Geriatric rehabilitation: Researchers seek to better understand who should be prioritized

Completing rehabilitation and going home is a major milestone on the path of recovery after hospitalization, especially for older adults.  As Canada’s population ages and demand grows for rehab units, it has become important to understand who is most likely to successfully return home after going to rehab so those patients are prioritized.

Andrew Perrella is a Geriatric Medicine fellow at McMaster University and a member of the Geras Centre for Aging Research, a centre of McMaster University and Hamilton Health Sciences.

We spoke with Perrella about rehab discharges for seniors, his latest research, and why he says ensuring a safe discharge and successful rehab stay for patients is paramount.

Before we get into unplanned discharges, can you first explain how inpatient rehab works when there are no complications?

In this example, let’s say our patient experienced a stroke. When they arrive in the rehabilitation ward, the patient meets with a team of experts for an assessment to determine the patient’s current capabilities and what they need assistance with.

This is also when an estimated discharge date will be determined. The discharge date isn’t typically set in stone and is discussed with the patient on a weekly basis.

Once the assessment is completed, a therapy schedule is crafted for the patient. This could involve sessions with physiotherapists, speech language therapists or occupational therapists. It is really dependent on the needs of the patient.

As long as the patient’s rehabilitation is progressing and their individual goals are being reached, the patient is discharged according to plan.

If someone experiences some sort of setback in their recovery, what happens?

Setbacks can happen in the normal course of rehab. For example, a patient could experience a serious fall during rehab and need to be taken back to an acute care ward to recover. This would be an example of an unplanned rehab discharge.

Before the patient is relocated, the rehab team conducts an assessment to gauge whether the medical issue can be managed on the rehab ward, and if the patient is fit enough to continue with high-intensity rehab. High-intensity rehab is a program that aims to get patients home within three weeks.

If the decision is made to stay on the rehab ward, then the patient continues their rehab, but their discharge date will likely be delayed a couple days or weeks because their rehab progress may have slowed down as they recover from their health issue.

If a patient must return to acute medical care, what should they know?

Following recovery from their illness or injury, they will be reassessed to continue their rehab. If they were progressing well prior to their illness, then the hope remains that they will return to the rehab unit shortly. If our patient was facing challenges undertaking their rehabilitation, and then became too unwell to continue, I would invite the family into a conversation regarding an optimal discharge destination. For example, if returning home alone is unsafe, we would inform the patient and their family that discharge planning would be continued on the medical ward. However, it’s important to note that every patient’s situation is different so we would ensure we work with them on the best possible course of action.

Keeping morale high is important, but doing our best to ensure that we have planned as safe a discharge as possible for our patient is paramount.

What is known about unplanned discharges for older adults?

Surprisingly little is known about this subject.

Most of the research on outcomes following inpatient rehabilitation focus on specific patient populations, such as those who have undergone hip or knee surgery, or who have had a stroke. Comparatively little has been written on rehabilitation for older adults.

Access to dedicated rehabilitation wards for elderly patients remains difficult in today’s health-care climate. Thus, it is imperative that the most suitable patients are selected for rehabilitation to ensure the ongoing appropriate use of this valuable health-care resource.

Your latest paper investigated the factors that can predict which older adult patients would be at risk of not being able to complete a course of rehabilitation. What did you find?

The overarching takeaway from this paper is that older adults with frailty can often successfully complete a geriatric rehabilitation course with only a minority having an adverse outcome.

We found over 90 per cent of patients underwent a successful course of rehabilitation following their acute illness and were able to be discharged home, undoubtedly due in large part to the continuous efforts of the highly proficient multidisciplinary team we have on the rehab ward.

Our team reviewed 251 charts of patients aged 65 or older who were admitted to a rehab unit from medical and surgical wards in Hamilton Health Sciences hospitals. Three key variables have been found that appeared to predict unfavourable outcomes for rehabilitation patients. The first variable was the need for assistance with so-called “basic” daily activities such as showering, dressing, and feeding.

The second variable was whether there was a diagnosis of lung disease, specifically chronic obstructive pulmonary disease, also known as COPD. The last variable was low levels of albumin, a protein circulating in our blood that can sometimes indicate malnutrition. The low albumin level as a predictor of poor outcomes has been replicated in prior literature, and our results further support its potential use as a clue for rehab success.

Where should the research go from here?

The reliance on others for support for activities and daily living and a diagnosis of COPD are interesting findings that predicted difficulty completing rehab. These results warrant further investigation or replication in large-scale studies on outcomes following geriatric rehabilitation.

The results of our research could prove important to physicians who continually assess patients for rehabilitation potential and provide ongoing care while on the rehab ward, as well as hospital policymakers who may view the largely positive outcomes following a stay on a geriatric rehabilitation ward as an impetus to expand this service if and whenever possible.