Geriatric Rehabilitation:Does It Really Work?

David X. Cifu, M.D.

The Herman J. Flax, M.D. Professor and Chairman Department of PM&R

Virginia Commonwealth University Health System

Who Cares About Geriatric Rehabilitation Efficacy

Increasing older adult population. Increasing rehabilitation needs related to

increased population, increased medical morbidity, and increased activity goals.

Increasing health care and rehabilitation costs limit the available medical dollars.

Increasing pressures to justify utilization of rehabilitation services.

Geriatric Rehabilitation Efficacy

Limited prospective research investigating the efficacy of specific rehabilitation interventions in the older adult.

Majority of rehabilitation interventions for diagnoses that are commonly seen in older adults have had some analysis of “efficacy.”

Awareness of available efficacy research is increasingly important.

Geriatric Rehabilitation ServicesSetting:

Inpatient• Acute Care [medical/surgical units]

• Rehabilitation Unit [IRF]

• Nursing Home – Skilled [SNF]– Custodial [ICF]

Outpatient• PT, OT, SLP, Psychology

• Day Rehabilitation Home Health

Geriatric Rehabilitation Services

Intensity Acute Care (MCR, Part A)

• 1-2 hours per day for 2-8 weeks• Multidisciplinary team• Cost = $ 30-60/day (no additional reimbursement)

Inpatient Rehabilitation Facility (MCR, Part A) • 3 hours therapy + nursing for 2-6 weeks• Interdisciplinary team• cost = $ 750-1250/day• reimbursement = IRF-PPS CMG payment

Geriatric Rehabilitation ServicesIntensity

Skilled Nursing Facility (MCR, Part A)• 1-2 hours therapy per day + nursing for 100 days• Inter- or Multidisciplinary team• Cost = $ 200-500/ day • Reimbursement = SNF-PPS CMG payment

Custodial Nursing Facility (MCD)• 0.5-1 hours therapy per day + nursing for 2-6 weeks• Multidisciplinary team• Cost = $15-30/day• Reimbursement = $15-60/day

Geriatric Rehabilitation ServicesIntensity

Outpatient Therapy (MCR, Part B)• 1-2 hours therapy per day, 3x/wk

• Multidisciplinary team

• cost = $ 30-60/day

• reimbursement = $30-100/session Day Rehabilitation (MCR, Past B)

• 2-4 hours therapy per day + nursing, transportation

• Interdisciplinary team

• Cost = $ 250-500/day

Geriatric Rehabilitation ServicesIntensity

Home Health Therapy (MCR, Part B)• 1-2 hours therapy per day, 3x/wk for 2-8 weeks

• Multidisciplinary team

• cost = $ 30-60/day

• reimbursement = $30-100/session

Finances of Aging Health

2001 national health care expenditures exceeded 1.4 trillion dollars or 14.1 percent of the gross domestic product The aging population is a high utilizer of these health care services.

Medicare is the largest single payer for these services, and two-thirds of Medicare spending is accounted for by 20% of its beneficiaries.3 This 20% of high end-utilizers have 5 or more chronic conditions

Federal Interagency Forum on Age-Related Statistics Older Americans 2000. Key

Indicators of Well-Being. Washington DC: U.S. Government Printing Office, 2000.

Finances of Aging Health

In 1999, 25 percent of all physician office visits (192.2 million) in the United States to physicians were by adults 65 and over.

The hospitalization rate for adults 65 to 74 was 1.9 times higher than the overall population while individuals 75 and over was 2.7 times higher in 1999.

Medicare

Medicare is a federally sponsored program, with uniform coverage throughout the United States.

Any individual who has paid into the federal tax system for 40 quarters (or was ever married to someone who has) and meets any of the following three criteria is eligible for Medicare part A at no cost: 1) age 65 years or older, 2) disabled and on Social Security Disability Insurance (SSDI) for more than 2 years, or 3) has end stage renal disease.

Medicare

Medicare Part A reimburses for IRF and SNF rehabilitation services and durable medical equipment.

Medicare Part B, which is available to individuals on Medicare Part A for a monthly fee (~$35), reimburses for physician services, home health and outpatient therapies.

75% Rule

Importantly, on average, 75% of Medicare patients admitted to an IRF must meet one of 10 established diagnoses for the IRF to qualify for payments. Developed 1984.

This “75% rule” unfortunately neglects many of the current rehabilitation diagnoses (e.g., post-CABG care, post-total hip replacement)

75 Percent Rule

StrokeSpinal Cord InjuryCongenital DeformityMajor Multiple

TraumaFemur Fracture

Brain InjuryPolyarthritisNeurologic Disorders

(MS, motor neuron disease, poly-neuropathy, muscular dystrophy, PD)

Burns

Medicaid

Medicaid is a state-sponsored program for the medically indigent, that provides variable reimbursement for inpatient (acute medical and rehabilitation), outpatient, home health, skilled nursing home, DME, and physician benefits.

In older adults however, Medicaid is typically not a primary source of health insurance, but rather may serve as a co-payment (as may commercial insurances).

Medicaid pays for more than 85% of all custodial nursing home care (which is not reimbursed by Medicare) in the

United States.

Finances of Rehabilitation

In 1997, Congress passed the Balanced Budget Act (BBA), which has produced changes in the reimbursement systems for Home Health Services (HHS), Skilled Nursing Facilities (SNF), and Inpatient Rehabilitation Facilities (IRF). These changes are predicted to produce $393.8 billion in Medicare savings between 1998 and 2007.

The BBA (1997) resulted in changes for HHS reimbursement, and the frequencies of these services dropped during 1997-1998 from 8,277 to 5,058 per 1,000 enrollees.

Finances of Rehabilitation

The Centers for Medicare and Medicaid Services (CMS) now reimburses IRF for services based on a Prospective Payment System (PPS).

The IRF-PPS was developed in an attempt to reimburse facilities based on a patient’s severity of disability and required utilization of resources. The IRF-PPS is based on the assignment of patients to specific Case-Mix Groups (CMG).

The more disabled patients, who will have a higher CMG score within a RIC, are predicted to require a greater use of resources and therefore are assigned higher reimbursement.

Finances of Rehabilitation

CMG assignment is determined by an individual’s; primary diagnosis (or Rehabilitation Impairment Category -RIC) Functional Independence Measure (FIM) motor score FIM cognitive score age on admission.

Specific categories for patients with short stays death early transfer to another Medicare rehabilitation facility, long-term

care hospital, inpatient hospital, or nursing home

Rehabilitation Efficacy:Common Geriatric Diagnoses

strokebrain injuryspinal cord injuryParkinson’s diseaseorthopedicamputationsdeconditioning [cardiac, pulmonary]arthritis

Efficacy: Interdisciplinary Teams

Interdisciplinary geriatric evaluation and management units (“GEMs”) have been demonstrated to result in decreased morbidity and mortality than multidisciplinary approaches.

Applegate N Engl J Med 322; 1990

Rubenstein J Am Geriatr Soc 39-s; 1991

Unfortunately, GEM approach rarely utilized in nursing homes, and is declining in utilization in Veterans Administration facilities.

Nursing Home Rehabilitation

Comprehensive analysis of 11,150 NH patients evaluated efficacy of rehabilitation services in variety of diagnoses.

Individuals who received rehabilitation services were >40% more likely to return home.

Increased therapy associated with increased likelihood to return home (3.6% increase for each hour of therapy weekly).

Weak association between decreased mortality and rehabilitation.

True for all individuals plus specific diagnoses of stroke, hip fracture, CHF, COPD, general deconditioning.

Murray: Arch Phys Med Rehabil 2003;84:1129-36

Home-Based Rehabilitation

Home-based rehabilitation for older adults with stroke, malignancy, and post-surgical debility (including hip fracture) is feasible and has produced durable outcomes, but significantly increased caregiver burden has been reported. Corrado: Age Aging 2000;29:97-8

Knowelden: J Public Health Med 1991;13:182-8.

Home-based rehabilitation for older adults following hip fracture has been demonstrated to produce durable (12+ months) outcomes, comparable to inpatient rehabilitation. Significant family supports are necessary.

Tinetti: Arch Phys Med Rehabil 1997;78:1237-47

Crotty: Arch Phys Med Rehabil 2003;84:1237-9

Stroke

> 500,000 strokes annually in U.S.

Incidence doubles for every decade after 55

Increase in average age of Americans has resulted in more strokes in older adults, despite declining overall incidence

Stroke

22 randomized controlled trials have demonstrated that after stroke, interdisciplinary vs multidisciplinary team care results in decreased mortality, dependency, and nursing home placement.Langhorne Lancet 342:1993

Ottenbacher Arch Neurol 5:1993

Interdisciplinary acute rehabilitation shown superior to SNF or custodial NH.

Kramer JAMA 277;1997

Stroke

75% of strokes occur in individuals aged 65 years and older.

An individual’s risk for stroke doubles with each decade of life after age 55.

When compared to their younger cohorts, older adults require longer lengths of rehabilitation stays demonstrate slower functional improvements demonstrate greater long-term functional dependency require nursing home placement more frequently

Flick: Arch Phys Med Rehabil 1999 May;80(5 Suppl 1):S21-6.

Traumatic Brain Injury

200 injuries/ 100,000 population in the >65 years age group

Fastest growing segment of TBI patients, representing the # 2 incidence

Falls is major cause of injury

Traumatic Brain Injury

A randomized, controlled trial demonstrated that after traumatic brain injury, interdisciplinary vs multidisciplinary team care results in deceased dependency and nursing home placement.

Semlyen Arch PM&R 1998

Traumatic Brain Injury

Individuals aged > 70 years are in second highest risk group for TBI.

An injury severity-matched investigation in TBI revealed that individuals aged 55 years and older had

twice the rehabilitation lengths of stay and costs half the rate of functional recovery greater cognitive impairment at discharge twice the nursing home placement rate the same level of physical impairment at discharge

Cifu: Arch Phys Med Rehabil 1996;77:883-8.

Spinal Cord Injury

Individuals aged > 70 years are in second highest risk group for SCI.

Injury severity-matched investigations in SCI revealed that individuals aged 55 years and older with paraplegia had

increased rehabilitation lengths of stay decrease in functional recovery and efficiency No differences in acute care lengths of stay, nursing home

placement, or neurologic recovery were noted. Seel: J Spinal Cord Med 2001;24:241-50.

McKinley: Neurorehabil 2003;18:83-90

Spinal Cord Injury

Individuals aged > 70 years are in second highest risk group for SCI.

Injury severity-matched investigations in SCI revealed that individuals aged 55 years and older with tetraplegia had

an increased nursing home placement rate a decrease in neurologic recovery a decrease in functional recovery and efficiency No differences in rehabilitation and acute care lengths of stay or

nursing home placement were noted. Cifu: Arch Phys Med Rehabil 1999;80:733-40

McKinley: Neurorehabil 2003;18:83-90

Parkinson’s disease

A critical review of the exercise therapy literature support the efficacy of several different types of physical and occupational therapy on improving activities of daily living independence and walking ability (walking speed, stride length), but not on neurologic symptoms or quality of life. De Goede: Arch Phys Med Rehabil 2001;82:505-15

Parkinson’s disease

A descriptive review of the speech and language pathology similarly supported the efficacy of speech therapy on improving voice and speech function. Education regarding appropriate dietary modifications and swallowing techniques (e.g., chin tuck, head positioning) has also been reported to assist in dysphagia with PD.

Schulz: J Commun Disord 2002;33:59-88. There is no available literature that critically examines the

specific efficacy of interdisciplinary rehabilitation services (inpatient or outpatient) on functional limitations because of

PD.

Orthopedic Rehabilitation

95 % of hip fractures occur in individuals aged 50 and older.

Over age 60 years, there is a doubling of incidence of hip fracture every 5-7 years.

> 500,000 hip fractures, THA, and TKA occur each year in people over 65.

Orthopedic Rehabilitation

Prospective, multicenter study does not demonstrate benefit of inpatient rehabilitation or SNF vs custodial NH care.

Kramer JAMA 277;1997

A randomized, controlled trial demonstrated that after total hip and knee replacement, interdisciplinary vs multidisciplinary team care results in deceased dependency and nursing home placement. Munin Arch PMR 77:1997

Orthopedic Rehabilitation

Home-based rehabilitation for older adults following hip fracture has been demonstrated to produce durable (12+ months) outcomes, comparable to inpatient rehabilitation. Significant family supports are necessary.

Tinetti: Arch Phys Med Rehabil 1997;78:1237-47

Crotty: Arch Phys Med Rehabil 2003;84:1237-9

Amputee Rehabilitation

More than 50,000 amputations annually.

Majority occur in individuals 51 to 69 years old.

Below knee amputation is most common type.

Amputee Rehabilitation

In older adults, it becomes increasingly important to understand the increase in energy expenditure with amputationsLevel METs increase [%]

Transmetarsal 10-20

Syme’s 0-30

Transtibial 40-50

Transfemoral 90-100

Bilateral Transtibial 60-100

Rehabilitation for Deconditioning

Functional losses sustained due to acute illness, exacerbation of chronic condition [COPD], acute hospitalization, or specific cardiac disorder [MI].

Focal or generalized weakness secondary to prolonged inactivity and sedentary lifestyle.

Not presently one of the ‘Big Ten” diagnoses within the 75% rule.

Deconditioning Rehabilitation

Submaximal endurance activities [40 % maximal heart rate] have training effect in older adults. Shepard JAGS 38; 1990

Strengthening exercises demonstrated to have effect in individuals in their 90’s.

Rudman N Engl J Med 323;1990

Agre Arch Phys Med Rehabil 78;1997

Deconditioning Rehabilitation

Cardiac rehabilitation programs demonstrated to improve VO2 Max, functional abilities, QOL, and decrease medical costs. Moldover Arch Phys Med Rehabil 78;1997

Pulmonary rehabilitation has been demonstrated to improve functional abilities,improve QOL, and decrease medical costs. Bach Arch Phys Med Rehabil 78;1997

Arthritis Rehabilitation

Osteoarthritis affects 35-40% of older adults.

50 % of older adults have some type of arthritic condition.

Rehabilitation therapies complement pharmacologic and surgical interventions.

Arthritis Rehabilitation 4-8 month rehabilitation program demonstrated improved strength,

endurance, and functional skills in patients with OA.

Fisher Arch Phys Med Rehabil 1991;72

Balancing exercise and rest appears to be key to programs.Merrit Arch Phys Med Rehabil 1983;64

Reductions in disability have been reported with group, individual and home-based exercise programs, with no clear difference seen when modes of exercise are directly compared. Exercise prescription for older adults with osteoarthritis pain: consensus practice recommendations. J Am Geriatr Soc 2001; 49:808-23

Minor: Arthritis Rheum 1989; 32:1396-405

Ettinger: JAMA1997; 277:25-31

van Baar: J Rheumatol 1998; 25:2432-9

Arthritis Rehabilitation

Aerobic activity well tolerated in patients with RA

[swimming, aquatic aerobics, dancing]. Swezey Arthritis Rheum 1974;3

Reports show that reductions in aerobic capacity due to inactivity in these patients have been corrected effectively through walking programs, use of a stationary bike or aquatic exercises.

Minor: Arthritis Rheum 1989; 32:1396-405

Ettinger: JAMA 1997; 277:25-31.

Arthritis Rehabilitation

Isometric exercises result in strengthening without increasing inflammation in patients with RA.

Machover Arch Phys Med Rehabil 1966;47

Improvements in strength can be achieved through low and high-intensity progressive resistance exercises, with greater improvements reported in studies utilizing higher intensity training.

Ettinger: JAMA 1997; 277:25-31

Mangione: J Gerontol A Biol Sci Med Sci 1999; 54:M184-90

Minor: Arthritis Rheum 1989; 32:1396-405

Summary

Complexity of geriatric care lends itself to interdisciplinary team management.

Geriatric rehabilitation services are being increasingly utilized.

Support exists for the vast majority of rehabilitation interventions in the older adult.