Disability Informal observation of ability in activities. Ceiling effect in outpatients Memory and cognitive function Abbreviated mental test (AMT) Mental impairment 10 questions Depression Geriatric Depression Scale Depressive symptoms Interview or self-administered Subjective morale Philadelphia geriatric center Morale Scale Quality of life Some overlap with depression A standardised instrument is one which has been tested and validated scientifically. This ensures that test results are: Representative (they test and show accurately what they are meant to show - which is established by comparing them with other lines of evidence) Reproducible (i.e. that the same results will be obtained in the same patient by another assessor or by the same person upon re-test). Standardised instruments used in Britain have been validated on British people by British doctors. Those used in different countries and indeed also on different specific populations e.g. immigrants, ideally need to be validated on the relevant populations. This is often not achievable, and so use of instruments is not always as helpful as at first it might appear. Confounding factors may arise from: Culture and population-specific experience (e.g. the nursery rhymes of England differ totally from those of other nations) Dialects and idioms (e.g. South American Spanish differs from European Spanish). It has even been stated by US doctors that some commonly used tests of cognitive and neuropsychological function are simply not salient or meaningful to Spanish-speaking immigrant groups. Standardised tests need to be validated on the populations on which they are used The process of rehabilitation The patient and their family must be actively involved at every stage of rehabilitation. Family (or friends): - Are with the patient far more than a therapist is - Are involved when the patient is discharged or therapy ceases (the patient may feel abandoned) - Can carry out rehabilitation in the home environment Sensitive measures of progress should be used which focus on single activities When functional recovery is likely to take weeks or months, the patient should be encouraged to focus on the short term Slow progress should prompt a search for one of the barriers to rehabilitation Functional deterioration should raise suspicions of an acute illness or reaction to drugs Patients should be expected to do things for themselves, even if tasks take them longer than they should Reasonable risk-taking by the patient should be encouraged, as long as it boots, rather than undermines, confidence Nurses must be involved in the rehabilitation of hospitalized patients; they may require extra training or support (e.g. by group meetings). The process of rehabiliation involves constant reassessment for both improvements and deteriorations Barriers to successful rehabilitation The patient may have poor motivation, due to: The disease process itself (e.g. disordered perception after a stoke) Complications (e.g. pressure ulcers) Co-morbid conditions (e.g. unrecognized cardiac failure, drug side effects, dementia) Short term psychological reactions (e.g. anxiety, subacute confusional states, embarrassment, fear of incontinence) A feeling of hopelessness because of bereavement, lack of social support or unsuitable housing Communication problems Unrealistic expectations Other hidden problems (periodic reassessment by the therapist may reveal these) Problems accepting that full function may never be restored. The patient may be poorly motivated, creating a barrier to successful rehabilitation Discharge home The main factors that determine whether a patient can return home or not are: The amount of support available at home The interval of care - e.g. whether care must actively continue through the night. Home discharge may be traumatic for the patient as they must learn to cope with their new disability in their old surroundings. Additional references Kalupa KJ, Apte-Kalade S, Fisher SV. Assistive devices and environmental modifications. In: Felsenthal G, Garrison SJ, Steinberg FU, eds. Rehabilitation of the Aging and Older Patient. Baltimore: Williams and Wilkins. 1994:449-465. ...