Geriatric Rehabilitation in Canada: Advancing the State of the Art

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Seventy-six year old Edgar Balcers fell in his kitchen and suffered a hip fracture. He was alone, frightened and unable to get to the telephone to call for help. Mr. Balcers propped himself up by the window, hoping he would be noticed, until help finally came. His hip fracture required surgery followed by rehabilitation. Geriatricians at Parkwood Hospital in London diagnosed and treated an underlying muscle condition called polymyalgia rheumatica (PMR), which likely contributed to his fall. Treatment of the PMR enabled him to gain the maximum benefit from his rehabilitation program. Members of an interdisciplinary team on the geriatric rehabilitation unit worked with Mr. Balcers to identify and achieve the personal goals he needed to reach in order to return home. This meant learning to stand on his own, climb stairs, wash and dress himself, prepare a meal, and get himself in and out of bed – simple tasks that many of us take for granted.

Although geriatric rehabilitation services are of increasing importance to maintain and restore the health and independence of growing numbers of seniors like Mr. Balcers, the roles, practices and outcomes of this emerging field are not well understood. In June 2000, the Ontario Ministry of Health and Long-Term Care, with the support of the Ontario Neurotrauma Foundation, called for proposals to conduct syntheses of research evidence in rehabilitation that could support provincial policy development. Researchers associated with London’s Lawson Health Research Institute and with the Regional Geriatric Programs in London and Ottawa saw this as an opportunity to advance the growing field of geriatric rehabilitation. A successful proposal was submitted by Dr. Michael Borrie, Dr. Paul Stolee and Dr. Jennie Wells from London, together with Dr. Frank Knoefel of Ottawa. A synthesis of research in geriatric rehabilitation was completed and a report submitted in August, 2001.

The research synthesis had three components: 1) Epidemiology: analysis of trends in acute care hospital utilization by older persons, using data from the Canadian Institute for Health Information, and a chart review to compare the medical complexity of geriatric rehabilitation patients with patients of general rehabilitation programs; 2) Best Practices: a literature review, surveys of geriatric rehabilitation programs, and analysis of geriatric rehabilitation goals and outcomes; 3) Service Issues: surveys of resources providing rehabilitation to older persons, and of health planning offices, to identify policy issues and service gaps.

The review found considerable regional variation in Ontario in the utilization of rehabilitation for frail older persons, suggesting opportunities for health systems research to compare different models of rehabilitation. Many older persons who would benefit from rehabilitation do not receive it – for example, persons with lengthy hospital stays experience muscle deconditioning and other new co-morbidities but are unlikely to receive a formal course of rehabilitation. The chart review confirmed that geriatric rehabilitation programs serve patients whose rehabilitation is more likely to be complicated by multiple medical problems, than is the case for patients in general rehabilitation programs. The literature review identified many practices that can be recommended as part of an appropriate standard of care in geriatric rehabilitation. These include: screening for rehabilitation potential, comprehensive geriatric assessment, medical care by team members trained in care of the elderly, medication review, self-medication programs, nutrition screening, swallowing assessments and nutritional supplementation. The Canadian survey of current, emerging and innovative practices in geriatric rehabilitation also identified many consistent elements of these practices. The analysis of the goals of geriatric rehabilitation programs illustrated the wide range of clinically important and measurable outcomes that these programs achieve for frail older patients. There is a need for more consistent approaches to outcome measurement to facilitate comparisons and benchmarking. Survey respondents identified a need for more resources, both to ensure access to specialized geriatric services, including geriatric rehabilitation, and to respond to an aging population. The most consistently expressed needs were for additional geriatric expertise and education, for inpatient geriatric rehabilitation beds, and for transportation services – especially to support day hospital programs. Improved linkages are needed among services to support ongoing communication and sharing of best practices and benchmarks. Further information is available on the project website: www.geriatricrehabilitation.org.

This research is being used as a starting point for a national consensus conference, to be held in conjunction with the annual meeting of the Canadian Geriatrics Society in April 2003, that will continue to advance the state of the art in geriatric rehabilitation for the benefit of older persons such as Mr. Balcers.