Why rehabilitation must be part of acute care

Kenneth Rockwood is Professor of Medicine (Geriatric Medicine & Neurology) and consultant geriatrician at Capital Health in Halifax, Nova Scotia, Canada and Honorary Professor of Geriatric Medicine at the University of Manchester.

Many older people leave hospital frailer than when they started. Some of that is preventable, but much of the damage done by acute illness is baked in to how frailty works. Some of it is reparable. That is why rehabilitation must be part of acute care: if we cannot prevent damage, we should at least treat it, especially damage that we inflicted unnecessarily.

The gist of it is easy enough. When frail patients are unwell enough to come to hospital, they typically are not thinking, functioning and moving like they were before they became ill.  That is usually why they come. That, and whatever other symptoms (breathlessness, pain, something red or swollen) signal a problem.  Even when fixing the precipitants, modern care often does nothing to address the worse thinking / mobility / function in which the problems were packaged.  Such complexity of need defines frailty.

Frailty is not new, but population ageing means that it is coming to attention. We must help health care decision-makers to understand that even when care does not harm, there will be a gap between what cognition, mobility and function are like once the precipitants have been treated, and what people need in order to return home. The time is ripe for health care providers to hear this message.

Once the message is heard, the arithmetic is simple. For many patients, the number of things that they have wrong (i.e. their degree of frailty) at the end of their acute care stay is too high for them go home. That is why they require rehabilitation.

QED. Well, not quite.

To get there, someone must measure the degree of frailty at baseline. Conveniently, this can be estimated by asking about mobility, function and the like two weeks prior to admission. For the gap between the degree of frailty at baseline and the degree of frailty on admission to be known that too measured. None of this is especially new. To the requirement to “take a history” we must simply add that it include some indication of problems in cognition, mobility and function. Likewise, to “do an exam, assess and diagnose” we must stipulate that what is being examined allow us to know whether, when and how the patient might be able to return home.

This knowing precisely what people were like two weeks before they became ill needs to be clear to the care team.  It gives them a specific way to talk to patients and carers about what must be achieved for the person to go home.  How close to health two weeks ago do we need to come? Knowing what to aim for clarifies the gap between the patient’s degree of frailty and the degree of frailty that carers can manage. Aiming to close that specific gap is not some magic incantation, but a specific, auditable, patient-centred goal-oriented program.

From this, it is easier to move to the next step in better care.  The people with the biggest gaps usually will be those who were frail at baseline.  That is because they are the most vulnerable: the poor get poorer.

And there’s the rub. Frail people do worse not just due to their illness, but to their treatment.  It’s not just that they are more susceptible to adverse drug reactions.  A lot of what we do in hospital is harmful.  No one benefits from sleep deprivation, or inadequate pain control, or not being mobilised, or inadequate nutrition, or being alone, but mostly, we get away with it.  Not so for frail patients, especially when they are acutely ill.  So some part of lessening the need for rehab to be part of acute care is to make acute care less hazardous.

Rehabilitation must be part of acute care if we wish to have fewer older people leave hospital frailer than when they started.

9 thoughts on “Why rehabilitation must be part of acute care

  1. I disagree, making rehab part of acute care is unaffordable, just look at the NHS which simply cannot afford full works acute care beds for anything other than acute care. A more measured approach would be to distinguish between convalescence and rehabilitation. The former may only need a supportive environment with a focus on health restoration as opposed to heavy duty rehabilitation. Neither is the same as a care home providing long term care or end of life care but failing to make the case for rehab in affordable settings will eventually lead to these patients being once inappropriately transferred to care home beds configured for LTC.

    The case you might make is to suggest the hospital team retain case management responsibilities.

    • Rehabilitation is not necessarily a separate ward, several weeks stay and a boot camp style visit to the gym every day. It is the physiotherapist that is no doubt already working along side you coming to the patient right from the outset and encouraging the patient to move. They are there on the admissions units seeing the patients between the doctors clerking and the fluids going up. It might only be deep breathing exercises and some knee squeezes if they are really unwell but they will get the patient out of bed at the earliest opportunity. The benefits of early mobilisation are well documented and Physiotherapy will endeavour to get the frail elderly to manage whatever level of activity is feasible given the degree of illness. For example the Parkinson’s chap that missed a dose of his medications (or several) and became stiff as a board will be helped to stretch and move those tight muscles the same day to avoid permanent loss of range by the end of the week.This is rehabilitation. The stroke patient whose high tone is already causing joint pain and tightening the hand into a fist with their nails piercing their palm the physio will be there stretching it, positioning it and educating the relatives how to help. This is rehabilitation. The elderly person that fell and has been scooped up by paramedics, left in A&E for 4 hours with no drink then moved to chaotic, noisy admissions unit and is too frightened to move, never mind ask for a toilet – the physio will be there holding their hand and encouraging them to ‘get back on that horse’ before it becomes too scary. This is rehabilitation. The patient with no fracture but a very painful hip that can’t walk and demands some oromorph – they will be helped by the physio to ease the pain through exercise and movement and taught how to use the walking frame so they can get to the bathroom – and will likely not need the second dose. This is rehabilitation. It doesn’t come with plinths and dumbbells and stretchy rubber bands but it is rehabilitation and we can afford it. We need to afford it because a few days of bedrest is also well documented to be a huge problem for the frail – muscle loss, DVT, constipation, loss of stamina, fear of falling, incontinence……

    • It really depends what you mean by rehabilitation. The risk of deconditioning following acute illness is huge, and unless this is addressed as part of the patients acute care, then length of stay increases, care packages on discharge are higher, as is the risk of readmission. It is not a case of “heavy duty” rehab, but simple strategies led by therapists and delivered by the whole mdt.

  2. Hospitals and illnesses make frail people who are not frail to start with. Geriatricians and associated teams are the only clinicians who can pick this up and deal with it. So if geriatricians only look after frail people in acute hospitals as in ‘acute frailty units’ we will fail to limit frailty in those developing it

  3. My relative had brilliant rehabilitation in a specialist unit following 2 weeks on an acute ward. However, on admission to the acute ward she could walk to the toilet with one person but, after shortage of staff over the Christmas period and lack of attention to her diet , she became immobile and incontinent. It took a month of rehabilitation to restore her to her previous level. I have wondered whether it would have been more cost effective and less upsetting for her to have adequate staff on the acute ward which could have prevented her deterioration in the first place.

  4. Indeed rehabilitation in acute care is paramount. Hope health care professionals upgrade their expertise in this regard.

    • Allied Health Professionals are rehabilitation experts and have all the skills necessary. There just aren’t enough of them.

  5. Affordability is always a big concern for a lot of stakeholders, when it comes to looking at issues such as having rehab as part of acute care. This view simply is borne out of the fact that rehab in such cases play preventative role. It is always difficult for “cost analysts” to see the need for rehab “preventative care” in the same light as we have campaigned for preventative public health vaccinations. However, given the increasing number of people living well into their 80s, the health care system can save a lot of money avoiding early admission of elderly people to continuing care facilities. That being said, the rehab professionals need to justify this shift (when it eventually happens) by doing more than just a “walking program” in acute care. A more focused interventions based on findings from good clinical assessments will be more appropriate for most patients in need of rehab.

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