Assessment of Disability in Older People and Rehabilitation

Assessment of Disability in Older People and Rehabilitation A. 20 High-Yield Points Framework and Terminology

WHO ICF (2001) replaced the impairment–disability–handicap model. Disability is the collective term for impairments, activity limitations and participation restrictions; functioning is the positive umbrella term. - Part 1 — Functioning and Disability: Body Functions and Structures; Activities and Participation - Part 2 — Contextual Factors: Environmental Factors; Personal Factors

Key definitions: Impairment — problem in body function or structure · Activity — execution of a task · Activity limitation — difficulty executing it · Participation — involvement in a life situation · Participation restriction — problem in that involvement · Environmental factors — the physical, social and attitudinal environment.

Vicious cycles: Parkinson's disease → difficulty with self-care and mobility → cannot pursue hobbies → falls and fractures hip → loses confidence → isolated, withdrawn, depressed. Rehabilitation can interrupt the cycle at any point — preventing progression of impairment to activity restriction, of activity restriction to participation restriction, and preventing further impairments.

Rehabilitation (UN definition): "a goal-orientated and time-limited process aimed at enabling an impaired person to reach an optimum mental, physical and/or social functional level, thus providing him or her with the tools to change his or her own life."

Determinants — must reproduce: Determinants of ACTIVITY restriction Determinants of PARTICIPATION restriction Type of impairment (nature and severity Intrinsic: attitude · personality · ability to adjust · cultural issues of disease) Presence of associated impairments Extrinsic: financial resources · housing · other resources · social supports (spouse, family, neighbours, friends, pets)

The greatest difference from younger patients is reduced physiological reserve — recovery is prolonged and may not reach premorbid level. But even very old people recover from major illness, and failure to progress can seldom be attributed to reduced reserve alone; of far greater importance is lack of activity and physical fitness. Weight training increases strength and improves functional capacity even in old age.

Assess BEFORE entry into a rehabilitation programme — to confirm the problems are remediable and to plan management. Patient selection is difficult: it is unfair to subject someone who cannot benefit to a demanding programme and raise false expectations; equally, those who can benefit even to a limited extent must not be denied access.

Assess "both the problem in the individual and the individual with the problem." Determine the nature and severity of all impairments, new and long-standing.

Obtain a baseline measure of functional status so progress can be monitored and efficacy reviewed. Reassess at least weekly.

Assessment of activity restriction: - Begin with the clinical history — determine premorbid as well as current function. - Use ADLs (washing, grooming, dressing, toileting, eating) and IADLs (meals, telephone, laundry, housework, gardening, shopping, public transport). - If difficulty is reported, ask how the person manages — is the task neglected, or does someone help? - Busy clinicians can estimate the extent of restriction with a few simple questions and observations; detailed standardised scaling is generally left to therapists and social workers. - No consensus exists on the best scale; highly valid and reliable scales are resource-intensive or intrusive, and the lack of uniformity inhibits comparative research.

RCP/BGS endorsed standardised scales — high-yield table:

Assessment of participation restriction: each person interacts uniquely with their environment, so participation restriction is unique to the individual and determined mainly by the ability to adapt. Some redefine rather than lose their social role, and a few people's lives are enriched by developing an impairment. Because such measurements are subjective and unstable over time (influenced by mood), assessing participation restriction is largely neglected in both clinical and research settings.

Eight steps — the single most examinable table: 1. Assessment → 2. Setting goals → 3. Therapy → 4. Aids and adaptations → 5. Education → 6. Psychological support → 7. Evaluation → 8. Follow-up. The steps overlap, occur simultaneously and must be regularly revisited.

Two overarching principles: - Early intervention is crucial — avoidable restriction develops soon after impairment onset and, once established, may be irremediable. Flaccid hemiplegia risks shoulder subluxation; proper handling and limb positioning immediately post-stroke minimises this. - A team approach is essential — doctors manage impairment, remedial therapists manage activity restriction, social workers manage participation restriction; nursing has a holistic brief influencing both. Teams need co-location for informal exchange plus regular formal meetings to review progress, revise goals, plan discharge and organise follow-up.

Goal setting: goals must be realistic, account for premorbid status, and be agreed by all team members and particularly the patient — a programme is seriously compromised if key people differ on the target. Sometimes modest goals are right (wheelchair independence rather than walking for an amputee). Patients with ambitious goals make greater progress, so the pragmatic approach is "ambitious but achievable." Set short-term (intermediate) and long-term (final) goals with flexible, regularly reviewed time frames.

Therapy — team roles: Doctors manage the presenting problem and coexisting impairments, minimise risk factors and anticipate complications (in embolic stroke: monitor anticoagulation, control hypertension, manage angina and diabetes). Occupational therapists assess and enhance ADL competence. Physiotherapists target cardiorespiratory, neuromuscular and locomotor function. Speech and language therapists address communication and swallowing. Plus clinical psychologists, podiatrists, dieticians.

Aids and adaptations: - A caution: providing an aid is not always best — it can foster dependence rather than independence. Conversely, those in real need often do not obtain even basic aids. - Match the adviser to the aid: occupational therapists for general aids, physiotherapists for mobility aids, speech therapists for communication aids, audiologists for hearing aids, continence advisors for continence aids — and they must follow up to ensure aids are used and maintained. - Prostheses replace body parts; orthoses are applied externally to support, improve function, or restrict or promote movement. - Home adaptation: handrails, ramps, improved shower and toilet access. Early occupational therapy input, often including a home visit, ensures modifications are appropriate and timed to facilitate discharge.

Education and psychological support: - Education is a vital component and doubles as secondary prevention — patients must understand their disease, its implications, prospects of recovery, risk factors and lifestyle modification; family should be included. - Psychological support requires good listening skills; people fear the unknown, and explanation reduces anxiety. Patients may fear future events (another stroke) as much as the present one. - Regular reassurance and positive feedback are simple and effective; a careless negative remark can profoundly demoralise a patient. Feedback must never become dishonest or generate false expectations. - Support spouses and relatives too; hospital settings foster a "therapeutic community", and self-help groups provide ongoing support after discharge.

Discharge planning, evaluation and follow-up: - Discharge is a transition in rehabilitation, not its conclusion. Many benefit from continuing outpatient therapy to gain further or prevent loss of gains. Some follow-up is essential. - Programmes are resource-intensive and must demonstrate effectiveness — at minimum compare patients on entry and at discharge, using increasingly standardised data.

Settings and specific programmes: - Settings: stand-alone rehabilitation hospitals · designated rehabilitation units · undifferentiated wards · nursing and residential homes · day hospitals · community day centres · outpatient centres · the patient's own home. Ideally a range of options should be available. - Co-location by condition (stroke units, ortho-geriatric units) fosters expertise, research and training. Stroke units improve survival and functional outcomes; evidence for ortho-geriatric units is less convincing. - Intermediate care is intensive, short-term, community- or home-based rehabilitation to prevent hospitalisation, facilitate early discharge and maximise independent living. Community-based rehabilitation only suits the least disabled and well-supported. - Cardiac rehabilitation — SIGN's four phases; exercise-based programmes reduce all-cause mortality by 27%. After uncomplicated infarct, feed self from the outset, sit out of bed within 24 hours, walk to the toilet within 48 hours. - Pulmonary rehabilitation reduces dyspnoea and fatigue, increases exercise capacity, improves quality of life and may prevent hospitalisation; benefits are seen in the "old old", and the greatest benefits are in the most impaired patients. Exercise: at least 3 times a week, at least 20 minutes, heart rate at least two-thirds of maximum, for at least 6 weeks and preferably 3 months. Gains are lost without a maintenance programme. - Musculoskeletal disorders — multidisciplinary rehabilitation is of proven benefit only in chronic back pain, other chronic pain, and after hip fracture in frail elderly people. - The elderly amputee — most lower-limb amputations follow peripheral vascular disease. Perioperative mortality 10–30%, two-year survival 40–50%, five-year survival 30–40% — unchanged over 50 years. Preserving the knee is critical: it takes 40% more energy to walk with an above-knee than a below-knee prosthesis. Prescription of a prosthesis is almost always indicated regardless of age, yet older amputees are less likely to receive one even after adjusting for comorbidity and function. - Emerging technologies — remote sensors and wearables give objective, quantitative data (existing scales are subjective and prone to observer variability), virtual reality and video-capture platforms, video games for post-stroke upper limb (must give feedback, avoid a sense of failure, and match challenge to capability), and GPS, robotics and mobile systems enabling early transfer from hospital to home-based rehabilitation.

Rehabilitation is now a recognised global public health priority. A World Health Assembly resolution endorsed in May 2023 marked the first time in 75 years that rehabilitation was recognised as a core global public health priority, aligned with the Rehabilitation 2030 action areas; WHO has supported approximately 78 countries to strengthen rehabilitation services. At the 3rd Global Rehabilitation 2030 meeting (July 2023) the World Rehabilitation Alliance was launched with 82 founding organisations, along with the Package of Interventions for Rehabilitation (PIR) — evidence-based interventions for 20 health conditions produced with Cochrane Rehabilitation — plus the Rehabilitation Competency Framework and health-financing and workforce guidance.

EuGMS definition of geriatric rehabilitation. Geriatric rehabilitation is "a multidimensional approach of diagnostic and therapeutic interventions, the purpose of which is to optimize functional capacity, promote activity and preserve functional reserve and social participation in older people with disabling impairments" — a definition following the WHO ICF framework. Common admission diagnoses are stroke, hip fracture, post-orthopaedic surgery, osteoarthritis and other musculoskeletal disease, movement disorders, oncological disease and cardiopulmonary conditions.

Predictors of successful geriatric rehabilitation are now defined. Discharge back to the community is associated with higher cognition, better mobility at admission, higher baseline functional independence, lower multimorbidity, fewer acute hospitalisation days and greater social support. In those over 90, higher functional independence at admission and fewer medications predict community discharge, whereas multiple comorbidities, hospital admission in the past year and lack of social work involvement predict readmission.

"No rehabilitation potential" is no longer acceptable. Rehabilitation for older people reduces hospital admissions, length of stay and carer burden while improving functional outcomes. The 2024 British Geriatrics Society report "Reablement, Rehabilitation and Recovery: everyone's business" argued that rehabilitation should be a component of all services caring for older people, and that rationing access on the dubious basis of "no rehabilitation potential" should be a thing of the past.

Meta-analytic evidence. A 2024 systematic review and meta-analysis in BMC Medicine of randomised trials in adults 65 and above undergoing inpatient or geriatric day-hospital rehabilitation versus usual care assessed mortality, care-home admission and functional status as primary outcomes.

Prehabilitation — a new stage before rehabilitation. Structured pre-operative exercise and education programmes are being trialled in older surgical patients; cognitive prehabilitation is being evaluated for its effect on postoperative delirium and delayed neurocognitive recovery. Evidence for physical prehabilitation before hip replacement remains conflicting.

Digital and mHealth rehabilitation. A systematic review of mHealth in geriatric rehabilitation found most outcomes improved in both arms with a majority favouring the intervention, but with high risk of bias and minimal reporting of integration into daily practice.

Assessment tools converging with CGA standards. The German S3 guideline (2024) sets six mandatory CGA dimensions — self-help ability, mobility, cognition/delirium, affect, nutrition and social situation. WHO ICOPE screens mobility, cognition, nutrition, vision, hearing and psychological well-being.