Overview of geriatric rehabilitation: Patient assessment and common indications for rehabilitation

INTRODUCTION — Disability, or limitation in the ability to carry out basic functional activities, becomes increasingly common with advancing age. The primary purpose of rehabilitation is to enable people to function at the highest possible level despite physical impairment. While rehabilitation may be provided to all age groups, the fastest-growing population of persons requiring rehabilitation services is adults over 65 years of age.

This topic will discuss assessing patients for rehabilitation services and indications for rehabilitation. Issues regarding comprehensive geriatric assessment, disability assessment, and components and settings for rehabilitation are discussed separately. (See "Comprehensive geriatric assessment" and "Disability assessment and determination in the United States" and "Geriatric rehabilitation interventions" and "Physical therapy and other rehabilitation issues in the palliative care setting".)

OVERVIEW — The World Health Organization's International Classification of Function, Disability, and Health (ICF) model describes disability as arising from the interaction between physical impairments resulting from health conditions and contextual factors that impact the person's ability to adapt to those impairments, such as social support and environment [1]. Models for the development of disability are discussed separately. (See "Geriatric rehabilitation interventions", section on 'Conceptual models for disability'.)

Rates of disability are rising around the globe, and although there is considerable heterogeneity across countries in the dominant causes of disability, the global disease burden has shifted from communicable to noncommunicable diseases, with many countries experiencing increases in age-related conditions as a cause of disability [2-4].

Disability has a tremendous impact on the quality of life of individuals and their caregivers and increases health care costs [2,5]. Having multiple chronic conditions is associated with greater levels of disability, and the proportion of older adults in the United States reporting multiple chronic conditions is increasing over time, with 13.7 percent reporting four or more chronic conditions in 2010 compared with 11.7 percent in 1998 [6]. A 2010 report from the US Department of Health and Human Services shows that 31.5 percent of all Americans had multiple chronic conditions, and that proportion rises steeply with age, such that over 80 percent of persons >65 years of age report multiple conditions [7].

In younger populations, disability often arises from a catastrophic illness or accident. In older persons with limited functional reserve, lesser stressors such as a fall, infection, or hospitalization may precipitate disability. In a prospective cohort study of previously nondisabled community-dwelling adults newly admitted to a nursing facility after a hospitalization, only one-third were able to return home at or above their previous level of function, while 46 percent returned home with new disability and 27 percent remained in the nursing home with disability [8].

Older adults can also present with subacute onset of disability and no clear precipitating event [9]. Disability resulting from multiple chronic conditions is dynamic, with patients' abilities and needs changing over time [9-11]. Observational studies suggest that while many disability episodes are brief, lasting one to two months, these events identify individuals who are at risk for recurrent or progressive decline in function and require evaluation and intervention to prevent disability. (See "Disability assessment and determination in the United States".)

APPROACH TO ASSESSING LATE-LIFE DISABILITY — Because of the complex interactions between multiple health conditions, impairments resulting from the health conditions, and contextual factors, a systematic approach is useful for the assessment of new-onset or progressive disability in an older adult and in related medical and rehabilitative treatment planning (table 1) [12]. In patients with multiple health conditions, it is frequently impossible (and unnecessary) to identify a primary cause or trigger for the disability. Rather, identifying all contributing conditions, impairments, and contextual factors and addressing these factors with appropriate interventions is the most effective means of reducing functional dependence.

Characterize the disability — The first step is to clearly describe the disability, including its onset, time course, and impact on patient and caregivers. In addition, attention should be paid to soliciting the following information:

●Associated symptoms to help identify the affected organ systems or musculoskeletal components and potential underlying conditions, such as:

•Sudden loss of function with an acute hip fracture versus insidious loss of function with osteoarthritis (OA) of the hip

●Compensatory strategies in use by the patient and caregiver to help guide choices in treatment interventions, such as:

•Physical (eg, use of assistive device)

•Environmental (eg, moving bedroom downstairs)

•Social (eg, Meals on Wheels, family support)

Identify impairments — The initial history and physical should focus on identifying the organ systems involved in causing the functional decline or disability (eg, musculoskeletal, cardiopulmonary). This can be achieved through use of screening questions and examination maneuvers to identify contributory sensory impairment, cognitive impairment, and/or impaired nutritional status (table 2).

Functional disabilities are commonly categorized according to the activities of daily living (ADLs) (table 3) or instrumental activities of daily living (IADLs) (table 4). ADLs include bathing, dressing, toileting, transferring, eating, and continence. IADLs include cooking, cleaning, shopping, transportation, finances, and medication management.

Example assessments might include:

●A brief screening test for cognitive impairment in a patient with new or progressive disability, even if the patient does not state that they have memory problems

•The Clock Draw Test [13] – Validated cognitive screen requiring less than five minutes (see "Mental status scales to evaluate cognition", section on 'Specific mental status scales')

●Assessment of gait or mobility

•The “Get Up and Go” or timed "Up & Go” test (table 5) [14]

●Assessment of executive function, joint range of motion, and fine motor skills [15]

•Watch the patient perform a simple functional task – Putting on a sock, taking off a jacket, or picking a small item off the floor

Identify health conditions — When the relevant organ systems are identified, standard differential diagnostic methods are used to identify the specific health conditions underlying or contributing to the patient's disability. In older adults, these are most commonly:

●Musculoskeletal conditions (eg, arthritis, sarcopenia)

●Cardiopulmonary disease (eg, heart failure, chronic lung disease)

●Affective disorders (eg, depression, anxiety)

●Neurologic conditions (eg, dementia, stroke, parkinsonism)

Laboratory or other testing should be guided by findings from the history and physical examination. For example, screening for anemia or common endocrinologic conditions, such as hypothyroidism, may be indicated if supporting symptoms are present.

Identify contextual factors — Understanding the patient's physical environment, social support, and financial resources is important in developing a feasible management plan. The perspectives of both the patient and caregiver are important to consider. When feasible, a home visit is the best way to understand how the patient functions within their environmental and social context; physical or occupational therapy (OT) home health assessments or other community programs may help to accomplish this.

APPROACH TO THE MANAGEMENT OF LATE-LIFE DISABILITY — Once the underlying health conditions, impairments, and contextual factors are understood, a practical management plan can be developed with the patient and family. These plans generally include strategies to enhance functional abilities (ie, improve capacity), decrease functional demands (ie, reduce demand), or both (table 6). This approach of reducing demand acknowledges the clinician’s role in helping patients to maintain function even in the setting of continued physical decline.

Strategies to improve capacity — For each health condition and impairment identified, the clinician should identify ways to improve the patient's capacity to cope with physical and environmental challenges. These generally fall into several broad categories.

●Medical interventions:

•Oxygen or cardiac medications to improve hemodynamics in patients with heart failure

•Antidepressants for patients with depression

•Treatment of pain with analgesics or other treatments (eg, acupuncture, mindfulness meditation, etc)

•Discontinuing unnecessary medications that may have adverse side effects (eg, chronic use of proton pump inhibitors [PPIs] may have effects on cognition and bone health)

●Surgery:

•Cataract excision to improve visual capacity

•Joint replacement in disabling arthritis

●Nutritional interventions:

•Weight loss for obesity

•Nutritional supplements when nutrition is impaired

●Exercise [16,17]:

•General physical activity to improve aerobic capacity [18]

•Targeted exercises to address a specific impairment (eg, knee range of motion and strengthening)

●Prosthetics and assistive devices:

•Hearing aids

•Artificial limbs

•Ankle orthoses

Detailed information on specific interventions to improve capacity are provided separately. (See "Geriatric rehabilitation interventions", section on 'Rehabilitation interventions'.)

Strategies to reduce demand — If the patient's capacity for physical function cannot be sufficiently improved by treating the underlying health conditions and/or use of interventions such as exercise alone, then strategies to reduce the task demands should be considered. Four general categories may be employed to reduce task demands:

●Environmental modifications [19]:

•Adding railings

•High-contrast/low-glare lighting

•Ramp for persons using wheeled mobility devices (eg, walker, wheelchair)

●Assistive devices [20] and adaptive equipment:

•Walkers

•Reaching aids

•Tub/shower chair

•Raised toilet seat

●Increasing human help by utilizing referrals for:

•Home health aide

•Assisted living environment

•Driving service

•Meals on Wheels

●Adaptive training to help patients learn strategies to reduce demand [21]:

•Low vision rehabilitation

•Energy conservation techniques

Some strategies are difficult to classify and may impact both demand and capacity.

Agents that may affect demand or capacity — Electrophysical agents are a subset of a group of devices sometimes referred to “electroceuticals,” “bioelectric medicine,” or “electrotherapy.” They may include traditional modalities to treat inflammation and pain, such as transcutaneous electrical nerve stimulation (TENS) devices or ultrasound, thus reducing demand. However, other devices may use electrical stimulation to enhance motor performance. These include use of functional electrical stimulation for treating foot drop in individuals post-stroke [22] and electrical stimulation to aid with sensory deficits affecting balance [23]. Finally, devices are available that incorporate more than one type of intervention, for example, advances in surgery and prosthetics that preserve musculotendinous proprioception and normal movement dynamics [24,25]. (See "Geriatric rehabilitation interventions", section on 'Modalities used by physical/occupational therapy'.)

Integrated approaches — Many evidence-based geriatric rehabilitation programs integrate strategies to improve capacity and reduce demand via multifactorial interventions. For example, results from the CAPABLE program [26] highlight the importance of addressing both person-directed and environmental modification to treat disability in older adults. In the original trial, 300 older adults in Baltimore, Maryland with >1 activity of daily living (ADL) or >2 instrumental activities of daily living (IADLs) disability(s) were randomized to receive either an in-home intervention or attention control. Intervention participants received 10 home visits over five months by occupational therapists, registered nurses, and home modifiers (ie, "handyman") to address self-identified functional goals by enhancing individual capacity and the home environment. This included up to USD $1300 worth of home repairs, modifications, and assistive devices. At five months, individuals receiving the intervention had a 30 percent reduction in ADL disability (relative risk [RR] 0.70, 95% CI 0.54-0.93) with a nonsignificant impact on IADL scores. At one year, scores continued to favor intervention participants but were not statistically significant.

Subsequently, CAPABLE has been tested in five additional sites. Findings from all studies favored the intervention; in the three randomized trials, the intervention groups had significant improvements in both ADL and IADL measurements, and improvements were found in all self-efficacy, pain, and depressive symptoms in some trials [27]. In addition, the average Medicaid spending per CAPABLE participant was USD $867 less per month than that of matched comparison counterparts over 17 months [28].

Role of the interprofessional team — Implementing a plan to reduce late-life disability requires coordination among multiple professionals, the patient, and caregivers. The role of physical and occupational therapists is discussed in detail elsewhere. (See "Geriatric rehabilitation interventions".)

Social work and nursing frequently are helpful for addressing contextual issues and providing patient self-management training or caregiver support. Nutrition and pharmacy professionals are critical when relevant impairments are identified. When available, geriatric evaluation and management clinics can provide such interdisciplinary care for older adults with disability. (See "Comprehensive geriatric assessment".)

PREVENTION OF LATE-LIFE DISABILITY — Because of the tremendous personal and societal burden of late-life disability, prevention is a priority. Prevention strategies can be considered in three broad categories:

●Optimizing functional reserve

●Avoiding or minimizing exposure to common precipitants of disability

●Early intervention after a precipitating event

Optimizing functional reserve — Advancing age impairs the functional reserve, or capacity to withstand and recover from stressors, for many organ systems including the cardiovascular, renal, and immune systems. Loss of functional reserve is thought to explain the observation that older adults experience more complications (eg, delirium) and recover more slowly from an injury or illness than younger persons. Frailty is the manifestation of decreased functional reserve that is observed clinically [29]. (See "Frailty".)

Interventions to optimize functional reserve are attractive for preventing disability arising from illness or injury. Exercise interventions are the best-studied means of improving functional reserve. In sedentary older adults at risk to develop the frailty syndrome, a 12-month physical activity intervention reduced the risk of development of frailty by nearly one-half, with 10 percent of subjects developing frailty compared with 19 percent of controls randomized to health education alone [30]. (See "Frailty", section on 'Exercise' and "Physical activity and exercise in older adults".)

"Prehabilitation" programs designed to improve exercise capacity and nutrition prior to an elective surgery have been developed with variable and modest results [31-35].

Evidence for benefit from other interventions is less robust.

●Nutrition interventions are theoretically attractive ways to improve functional reserve, although evidence that they improve or delay the development of frailty is lacking. (See "Frailty", section on 'Nutritional supplementation' and "Geriatric nutrition: Nutritional issues in older adults".)

●Pharmacologic interventions have not proven beneficial, other than to review medications and discontinue those that may no longer be needed. (See "Frailty", section on 'Medication review' and "Frailty", section on 'Ineffective interventions'.)

Prevent common disability precipitants — Common and potentially preventable medical conditions which may precipitate or contribute to late-life disability include cardiovascular events, infections, falls, and fractures. For example, 25 percent of older persons visiting the emergency department for a minor injury reported a decline in function over the next three to six months, with frailty and cognitive impairment significantly increasing that risk (adjusted odds ratio 2.09 relative to non-frail, cognitively intact persons, for functional decline at six months) [36]. Over 25 percent of older adults who are undergoing elective surgery report loss of valued life activities up to six months after surgery, with the greatest proportion of persons reporting losses being in recreational activities (29 percent) and mobility (25 percent) [37]. Risks for such precipitating events may be reduced with a variety of medical interventions, including blood pressure management, smoking cessation, fall prevention, osteoporosis screening, and vaccination against influenza, pneumococcus, and herpes zoster. (See "Geriatric health maintenance".)

Early intervention — Interventions soon after an acute precipitating event may prevent or ameliorate the development of disability. In-hospital programs to enhance mobility, such as early mobilization and walking programs, may decrease length of stay and improve functional outcomes [38]. Models of care of acutely ill older adults, which employ interprofessional assessment and intervention (eg, Acute Care for the Elderly Unit, orthogeriatrics unit), have been shown to improve functional outcomes, although programs are heterogeneous [39]. (See "Hospital management of older adults".)

Intervention may also take place in the emergency department or as an outpatient (eg, referral to physical therapy after a fall to enable full gait evaluation with related recommendations). Several retrospective cohort studies in a general adult population found that early physical therapy (PT) for outpatient musculoskeletal disorders was associated with decreased risk of advanced imaging, clinician visits, surgery, injections and opioid medications [40].

REHABILITATION FOR SPECIFIC CONDITIONS — Types of rehabilitation for several conditions that commonly causing late-life disability are shown in the table (table 7), which includes the frequency, care duration, and settings in which that care is provided.

Rehabilitation in the older population is made more challenging by the frequent need to provide rehabilitation care across multiple settings. As an example, for patients with hip fractures or strokes, rehabilitation may start while the patient is in the acute hospital and then transition to intensive inpatient rehabilitation, skilled nursing facility, home health, and outpatient care over the course of the patient's recovery. Transitions across multiple locations increase the risk of multiple problems, including errors in medication orders, discontinuity in rehabilitation interventions, patient confusion, and depression [41].

Rehabilitation in the palliative care context is discussed separately. (See "Physical therapy and other rehabilitation issues in the palliative care setting".)

Neurologic

Stroke

General principles — A stroke can affect functionality across diverse organ systems (eg, speech, vision, strength, coordination, balance), and multidisciplinary rehabilitation is required. A wide spectrum of rehabilitation providers and care settings, ranging from the neurologic intensive care unit to outpatient clinics and the patient's home, may be involved. Interventions can range from exercise to cognitive retraining to learning compensatory strategies. Stroke outcomes are also affected by the underlying health conditions that caused the stroke (eg, hypertension, atrial fibrillation) and by comorbidity related to the stroke (eg, dysphagia causing malnutrition). An overview of stroke complications is presented separately. (See "Complications of stroke: An overview".)

Essential principles includes the following:

●Early patient assessment should be carried out using the National Institutes of Health (NIH) Stroke Scale and should also include assessment of risk factors for recurrent stroke (eg, hypertension, hyperlipidemia, atrial fibrillation) and stroke-related complications (eg, deep vein thrombosis [DVT], cognitive dysfunction, dysphagia and malnutrition, mobility impairment).

●The patient and caregiver should be involved in decisions in all phases of the rehabilitation process, in turn improving participation in the rehabilitation processes and outcomes.

●Stroke rehabilitation should be started as soon as possible (ie, while an acute inpatient), including early mobilization in the intensive care unit, as tolerated, and rehabilitation needs must be assessed before discharge [42-44]. Patients with significant physical or functional impairment should receive intensive inpatient rehabilitation if they are able to tolerate three hours per day of therapy.

●The selection of the post-acute setting for rehabilitative care should be based on the patient's degree of dependency in activities of daily living (ADLs; eg, patients with minimal functional impairment may be managed at home with home health or outpatient follow-up, patients with greater degrees of functional impairment benefit from inpatient rehabilitation), ability to tolerate intensive rehabilitation (eg, patients must be able to tolerate at least three hours per day of therapy to qualify for intensive inpatient rehabilitation), and ability to participate in rehabilitation and overall prognosis.

For patients who are unable to tolerate intensive rehabilitation, options include rehabilitation in a skilled nursing facility or via home health. The best location for providing rehabilitation is determined individually and depends on the extent of the patient’s functional impairment and available social support. Persons who are not homebound may be treated in the outpatient setting. Providers may also use telehealth to reach out to persons with stroke who otherwise may have limited access to services, as these interventions show similar efficacy to standard care. [45-48].

●Post-acute rehabilitation should be in a coordinated multidisciplinary inpatient setting or with an organized team approach in the home health or outpatient setting.

●Rehabilitation should be continued until the patient reaches a plateau, which is highly variable between individuals. Neurologic recovery depends in part on the severity of the stroke and presence of prior strokes or other neurologic disorders [49]. In general, most patients have the most rapid recovery early on (one to three months), with a gradual flattening in the slope of recovery over time.

Evidence suggests benefit from early rehabilitation post-stroke. Few studies have examined prolonged duration of rehabilitation, but at least one study showed that participation in supervised exercise for up to six months post-stroke improved outcomes [50]. Some research studies have targeted patients six months or more post-stroke, to control for natural recovery, and have shown effects on functional outcomes, although it is difficult to sort out to what extent these effects may be due to untapped neural plasticity versus deconditioning [51-54]. However, such programs are frequently not covered by insurance and are difficult to access. The optimal setting for care may change over time depending on the patient's response to rehabilitation and neurologic recovery.

Guidelines — Evidence-based guidelines from the American Heart Association and the Veterans Health Affairs address early stroke-related care and decision-making for rehabilitation [55,56]. The Canadian Stroke Best Practice Recommendations: Stroke Rehabilitation Practice Guidelines is another excellent resource for information on evidence-based stroke rehabilitation [57]. Evidence-based reviews pertaining to diverse aspects of stroke rehabilitation have been developed by the Canadian Partnership for Stroke Recovery [58].

Treatment advances — Methods for stroke rehabilitation are advancing rapidly, facilitated in part by new technology, such as functional magnetic resonance imaging (fMRI), which provides information on the neurologic effects of rehabilitation and the effectiveness of novel methods to enhance delivery of exercise-related interventions.

For example, a systematic review of randomized trials evaluated a variety of interventions for improving upper limb function after stroke and found some evidence for the effectiveness of constraint-induced movement therapy, mental practice, mirror therapy, and a high dose of repetitive task practice [59]. However, the review identified insufficient high-quality studies to allow comparison of specific kinds of interventions.

Similarly, robotic therapy to facilitate participation in high-dose repetitive exercise is an active area of investigation with some promising results, but it largely remains at an experimental stage [60]. A 2017 Cochrane review did not find virtual reality or interactive video gaming to be more beneficial than standard care but did find it may be beneficial as an adjunct to usual care [61]. Transcranial magnetic stimulation and transcranial direct current stimulation also are areas of active research, with some evidence that they can potentiate outcomes from rehabilitation [62-64]. Another novel therapy for moderate to severe upper extremity motor deficits associated with chronic ischemic stroke involves an implantable device which stimulates the vagus nerve [65,66]. This surgically implanted device was approved by the US Food and Drug Administration (FDA) in August 2021, but it is not yet available for widespread clinical use [67]. Finally, electromechanical assistance for gait therapy (eg, body-weight supported treatment training) may be beneficial for enabling independent walking, particularly in the first three months after stroke and among people who cannot otherwise walk [68].

Other innovative treatments include aerobic exercise and increased physical activity. One systematic review found that stroke patients who can tolerate it may benefit from aerobic exercise programs with improved aerobic capacity and endurance [69]. Similarly, a randomized trial found that adherence to physical activity and exercise guidelines (30 minutes of daily physical activity and 45 to 60 minutes of weekly exercise) resulted in improved functional outcomes over 18 months among persons with mild to moderate stroke [70].

Other neurologic conditions — Rehabilitation needs differ widely across the spectrum of neurologic impairments related to conditions such as Parkinson disease, spinal cord trauma, or traumatic brain injury. Rehabilitation may be provided by a single discipline or multiple disciplines, typically in a post-acute setting, with the amount and type of therapies tailored to the particular impairments or tasks manifesting a decline in function.

Spinal cord injury — Rehabilitation for a patient with an acute spinal cord injury resulting in paralysis likely would involve physical therapy (PT), occupational therapy (OT), nursing, and medical rehabilitation specialists (ie, physiatry). Comprehensive rehabilitation and a multidisciplinary team are needed to address problems with weakness, mobility, self-care, and potential complex physiologic effects of the injury [71]. The presence of comorbid conditions would determine the aggressiveness of the therapies and their optimal delivery site, considering the impact of comorbidity on the patient's probable functional outcomes and ability to tolerate intensive therapy or cooperate with the therapists. The chronic complications of spinal cord injury are discussed separately. (See "Chronic complications of spinal cord injury and disease".)

Parkinsonism — In contrast to an acute injury, parkinsonism is slowly progressive and response to PT is modest and short-lived [72]. Improvement in physical function largely relates to treating concomitant deconditioning and/or use of compensatory strategies; evidence on the effectiveness of speech therapy for parkinsonism is of insufficient quality to make definitive recommendations [73]. Typically, rehabilitation for parkinsonism is provided by a single discipline and focused on a particular problem, with interventions targeted towards compensatory strategies and actions that the patient will be able to continue at home that may help avert deconditioning (eg, home exercise programs). The role of physical, speech, and occupational therapy in patients with Parkinson disease is discussed separately. (See "Nonpharmacologic management of Parkinson disease".)

Musculoskeletal conditions — A wide variety of musculoskeletal conditions are treated with rehabilitation services. Typical treatment is by a single discipline and as outpatient, but this may vary depending on comorbid conditions and patient residence (eg, institutional residence, homebound). The number of visits provided varies according to the nature of the condition (eg, severity) and other comorbid conditions (eg, cognitive impairment).

Hip fracture — Specific guidelines are lacking for hip fracture rehabilitation. Evidence shows that early and frequent PT helps improve outcomes [74], yet prolonged PT may be required to reach maximal functional outcomes [75-77]. Post-fracture rehabilitation should be provided across the continuum of care, starting in the acute hospital. After discharge from acute care, hip fracture rehabilitation is commonly provided in skilled nursing facilities and inpatient rehabilitation facilities, but there is little evidence to show greater benefit from one inpatient location or the other, after accounting for length of stay [78]. Some evidence suggests that home rehabilitation, compared with inpatient rehabilitation, may have greater benefit. The choice of location largely depends on local availability and comorbid conditions. Patients who have multiple comorbid conditions and/or who cannot participate in intensive rehabilitation are best served in a skilled nursing facility, while patients who can tolerate intensive rehabilitation may do well in an inpatient rehabilitation facility or at home with a combination of home health followed by outpatient rehabilitation.

Hip fractures predominantly affect mobility, but the impaired mobility affects self-care activities that require mobility and lower-extremity flexibility, such as dressing, toilet transfers, and use of the tub/shower. While the predominant discipline involved in hip fracture rehabilitation is PT, OT also is involved, albeit for a shorter period of time. Multidisciplinary inpatient rehabilitation for older patients may improve outcomes, but data are limited [79].

Hip fractures in older adults are commonly associated with other common geriatric problems:

●Cognitive impairment impacts recovery [80]. Nonetheless, hip fracture patients with concomitant cognitive impairment benefit from rehabilitation [81]. The rehabilitation goals and types of services may need to be adapted according to the patient's ability to participate and with consideration of his or her premorbid function.

●Frailty and sarcopenia are also common comorbid conditions. Little is known about how to optimize outcomes after hip fracture in that subpopulation, but close attention to ensuring adequate nutrition, particularly protein, and use of resistive exercise is consistent with beneficial strategies for frailty in general. (See 'Prevention of late-life disability' above and "Frailty" and "Geriatric nutrition: Nutritional issues in older adults" and "Physical activity and exercise in older adults".)

Elective joint replacement — Rehabilitation principles are similar for hip fracture and joint replacement patients but, unlike a hip fracture, an elective joint replacement allows the opportunity to carry out "prehab." There is some evidence of benefit from PT-guided exercise in patients awaiting hip replacement, particularly for pain and functional outcomes [82]. Even though persons getting an elective joint replacement are younger and healthier than persons with a primary hip fracture, there is fair evidence that early multidisciplinary rehabilitation can reduce hospital stay and complications after a hip or knee replacement [83] (see 'Early intervention' above). Rehabilitation following total hip and knee arthroplasty are discussed separately. (See "Total knee arthroplasty", section on 'Rehabilitation' and "Total hip arthroplasty", section on 'Rehabilitation'.)

Effects of location for rehabilitation are similar to hip fracture, with intensive rehabilitation facilities being more efficient for length of stay and skilled nursing facilities being more cost-efficient [84]. Functional outcomes are marginally better for patients treated in intensive rehabilitation facilities than in skilled facilities but may relate to the frequency of therapy, as skilled facilities that provide more therapy visits achieve equivalent outcomes [85,86]. For patients who can tolerate going home, in-home rehabilitation provides comparable or better outcomes than conventional rehabilitation [83].

Arthritis — Osteoarthritis (OA) is a common problem in older adults. Joints often affected by OA include the spine, hip, knee, and shoulder, with many older persons having multiple joints affected. Rehabilitation interventions differ substantively across these conditions, with some joints being more responsive to exercise-based interventions (eg, shoulder, knee), other joints benefitting from use of braces and/or mobility aids (eg, hip, knee), and yet other joints responding to soft tissue manipulation in combination with exercise (eg, spine). Rehabilitation for OA must take into account all of the affected joints and comorbid conditions. For example, exercises for knee OA will differ if the person has balance problems or uses a walker (eg, stair-rises would be contraindicated), if the person has cognitive impairment (exercises may need to be simplified or performed with a caregiver assist), or if there is hand or shoulder arthritis which limits the ability to handle resistance bands.

The knee serves as an example of the spectrum of services that may be provided through rehabilitation [87,88], and as follows below:

●Rehabilitation clinicians may guide use of nonoperative medical interventions (eg, injections with corticosteroids or hyaluronic acid, use of topical creams or oral medications), various “modalities” (eg, heat, cold, ultrasound, electroceuticals such as transcutaneous electrical nerve stimulation [TENS]) and nonpharmacologic interventions (eg, gait aid, brace).

●Physical therapists may recommend gait aids, braces, and orthotics and provide fitting and training in use of such devices.

●Podiatrists may fit and provide orthotics, although physical therapists may make recommendations as well. Occupational therapists or certified hand therapists will make splints for the upper extremity (eg, to treat carpal tunnel syndrome or de Quervain tendinopathy).

●Physical therapists and/or occupational therapists provide education on joint protection techniques, activity pacing, home exercise programs, and in-person supervised exercise programs individualized according to the patient's condition.

The role of exercise in knee OA is discussed separately. (See "Management of knee osteoarthritis", section on 'Exercise'.)

Palliative care — Rehabilitation for patients in palliative care is discussed separately. (See "Physical therapy and other rehabilitation issues in the palliative care setting".)

Coronavirus disease 2019 — Several studies have documented the functional sequelae of coronavirus disease 2019 (COVID-19) infection in older adults, which often include fatigue, shortness of breath, cognitive, and psychological symptoms [89,90] as well as reduced health-related quality of life and functional capacity [91,92]. One study of 695 patients hospitalized with COVID-19 found that at three months, half reported fatigue, shortness of breath, and/or cognitive problems; 20 percent had reduced endurance; 60 percent had reduced leg strength; 35 percent had reduced diffusing capacity for carbon monoxide; and 18 percent had reduced total lung capacity [93]. At 12 months, one-third of patients still had fatigue, shortness of breath, and/or cognitive problems; 30 percent had reduced leg strength; 21 percent had reduced diffusing capacity for carbon monoxide; and 16 percent had reduced total lung capacity.

Limited data show positive outcomes using standard pulmonary rehabilitation for patients with pulmonary sequelae [94,95] and fairly good outcomes with standard inpatient rehabilitation for persons with more diverse sequelae [96]. A few studies have examined novel telerehabilitation interventions, typically exercise-based, to prevent or treat COVID-19 sequelae and generally found them better than no rehabilitation at all [97-99].

The Cochrane Rehabilitation REH-COVER (Rehabilitation COVID-19 Evidence-based Response) project reports there is still a lack of high-quality data investigating the disease course, although there are an increasing number of studies investigating intervention efficacy which generally support safety and efficacy of pulmonary or physical rehabilitation [100]. A systematic review of five trials studying rehabilitation for post-acute COVID-19 syndrome found that rehabilitation seemed to improve dyspnea, anxiety, and kinesiophobia [91]. Results on pulmonary function were inconsistent, but improvements were found in muscle strength, walking capacity, sit-to-stand performance, and quality of life. However, the review provided limited insight on the potential efficacy of rehabilitation for particular subpopulations (eg, according to COVID-19 severity, vaccination history).

SUMMARY AND RECOMMENDATIONS

●In younger populations, disability frequently arises suddenly from a catastrophic illness or accident. In older persons with limited functional reserve, lesser stressors may precipitate disability or there may be subacute onset with no clear precipitating event. Disability resulting from multiple chronic conditions is dynamic, with patients' abilities and needs changing over time. (See 'Overview' above.)

●A systematic approach to assessing late-life disability focuses on identifying all contributing conditions, impairments, and contextual factors and addressing these factors with appropriate interventions. In this assessment, the clinician(s) should describe the disability, including its onset, time course, and impact on patient and caregivers; identify associated symptoms; and identify contextual factors that may impact the impairment. (See 'Approach to assessing late-life disability' above.)

●A practical management plan, developed with the patient and family, identifies strategies to enhance functional abilities and decrease functional demands. Maximizing capacity (functional ability) may include initiating or discontinuing medication, nutritional and exercise intervention, and providing prosthetics (eg, hearing aid). Decreasing demands may involve assistive devices (eg, walkers), environmental modification (eg, improved lighting), increasing human help, and adaptive training. Implementing a plan to reduce late-life disability requires coordination among multiple professionals, the patient, and caregivers. (See 'Approach to the management of late-life disability' above.)

●Rehabilitation in the older population is made more challenging by the common need to provide rehabilitation care across multiple settings, with patients potentially transitioning from the acute hospital to intensive inpatient rehabilitation, skilled nursing facility, home health, and outpatient care over the course of recovery. Transitions across multiple locations increase the risk of multiple problems, including errors in medication orders, discontinuity in rehabilitation interventions, patient confusion, and depression. The most appropriate rehabilitation strategies need to be based on the specific conditions that are believed to be causing and/or exacerbating specific functional impairments, the acuity of the various conditions, and the patient's response to prior efforts at rehabilitation. (See 'Rehabilitation for specific conditions' above.)

●Because of the tremendous personal and societal burden of late-life disability, prevention is a priority. Prevention strategies can be considered in three broad categories (see 'Prevention of late-life disability' above):

•Optimizing functional reserve

•Avoiding or minimizing exposure to common precipitants

•Early intervention