Overview of geriatric rehabilitation: Patient

assessment and common indications for

rehabilitation
Authors: Helen Hoenig, MD, MPH, Cathleen Colon-Emeric, MD
Section Editor: Kenneth E Schmader, MD
Deputy Editor: Jane Givens, MD, MSCE

Contributor Disclosures

All topics are updated as new evidence becomes available and our peer review process is
complete.

Literature review current through: Mar 2023. | This topic last updated: Jan 24, 2023.

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
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