Key Facts

Rehabilitation is a core function of geriatric medicine. It requires active patient participation, realistic goal-setting, and coordinated multidisciplinary input.

Epidemiology

• Approximately 30-50% of hospitalised older adults experience functional decline during admission
• 10 days of bed rest in a healthy older adult leads to 14% loss of aerobic capacity and 10% loss of muscle strength
• Intermediate care and rehabilitation services handle >500,000 episodes per year in England

Aetiology

Rehabilitation is needed after:

• Acute illness (pneumonia, sepsis, AKI)
• Surgical procedures (hip fracture, joint replacement, cardiac surgery)
• Neurological events (stroke, head injury)
• Prolonged immobility or deconditioning
• Falls and fractures
• Amputation

Pathophysiology

• Deconditioning syndrome: bed rest → sarcopenia, reduced cardiovascular fitness, joint contractures, pressure ulcers, constipation, postural hypotension, depression, cognitive decline
• Neuroplasticity: the brain can reorganise after injury (basis for stroke rehabilitation)
• Motor learning: repetitive task-specific practice improves function

Assessment

• Pre-morbid function (what could the patient do 2 weeks before admission?)
• Current functional ability (mobility, transfers, washing, dressing, toileting, feeding)
• Cognition (capacity to participate, learning ability)
• Mood (depression significantly impairs rehabilitation participation)
• Social circumstances (home setup, carers, support)
• Patient's own goals and priorities

Rehabilitation Potential

• Motivation and engagement
• Pre-morbid function
• Cognitive ability to learn and participate
• Medical stability
• Adequate nutrition
• Realistic goals achievable within timeframe

Red Flags

• Failure to progress despite appropriate rehabilitation
• New medical deterioration during rehabilitation
• Persistent delirium impeding participation
• Safeguarding concerns (e.g. unsafe home environment)
• Worsening mood/psychological distress

Bedside

• Barthel Index: ADL assessment (0-100; higher = more independent)
• Functional Independence Measure (FIM): 18 items, motor + cognitive (18-126)
• Timed Up and Go (TUG): functional mobility
• Grip strength: dynamometry
• Cognitive assessment: MoCA, ACE-III
• Mood screening: GDS-15, PHQ-9
• MUST: nutritional assessment
• Home assessment (OT): evaluate equipment needs, safety

Bloods

• FBC, U&Es, vitamin D, albumin, TFTs, B12/folate (optimise medical status)

Imaging

• As indicated by medical conditions

Special Tests

• COPM (Canadian Occupational Performance Measure): patient-centred goal-setting
• EQ-5D: quality of life measure
• Therapy assessment: detailed physiotherapy and OT assessments

Non-pharmacological

• Early mobilisation: within 24 hours of admission (unless contraindicated)
• Physiotherapy: strength training, balance, gait re-education, endurance
• Occupational therapy: ADL practice, home assessment, equipment provision, cognitive rehabilitation
• SALT: swallowing rehabilitation, communication therapy
• Dietitian: nutritional optimisation (protein 1.0-1.2 g/kg/day)
• Psychology: managing adjustment, depression, anxiety, motivation
• Social work: care packages, housing, benefits, carer support
• Goal-setting: SMART goals, reviewed weekly at MDT meeting
• Discharge planning: starts from day 1; community rehabilitation, intermediate care, home adaptations

Pharmacological

• Optimise medical conditions: pain management, blood pressure, diabetes, heart failure
• Vitamin D supplementation: 800-1,000 IU daily
• Treat depression: SSRIs if indicated (may improve rehabilitation engagement)
• Medication review: stop medications causing sedation, postural hypotension, or cognitive impairment

Surgical/Interventional

• Joint replacement rehabilitation protocols
• Hip fracture rehabilitation (BPT standards: physio from day 1)
• Post-amputation rehabilitation and prosthetic fitting

Referral Criteria

• All older adults with functional decline: rehabilitation assessment
• Complex needs: community rehabilitation or intermediate care
• Stroke rehabilitation: specialist stroke rehabilitation unit (NICE NG236)
• Unable to return home: social services, intermediate care, residential assessment

• Early mobilisation reduces hospital LOS by 1-2 days and reduces complications
• Intermediate care rehabilitation: 60-70% of patients return home
• Hip fracture rehabilitation: 50% regain pre-fracture mobility
• Stroke rehabilitation: greatest recovery in first 3 months; continued improvement up to 12 months
• Deconditioning is largely reversible with appropriate exercise
• Factors predicting good outcome: good pre-morbid function, motivation, intact cognition, social support

Barthel Index (Modified)

Rehabilitation Settings