Rehabilitation is described as "the continuing and comprehensive team effort to restore an individual to his/her former functional and environmental status, or alternatively, to maintain or maximize remaining function."1 Rehabilitation, then , is a continuing process; it is not the last phase of health care following prevention and medical and/ or surgical intervention. Instead, it encompasses all phases of medical and nursing care.
Rehabilitation not only aims to restore an individual to the highest functioning level, it also seeks to maintain function at that level, prevent complications of disability, facilitate adaptation to a changing lifestyle, and promote quality of life.2 Each disabled person has the right to pursue these goals, just as each healthcare worker has the responsibility to promote the rehabilitation efforts of the disabled person. Rehabilitation is a right of alt disabled persons.
Unfortunately, attitudes of healthcare workers and societal myths support the view that older adults are not likely rehabilitation candidates. These attitudes may influence the perceptions older adults as well as healthcare workers have regarding care of the disabled older client. Yet, it is known that at least one third of the disabled population is over 65 and would benefit from rehabilitation.
Rehabilitation goals should be realistically set guided by whether or not a client needs primarily restorative care or maintenance care. Also, cost-effectiveness, healthcare regulations, and appropriate rehabilitation settings for the older adult must be realistically assessed. This article examines the attitudes and perceptions of healthcare workers and society regarding rehabilitative care for the disabled older adult, explores different settings providing rehabilitative care, suggests future research questions, and defines nursing implications and interventions.
Attitudes Toward Rehabilitation
Disabled older adults are viewed by some as not being likely rehabilitation candidates. Rehabilitation of disabled older adults has traditionally had low priority among rehabilitation professionals.3 In a demographic study, Blake found that the incidence of disabilities increases with age and "as the incidence of disabilities increases, contact with and service by rehabilitation appear to decrease.4 The belief exists that institutionalized disabled older adults are too far gone and too senile for rehabilitation and thus should only be given custodial care.
A study conducted by Heller et al found that there is a significant relationship between the attitudes of nurses and perception of type of care needed in institutionalized aged. Registered nurses (RNs) and licensed practical nurses (LPNs) who held negative attitudes toward older adults believed custodial care was appropriate. Those RNs and LPNs who held positive attitudes toward older adults believed rehabilitative care was appropriate.5 A similar study by Kosberg and Gorman found that the healthcare workers (nursing assistants and LPNs) caring directly for disabled older adults in an institutional setting viewed the adults as unable to be rehabilitated.
On the other hand, social workers, professional nurses, and volunteers in the same setting viewed the residents as having rehabilitation potential. Interestingly, 92% of the residents in this institution viewed themselves as poor rehabilitation candidates. Were the residents holding this belief because of their own discouragement, or were they reflecting the attitudes of their caregivers?6
Other myths perpetuating the belief that disabled older adults should not have rehabilitation services include: the elderly are not able to learn, and older adults are burdens and not worth the economic effort because they will die soon anyway. Why do these negative attitudes persist? Is it because old age is considered to be a disability, and/or a physical, mental, or social handicap?7 Or is it because younger adults feel threatened by aging and are reminded of their own aging , or the aging of their parents and/or grandparents?
Need for Rehabilitation
Despite ageism, negative attitudes and myths rampant in society, older adults do need and can benefit from rehabilitation. Presently, at least onethird of the functionally disabled population is 65 years of age or older.8 Furthermore, the "likelihood of disability increases with age."9 In 1980, 11% of the United States population was age 65 and over representing about 25 million people. In 1900 only 4% of the US population was age 65 and over representing about 3 million people.10 By the year 2000, it is projected that 31 million people in the United States will be 65 and over.9 It is apparent from these statistics that there is a present and a future need for rehabilitation of disabled older adults.
Numerous studies reveal that disabled older adults do improve and benefit from rehabilitation services.11-14 Areas that have shown improvement include, but are not limited to, self-care ability, balance, communication, restlessness at night, incontinence, and social skills.13 One study concluded that "well-planned rehabilitation is effective in the very old patient."14 Very old in this case is over 85 years of age. Even this population is not too old, too weak or too depressed to improve.
Learning does not decrease as age increases. Research by Avorn and Langer concluded that not only can older adults learn a task and improve with practice, but by giving extensive assistance with self-care tasks, healthcare providers are inducing a "learned helplessness" in disabled older adults by decreasing their opportunity to practice the skill and conveying the message that the task is too difficult. l5 Rehabilitation is not age-specific. Society needs to ensure that all people with disabilities have the opportunity to reach maximum function.
The specialties of rehabilitation and geriatrics have many similarities in their philosophies of care. They both espouse the need for multidisciplinary teams and continuity of care, use functional assessments as keystones for planning care, concentrate on the "quality of life" rather than "quantity" or productiveness in life, and recognize the need to assist the individual in adjusting to losses. This is true in nursing as well as in medicine.16·17 Unfortunately, history has shown little collaboration between geriatrics and rehabilitation.
Rehabilitation for the aged has been overlooked by medicine with few rehabilitation specialists consulted for inpatient geriatric units, and the geriatric population has only recently been considered for study by rehabilitation residency programs . 3 Rehabilitation nurses in traditional settings may see older adults as not being good rehabilitation candidates, and gerontological nurses in traditional settings may view rehabilitation as a luxury or for only a select few.
Perhaps it is because of this frequent lack of collaboration between rehabilitation and geriatrics plus society's pervasive negative attitudes toward the aged, coupled with current funding regulations, that poses these questions: Within the constraints of current healthcare regulations, what rehabilitation goals are appropriate for disabled older adults? And, which rehabilitation settings best serve disabled older adults?
ftpper depicts the "ultimate goal" for a disabled person as "... the restoration ... to a life that is purposeful and satisfying . . . with an opportunity to function adequately as family members, citizens, and economic contributors."18 While keeping the ideal goal in mind, Clark and Bray provide the following helpful guidelines when coordinating goals with the best rehabilitation plan and setting for the older adult. If the goals are primarily restorative in nature, then the treatment plan should be to reverse the disability and increase function.1 One example of a restorative goal for a client recovering from a hip fracture would be "The client will return to independent living in her apartment and will perform all activities of daily living."
Restorative treatment can be done in a number of different settings with varying intensity. If the goals are primarily maintenance in nature, then the treatment plan should emphasize preserving function and preventing complications.1 An example of a maintenance goal for a client living in a semicomatose state, as a result of a cerebral infarcì, would be "The client will maintain present system functions manifested by the absence of secondary complications such as pneumonia, contractures, acute confusion, and deep venous thrombosis. " Maintenance care is handled mostly by trained nursing staff in a variety of settings. Maintenance care should take place in every setting and should be concurrent with restorative care. Sometimes, however, the primary emphasis is placed on either restorative goals or maintenance goals in a particular setting.
lnpatient Rehabilitation Unit
Which rehabilitation settings best serve disabled older adults? The first setting is a standard, intensive, inpatient rehabilitation unit. This is primarily a restorative setting, a unit where adults of all ages, ranging from adolescence to older age, are served. The disabled population includes those with spinal cord injuries, head injuries, strokes, amputations, and general debilitation. This is usually an excellent environment for rehabilitation because all members of the multidisciplinary team are readily available. Both Anderson and Young suggest that this environment may be appropriate for those older adults with specific disabilities such as hip fractures or hemiplegia resulting from a cerebral vascular accident.19,20
However, for many older adults this type of unit is too intense or simply not appropriate for their needs. In September 1982, Medicare added the stipulation that any person upon admission to an intensive rehabilitation hospital or Diagnostic-Related Group (DRG) exempt unit receiving Medicare benefits must meet the following requirement: "The patient has the physical capacity of benefiting from and participating in at least three hours of physical therapy and/or occupational therapy."21 This requirement is usually interpreted to mean three hours of physical therapy and/or occupational therapy a day for five days a week.
Since the advent of this three-hour regulation, one significant study has been done evaluating its cost effectiveness. Johnston and Miller concluded that "the Medicare three-hour regulation increased costs, and no beneficial effect on patient progress or outcomes could be detected."22 Unfortunately, this regulation has increased costs without increased outcomes. Also, many of the older adults who receive Medicare benefits cannot tolerate three hours of PT and/or OT a day along with their other important therapies such as speech, social work, psychology, and nursing.
Johnston and Miller also added that physiatrists have traditionally graded the intensity of the rehabilitation therapy to meet the individual client's needs. Usually as a client recovers strength, intensity of therapy increases.22 This new regulation is keeping many older patients from receiving the rehabilitation they need early in their hospital course to prevent secondary complications of immobility and disability.
The inception of prospective payment systems, one being DRGs, has had another impact on inpatient, intensive rehabilitation units. Since these units are DRG exempt, they are at a premium because they are excluded from the reimbursement constraint.23 There has been little to no research conducted on the impact of this phenomenon, but one question remains: While working up to the point at which they can withstand three hours of therapy, are older adults losing out on the opportunity to be admitted into rehabilitation units because these units are filling up due to the DRG exempt status?
As mentioned earlier, there are some groups of older adults for whom intense, inpatient standard rehabilitation is inappropriate. One such group is older adults suffering from dementia. A study by Schuman et al found that standard rehabilitation techniques are beneficial to patients without significant mental impairment, are of unclear benefit to those with mild mental impairment, and are not beneficial to those adults with severe mental impairment.24
Specialized Geriatric Units
Hunt echoes a common sentiment when he says, "A tragedy of geriatric medicine is the fact that almost as many elderly patients are made worse by our hospitals as are benefited by them."25 An alternative setting that provides rehabilitation to older adults is a geriatric unit. There are varying types of geriatric units, but their unifying theme is to remedy this tragedy.
One type of unit is an acute medicalsurgical unit that provides early rehabilitative care. Restoring function and preventing complications are dual primary goals in this setting. In some of these medical/surgical units, all ages of adults are treated and older adults with disabilities receive rehabilitative care. Other units treat a specific age group of older adults. In two separate research studies, it was found that rehabilitation for older adults in an acute care setting can have positive effects by lowering hospital charges, increasing self-care activities, discharging more patients to home, and potentially decreasing hospital readmissions as compared to patients who had not received any rehabilitation.12,13
Another type of geriatric unit is a geriatric rehabilitation unit, which is similar to the acute care unit except that the client must usually be medically stable. Geriatric rehabilitation units also serve a specific age range of older adults. Three different research studies examining geriatric rehabilitation units all found that most of the older adults treated in the units had an increase in the level of functional abilities and selfcare. A range of 69% to 76% of the clients were discharged to either their own home or a relative's home in the community.11,14,26
Geriatric rehabilitation units have the advantage of working to meet the specific rehabilitative needs of the older adult. The acute units have the advantage of starting rehabilitative intervention early and treating any medical complications right on the unit, whereas a geriatric rehabilitation unit usually must transfer a client to a medical unit if a complication occurs.
Day hospitals are yet another type of rehabilitation setting. Some day hospitals focus on restoring function, while others emphasize preserving function. Day hospitals are for clients who do not require 24-hour nursing care, but who, for example, may come in for a full day of therapy five days a week.
Cummings et al compared the outcomes of the day hospital with the outcomes of an intensive, inpatient rehabilitation unit. In this case, the day hospital was used in place of an inpatient rehabilitation setting. The family cared for the individual at home, and the client came to the day hospital for therapy each day. The study concluded that both the inpatient and day hospital groups achieved the same functional outcomes, but the day hospital was more cost-effective when costs were adjusted for full occupancy.27
A similar study by Tucker et al , using disabled older adults as a population, found that the patients at day hospitals had a significant improvement in performance at six weeks but not at five months. Also, the day hospital cost was one-third greater than inpatient costs (this study did not adjust costs for full occupancy).28 The US traditionally uses day hospitals as transitional day care for clients who have received inpatient therapy and still need some followup therapy with the equipment and services the day hospital provides.
This transitional service may be most realistic for disabled older adults who may not have family members to care for them at home or who may not be able to withstand the stress of driving back and forth to the hospital each day soon after the onset of a disability. But cost may be a determining factor. One study performed in the US found the day hospital to be the most expensive option among community services and nursing homes.29
Probably the most forgotten rehabilitation setting for the older adult is the nursing home. Much attention has been given to the rehabilitation of the nursing home resident. Brody reports that in 1977, 75% of residents living in a Skilled Nursing Facility (SNF) were dependent in at least one area of activities of daily living and needful of rehabilitation services, yet only 35% of the SNF population received any therapy.10
Furthermore, most of the rehabilitation services reported in the 1977 document were received by short-stay residents (discharge within 90 days or less).23 These short-stay residents are in need of rehabilitation in the SNF since DRGs are pressuring hospitals to discharge Medicare recipients sooner. However, the long-term nursing home residents also need rehabilitation services. Some of the older adult nursing home residents may be candidates for restorative care with subsequent independent or supervised living in the community.
However, many nursing home residents are in need of expert rehabilitative nursing care to maintain and maximize their existing function.23·30 This rehabilitation should include a rehabilitation medicine specialist as a consultant as well as therapists, at least on a parttime basis, who will train nursing home staff how to include therapeutic measures in every daycare.18 Use of parttime therapists can be cost-effective by preventing secondary complications. It is more costly to treat pneumonia and pulmonary emboli resulting from immobility than to prevent complications with proper mobilization and therapy. There are some disabled older adults whose long-term maintenance rehabilitation will be left to the SNF: those who are so disabled that family members cannot care for them at home, and those who are minimally disabled but have no social support systems to help with some aspect of care in the community. It is essential that the nursing home, or SNF, be a rehabilitative setting for the disabled older adult.
The home is also an essential place for rehabilitation. The disabled older adult needs long-term continuity of care, not just crisis intervention. A rehabilitation case manager such as a primary physician, a geriatric nurse practitioner, or gerontological clinical nurse specialist could provide follow-up care. A client may need short intervals of restorative care following an illness, suggestions on how to maintain strength, or recommendations on how to modify coping mechanisms.31 The home is also being explored as an alternative to long inpatient rehabilitation stays because the home is a more realistic setting in which to practice activities of daily living, and the older adult's familiarity with his/her home surroundings relieves some relocation stress.20
Considering the different rehabilitation settings for older adults that have been explored - intensive, inpatient rehabilitation units, geriatric units, day hospitals, nursing homes, and clients1 homes - which settings best meet the rehabilitation goals of the disabled older adult? This is a question that needs research. Research studies should explore which groups of disabled older adults benefit most from which services.8 Perhaps the best setting is not yet in practice.
After examining that question, research studies could suggest how to provide those services to the largest number of disabled elderly adults. Other questions to research include: Are specialty geriatric units combining acute medical/surgical and rehabilitation services, the most cost-effective way to provide inpatient services to older adults with the goals of preventing complications and maximizing and restoring function? How much therapy time per day is needed for disabled older adults to restore and maximize function? What role does fatigue play in rehabilitation of the older adult?
Nurses have an opportunity to provide rehabilitative care for older adults in all of the settings mentioned. When planning a rehabilitation program, nurses need to consider some special healthcare needs of the older adult. First of all, the general health status of the disabled adult must be considered. A person in the older age group usually has several diseases interacting with each other. In one study, the mean number of medical diagnoses for groups of older adults being rehabilitated were 6.5 and 7. 1.13 Usually more than one body system is involved, and the interaction of the involved systems should be well understood by professional nurses directing care of other workers.
Another important consideration when planning a rehabilitation course for an older adult is the potential for secondary complications. All nursing and medical efforts should be made to prevent such complications as decubiti, weakness, atelectasis, thrombosis, osteoporosis, contractures, dehydration, confusion, hyperthermia, and pain. The body's response to stress is less efficient as a person ages. Complications from immobility and disease are not as easily warded off by the aging body.
Rehabilitation should be initiated as soon as possible after disability occurs so as to prevent these secondary disabilities. Nursing interventions such as turn, cough, and deep breathe, encouraging fluids, range of motion, providing for adequate nutrition, developing bowe! and bladder programs, providing meticulous skin care, and use of orientation devices may seem basic but are essential in preventing complication superimposed upon complication.
It is unfortunate but true that all of these multiple medical problems and complications may interfere with therapy. With the disabled older person, time away from therapy should be expected and incorporated into the rehabilitation program.32 However, less therapy time does not mean an absence of a rehabilitation program. It means prioritizing time to relieve fatigue and giving attention to conditions needing medical treatment.
Fatigue due to physical and/or emotional stress can also interfere with therapies. The nurse involved in a rehabilitation program has the responsibility of arranging the therapy schedule to meet the needs of the older adult. Pepper suggests short intensive periods of therapy for the older adult rather than prolonged, intermittent periods. He also recommends concentrating therapy time in the morning hours and providing rest periods in the afternoon.18
The physical realm is not the only one with special considerations for the older adult involved in rehabilitation. Facilitating adaptation to losses and supporting effective coping mechanisms is important in any rehabilitation program. For the older adult, it is important to remember that he or she is facing many losses at once. Not only has that person lost some physical function, he or she may be experiencing loss of adequate income due to retirement, loss of family and friends due to death, loss of dignity due to insiitutionaïization, and loss of self-esteem and selfworth due to the public's negative attitudes toward aging.
Linked in with these multiple losses is the failing social support network that may surround the older adult. Tins is an especially important consideration when planning discharge. There may not be family available or friends capable to help the elderly client with selfcare needs. Discharge planning becomes an art for the nurse who must balance the losses of the older adult with the provision of continuing care. Professional nurses need to be informed of the services provided in their community through networking with other healthcare professionals.
Time is one more need of the older adult to take into account in developing a rehabilitation plan. Older adults can and do learn, although the assimilation and processing of information takes longer than for a younger adult.15 Nurses and other healthcare workers need to allow extra time for older adults to perform self-care activities rather than completing the task for the client. Extended time may also be needed to teach information when sensory impairments are present.33 Taking the time to make sure a hearing aid is working or glasses are clean may make communication much easier.
Lastly, realistic goals need to be identified when developing a rehabilitation plan for a disabled older adult. As tapper stated, start with what is bothering or frustrating the patient the most. 18 In other words, what is the patient's goal? What is the family's goal? Include the older adult and family members in goal setting. Clients who participate in goal-setting are more likely to be motivated to reach the goals.34
The older adult and family members need to be listened to since they are the ones who will be dealing with the disability for the rest of their lives. For some older adults, a goal may be to return to the workplace. For other older adults, independent living is a goal. When listening to the client and family, however, it is important to help them set realistic goals. They may be dealing with the disability by denying its consequences, so assistance in goal-setting by staff is important.
Healthcare workers directly caring for older adults may also need assistance. Nurses not responsible for direct care such as geriatric nurse educators should be challenged to teach rehabilitative nursing to nurses and other workers caring for older clients. One study found a direct correlation between a positive attitude toward geriatrics and rehabilitation and a knowledge of geriatrics and rehabilitation.35 Not only nurses need training in rehabilitation and geriatrics, all healthcare workers need to learn and integrate the two specialties.
Inservice coordinators and nurse managers need to help all staff members explore and confront their stereotypes and attitudes toward older adults. Based on the principle that "individuals often conform to the opinions of and expectations held by others,"6 nurse managers should expect positive attitudes from their staff members so that older adults will not have the opportunity to conform to any negative opinions and attitudes of caregivers. One example of helping staff explore and deal with attitudes toward the aging is by a gaming technique where participants role-play potential real-life situations. Into Aging is one such game that has met with enthusiasm from nursing staff members; this game may be a good idea to include in routine orientation of new staff members working with older adults.9
Nursing needs leaders to plan and direct rehabilitation in many situations where the only common healthcare provider is a nurse. One way to develop that leadership is through a graduate level program producing gerontological clinical nurse specialists and geriatric nurse practitioners interested in rehabilitation for older adults. These leaders can serve to educate the many who work with older adults. The hope is that all healthcare workers will accept the challenge to wed rehabilitation with the care of the disabled older adult.
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