Geriatric Rehabilitation

(Basic Conceptual Model)

Robby Tjandra K

Physical Medicine and Rehabilitation Instalation

Dr. Kariadi General Hospital
Semarang
2018
Introduction -- age-related problems in
geriatrics

Biologic
Muscle strength Psychologic
Cardiac function Slow learning pace
Pulmonary function More repetitions
Aerobic capacity Belief about revocery
Vital capacity Belief about self
Minute volume
Orthostatic changes
Peripheral resistance

Social
Negative views of aging
Less frequent referrals
Financial barriers
 Geriatric population sooner or
later need Medical Rehabilitation
Medical rehabilitation in geriatric
health care

Medical Rehabilitation is a critical component

of geriatric health care, because disabling
conditions, which are common among older
adults, profoundly affect their quality of life
and are amenable to treatment.
How to provide best functional
recovery in geriatric rehab
 use systematic approaches to assess the causes
of disability
 be familiar with the advantages and
disadvantages of the various sites of
rehabilitative care
 understand the role of multidisciplinary teams
and care plans
 adapt care to other diseases and disabilities
 be familiar with the basic requirements for
rehabilitation of common geriatric conditions
Conceptual models for geriatric
rehabilitation
 geriatric rehabilitation services can be organized
on the basis of a conceptual model of disability
 allows optimum assessment of the status and
needs of the patient
 an appropriate match of treatments with
specific conditions, and evaluation of
rehabilitation outcomes
The ICIDH-2 (ICF) framework

The revised International Classification of

Impairments, Disabilities, and Handicaps (ICIDH-2)
or International Classification of Functioning (ICF)
of the World Health Organization (WHO) offers a
useful framework
ICF framework

Impairment Restriction
Limitation
Expression of ICF component
ICF framework
The ICF framework has two main parts:
 body structure & function, activity, participation
 contextual factors
The body component is considered to have both
 structures such as organs and limbs and
physiologic functions
 impairments are defined as problems in body
function or structure, such as a significant
deviation or loss
ICF framework
The activities and participation components
address :
 functioning from both an individual and a
societal perspective
 activity is defined as the execution of a task or
action by an individual
 participation is defined as involvement in a life
situation
 participation restrictions are problems a person
experiences in his or her involvement in work,
leisure, and social activities.
ICF framework
The second part of the WHO framework is the
contextual factors, including
 Environmental factors
- have an impact on all components of
functioning and disability
- range from an individual’s immediate
environment to the general environment
 Personal factors
- include age, race, gender, educational
background, personality, fitness, and life style.
ICF model and medical rehabilitation
intervention
In the ICF model, interventions can be designed
to modify :
 impairments
 limitations in activities
 restrictions in participation
Example of interaction between ICF’s
component
 a treatment plan may be developed to improve
strength (impairment level),
 the significance of this intervention is due to its
effect on physical mobility (activity)
 and ultimately the ability to return to social or
physical roles (participation)
 the effect of gains in strength and physical
mobility on participation could be modified by
the person’s motivation or social support.
The role of environment
 if a person improves in strength and balance but
family and friends continue to do everything for
him or her and thus discourage independent
function, the person may remain dependent
 the physical environment is another powerful
modifier
 if physical barriers to access are not removed
with such facilities as ramps or modified
bathrooms  even a person achieves improved
function, cannot regain prior public and personal
roles
In summary
 the interaction of disease and disability is
particularly complex in older adults
 The ICF model is useful for structuring organized
approaches to
1. assessment
2. treatment
3. evaluation of outcomes
Site of rehabilitation services
 rehabilitation services are offered in both
inpatient and community-based sites
 inpatient care may be provided in hospital
rehabilitation center or nursing facilities
 outpatient rehabilitation services can be provided
in hospital-based or independent clinics, in day
hospital settings, or at home
 eligibility requirements, the services provided,
and costs vary across sites of care
Advantages and disadv between inpatent
and outpatient care (pts perspective)
 inpatient care is the most intense but may not
be possible for frail elderly patients
 skilled nursing offers 24-hour care for those
who cannot care for themselves / do not have a
full-time caregiver
 patients often prefer to return to their own
homes but not have the caregiving they need.
 participation in a day hospital or outpatient
clinic requires transportation, which can be
costly and time consuming
Multidisciplinary team

Medical Rehab team Consultants in relevant

• physiatrist specialistic medical care
• physiotherapist  geriatrician
• occupational therapist  neurologist
• orthotic-prosthetic  psychiatrist
 nutritionist
• medical social worker
 pharmacist
• psychologist
 nurse, etc..
• speech therapist
• rehabilitation nurse
Multidisciplinary teams
 for many older adults, health professionals in
several fields are required if their rehabilitation
needs are to be met
 the primary goal of multidisciplinary team
management is to ensure that patients receive
comprehensive assessments and interventions
for the disabling illness and for associated
comorbid
 an effective team establishes common goals and
a cohesive treatment plan for each patient
Multidisciplinary teams
 the patient’s and family’s expectations and
preferences must be integrated into care
planning
 rehabilitation treatments require active patient
participation
 a patient-centered decision-making framework
makes sense, given the chronic nature of many
disabilities of older adults
Disease-related factors that may
affect rehabilitation

Biologic
Multiple diseases
Deconditioning Psychologic
Contractures Cognitive deficits
Disease-disease Depression
interactions Atypical presentations
Polypharmacy motivation
Subclinical organ
dyfunction

Social
Societal prejudice
(“Disabilityism”)
Lack of services
Inaccessible buildings
Reimbursement regulations
Impacts of comorbidities
 comorbidities often require adaptations in the
rehabilitation care plan and may even prevent,
interrupt, or delay treatment
 many illnesses that can interfere with the
rehabilitation of the older patient are predictable
in this high-risk population and are potentially
preventable
 a systematic approach to the assessment,
prevention, and management of comorbidities
 improve the patient’s chance of receiving
maximal benefit from rehabilitation services
Rehabilitation strategies, an overview
 The primary goals of rehabilitation are :
1. restitution of function,
2. compensation or adaptation to functional
losses
3. prevention of secondary complications
 Rehabilitation should maximize the older
person’s potential for participation in social,
leisure, or work activities
Rehabilitation strategies, an overview
 rehabilitation should not be defined simply as
improving independence in ADLs but also as a
program to prevent disability
 a wide variety of strategies can be used to
achieve these goals
Examples
 therapeutic exercises to improve flexibility,
strength, motor control, and cardiovascular
endurance  improving in mobility, activities of
daily living, participation, or reducing risk of
falling
Rehabilitation strategies, an overview
Examples
 repeated practice of task-specific activities, such
as bed mobility, transfers, and walking, can
improve functional mobility
 speech and language therapy and cognitive
rehabilitation  can be used to improve their
alertness and attention
 balance training may reduce the risk of falls
Rehabilitation strategies, an overview
Examples
 upper-extremity function can also be improved
with specific functional training activities, such
as grasps, reaches, and fine manipulations
 retraining in instrumental activities of daily living
(IADLs), such as cooking, managing finances, etc
 mobility aids, orthotic and prosthetic devices
and splints, and dressing and bathroom aids 
replace the function of impaired body parts 
reduce limitations in activities and participation
Rehabilitation strategies, an overview
 contextual factors, need to be addressed
in rehabilitation to minimize restrictions on the
older person’s activities and participation
 environmental modifications may be required to
optimize the older person’s independence in the
home and the community
 good patient and family education, and support
groups may be used to address such personal
factors as motivation
Summary
 comprehensive assessment of each elderly patient is
necessary for appropriate clinical management and
evaluation of outcomes
 the treatment plan should be guided by the results of
the assesment
 multidisciplinary management ensure
comprehensive assessments and interventions
 the ICIDH-2 / ICF of the WHO offers a useful
framework
 rehabilitation should maximize the older person’s
potential for activty, participation in social, leisure, or
work activities
 Rehabilitation
Is a bridge spanning the gap
between
Uselessness and Usefulness
Hopelessness and Hopefullness
Despair and Happiness
 Rehabilitation

is not only to add years to life,

but
also add life to years
Thank You