Residency · Residency · Physical Medicine Rehabilitation
Rehabilitation in the Geriatric Population
Introduction
Geriatric rehabilitation addresses the unique needs of older adults recovering from illness, injury, or surgical procedures. The aging population presents with multimorbidity, frailty, cognitive decline, polypharmacy, and psychosocial complexity that require adapted rehabilitation strategies. The primary goals are to maximize functional independence, prevent secondary complications, reduce institutionalization, and maintain quality of life. Physiatrists must integrate geriatric medicine principles into rehabilitation planning and delivery.
Aging and Functional Decline
Sarcopenia: age-related loss of skeletal muscle mass and strength; begins after age 30 with accelerated decline after age 60; contributes to falls, disability, and mortality. Decreased cardiopulmonary reserve: reduced VO2 max (approximately 10% per decade after age 30), decreased cardiac output, and reduced pulmonary compliance. Neurological changes: slowed processing speed, reduced balance reflexes, decreased proprioception, and mild memory changes. Musculoskeletal changes: decreased bone mineral density, joint degeneration, reduced flexibility, and increased tendon stiffness.
Sensory decline: presbyopia, presbycusis, and decreased vestibular function impair balance, communication, and safety. Functional reserve is the difference between maximum capacity and daily demands; aging narrows this reserve, making patients vulnerable to functional decline with acute illness.
Comprehensive Geriatric Assessment
Functional status: Barthel Index, Functional Independence Measure (FIM), Katz ADL Index. Cognition: Montreal Cognitive Assessment (MoCA), Mini-Mental State Examination (MMSE), Clock Drawing Test. Mood: Geriatric Depression Scale (GDS-15); PHQ-9. Nutrition: Mini Nutritional Assessment (MNA); serum albumin and prealbumin.
Falls risk: Timed Up and Go (TUG), Berg Balance Scale, falls history. Medication review: Beers Criteria for potentially inappropriate medications; reconcile polypharmacy. Social assessment: caregiver availability, home environment, financial resources, advance directives. Frailty assessment: Fried Frailty Phenotype (weight loss, exhaustion, low activity, slow gait, weak grip) or Clinical Frailty Scale.
Common Geriatric Rehabilitation Diagnoses
Hip Fracture
Most common indication for geriatric rehabilitation; 300,000 hip fractures annually in the US. Mortality: 20-30% one-year mortality in patients over 65 years. Early mobilization (within 24-48 hours post-surgery) reduces complications and improves survival. Weight-bearing status depends on fracture type and fixation method; trend toward early weight-bearing as tolerated. Address osteoporosis workup and treatment during rehabilitation admission.
Deconditioning
Hospitalized elderly lose 1-5% of muscle strength per day of bed rest. Functional decline occurs in 30-60% of hospitalized older adults. Prevention: early mobilization, minimizing restraints and catheters, structured exercise programs. Recovery of function after deconditioning takes 3-5 times longer than the duration of immobility.
Cardiac Rehabilitation in Older Adults
Safe and effective in patients over 65; improves functional capacity, reduces mortality. Modified protocols with lower initial intensity and slower progression. Address comorbid conditions: arthritis, neuropathy, cognitive impairment.
Post-Surgical Rehabilitation
Joint replacement (hip and knee arthroplasty): fastest-growing surgical indication in geriatric rehabilitation. Cardiac surgery, abdominal surgery, and amputation rehabilitation. Prehabilitation programs improve postoperative recovery.
Frailty and Pre-Frailty
Frailty is a state of decreased physiological reserve and increased vulnerability to stressors. Prevalence: 10-15% of community-dwelling adults over 65; up to 50% in those over 85. Frail individuals have 2-3 times greater risk of falls, hospitalization, disability, and death. Pre-frailty (1-2 criteria on Fried Phenotype) is a reversible state amenable to exercise intervention.
Multicomponent exercise programs (resistance, balance, flexibility, aerobic) are the primary evidence-based intervention for frailty.
Exercise Prescription in Older Adults
Resistance training: 2-3 times per week; moderate-to-high intensity (60-80% 1RM); improves strength, function, and muscle mass even in the ninth decade. Aerobic exercise: 150 minutes per week of moderate-intensity activity; improves cardiovascular fitness and cognition. Balance training: Tai Chi, standing balance exercises, perturbation training; reduces falls by 20-30%. Flexibility and stretching: maintains joint ROM; reduces injury risk.
Adapt exercise to individual capacity; use Rate of Perceived Exertion (RPE) rather than heart rate targets when chronotropic incompetence or beta-blockers are present. Supervised exercise produces better outcomes than unsupervised home programs in frail populations.
Falls Prevention
Falls affect one-third of adults over 65 annually; leading cause of injury-related death in this population. Multifactorial risk assessment: intrinsic factors (weakness, balance, vision, cognition, medications) and extrinsic factors (environment, footwear, lighting). Evidence-based interventions: exercise programs (strongest evidence), medication review and reduction, vision correction, home safety assessment, vitamin D supplementation (800-1000 IU daily). Medication review: reduce sedatives, anticholinergics, antihypertensives causing orthostatic hypotension. Assistive devices: properly fitted canes, walkers, and rollators; hip protectors for high-risk individuals.
Polypharmacy and Medication Management
Defined as use of 5 or more medications concurrently; present in 40% of adults over 65. Increases risk of adverse drug reactions, drug interactions, falls, cognitive impairment, and non-adherence. Beers Criteria: identifies potentially inappropriate medications in older adults (e.g., benzodiazepines, anticholinergics, NSAIDs with chronic kidney disease). STOPP/START Criteria: European tool identifying medications to stop and appropriate medications to start.
Deprescribing: systematic reduction of unnecessary medications; requires careful tapering and monitoring. Physiatrists should conduct thorough medication reconciliation at rehabilitation admission and discharge.
Cognitive Impairment and Rehabilitation
Dementia affects 10% of adults over 65; prevalence doubles every 5 years after age 65. Cognitive impairment reduces rehabilitation participation and functional gains but does not preclude benefit. Adapted strategies: simplified instructions, consistent routines, errorless learning, visual cues, structured environment. Caregiver training is essential for carryover of therapeutic gains.
Delirium is common during acute rehabilitation; occurs in 15-30% of geriatric rehabilitation patients; identify and treat underlying causes.
Discharge Planning and Transitions of Care
Begin discharge planning at admission with patient, family, and interdisciplinary team. Assess home environment for safety and accessibility; home visits or virtual assessments when available. Coordinate outpatient therapy, home health services, and community resources. Ensure medication reconciliation at every transition.
Follow-up within 7-14 days of discharge to reduce readmission risk. Address advance care planning, goals of care, and caregiver support needs.
Key Clinical Pearls
Hospitalized older adults lose muscle strength rapidly (1-5% per day of bed rest); early mobilization is the single most protective intervention against functional decline. Frailty and pre-frailty are not inevitable consequences of aging; multicomponent exercise programs can reverse pre-frailty and slow the progression of frailty. Always review the medication list using Beers or STOPP/START criteria; polypharmacy is a modifiable cause of falls, delirium, and functional decline in geriatric rehabilitation. Cognitive impairment does not preclude rehabilitation benefit; adapted strategies and caregiver involvement enable meaningful functional gains. Hip fracture rehabilitation is a critical window; one-year mortality approaches 30%, and early mobilization within 24-48 hours is associated with improved survival.
References
- Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. Journals of Gerontology Series A. 2001;56(3):M146-M156.
- American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society. 2023;71(7):2052-2081.
- Bachmann S, Finger C, Huss A, et al. Inpatient rehabilitation specifically designed for geriatric patients: systematic review and meta-analysis of randomised controlled trials. BMJ. 2010;340:c1718.
- Sherrington C, Fairhall NJ, Wallbank GK, et al. Exercise for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews. 2019;(1):CD012424.