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Geriatric Rehabilitation Services in the Veterans Health Administration

Author Cifu, David X

ProQuest document link

Abstract Rehabilitation services available within the VHA to optimize the physical functioning of older veterans

include physical medicine and rehabilitation (PM&R), physician assessment and care, rehabilitation therapies

for assessment and treatment (occupational therapy, physical therapy, kinesiotherapy, recreation therapy,

speech and language pathology), special sensory assessment and care (audiology services, vision

rehabilitation), pain management services, specialty rehabilitation programs (amputation system of care,

inpatient medical rehabilitation, brain injury rehabilitation program, assistive technology centers of excellence,

Parkinson's Disease rehabilitation, cardiac rehabilitation), specialty assessment programs (drivers rehabilitation,

mobility assessment clinics, and adaptive aide evaluations), and community living center (CLC) rehabilitation

programs (skilled nursing facility-level rehabilitation, therapy services). Individuals who have had a stroke are

optimally rehabilitated in an inpatient rehabilitation facility (IRF), and have shown decreased mortality,

dependency, and more frequent nursing home placement when compared with acute care (Langhorne et al.,

1993; Ottenbacher and Jannell, 1993) or nursing home-based care (Kramer et al., 1997).

Full text Headnote

Research evidence supports the roles of rehabilitation interventions for the care of older adults with acute or

chronic diseases and disabling conditions.

The population of veterans in the United States has a mean age of 57.4 years, and 36.7 percent of all veterans

are ages 65 years and older (U.S. Census Bureau, 2000). The Veterans Health Administration (VHA) provides a

broad array of integrated rehabilitation services to meet the diverse needs of the aging population of veterans.

Rehabilitation services available within the VHA to optimize the physical functioning of older veterans include

physical medicine and rehabilitation (PM&R), physician assessment and care, rehabilitation therapies for

assessment and treatment (occupational therapy, physical therapy, kinesiotherapy, recreation therapy, speech

and language pathology), special sensory assessment and care (audiology services, vision rehabilitation), pain

management services, specialty rehabilitation programs (amputation system of care, inpatient medical

rehabilitation, brain injury rehabilitation program, assistive technology centers of excellence, Parkinson's

Disease rehabilitation, cardiac rehabilitation), specialty assessment programs (drivers rehabilitation, mobility

assessment clinics, and adaptive aide evaluations), and community living center (CLC) rehabilitation programs

(skilled nursing facility-level rehabilitation, therapy services).

Geriatric Rehabilitation Services

Research evidence supports the roles of rehabilitation interventions for the care of older adults with acute or

chronic diseases and disabling conditions (Roig et al., 2004). Across the VA system of healthcare, these

rehabilitation efforts are available in a variety of facilities. The setting, intensity, and duration of rehabilitation

services should be provided based on the medical and disability characteristics of the older adult, the expertise

of the providers, and the availability of caregivers to reinforce and maintain the functional gains achieved. An

overview of these services is provided in Table 1.

The VHA has a diverse range of geriatric rehabilitation services to meet the specialized needs of older veterans,

including focused therapy for minor impairments, intensive inpatient rehabilitation for acute catastrophic

disability, and preventive exercise and activity programs. While older adults have many of the samerehabilitative needs as younger adults, often the interventions must be modified to take into account the

physiologic, psychosocial, and cultural differences seen in older veterans. The major trends seen in geriatric

rehabilitation services in the VA have been a focus on the establishment of integrated-systems care based on
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diagnosis and disability (such as Parkinson's Disease or amputations) and a renewed emphasis on long-term

preventative care. Early and frequent usage of rehabilitation services has been shown most effective, and

integration of rehabilitation care into existing inpatient, outpatient, and home-based geriatric programs is likely to

have the greatest impact.

In the acute setting, rehabilitation services may be used to assist in the management of older adult veterans

with acute illness and disability, for both diagnostic and early mobilization (Cifu et al., 1993; Weinrich et al.,

2004). Early initiation of rehabilitation services for many acute conditions is associated with improved medical

and functional outcomes (Cifu and Stewart, 1999). Rehabilitation professionals may also be consulted in the

acute phase of recovery from medical illness, surgery, or injury to provide recommendations on postacute care

once medical stability is reached.

Comprehensive, interdisciplinary rehabilitation services are delivered in the VA in one of its thirty-four units

accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF). These settings are reserved

for individuals who have either acute-onset disability or an exacerbation of a chronic disability, have moderate to

severe functional deficits, are unable to be safely managed at their home, can tolerate and benefit from

intensive rehabilitation services, and have sufficient caregiver support that will allow them to return to home

after completion of the rehabilitation stay.

For individuals who suffer a stroke, 75 percent are 65 years and older, and the incidence doubles for every

decade after age 55 (Feigin et al., 2003). Individuals who have had a stroke are optimally rehabilitated in an

inpatient rehabilitation facility (IRF), and have shown decreased mortality, dependency, and more frequent

nursing home placement when compared with acute care (Langhorne et al., 1993; Ottenbacher and Jannell,

1993) or nursing home-based care (Kramer et al., 1997). When compared to their younger cohorts, older adults

with acute stroke require longer lengths of rehabilitation stays, demonstrate slower functional improvements,

demonstrate greater long-term functional dependency, and more frequently require nursing home placement

(Flick, 1999; Stewart and Cifu, 1994). Older adults represent the second highest and fastest growing risk group

for traumatic brain injuries (TBI), which are also best rehabilitated in an IRF, with a decrease in both functionaldependency and nursing home placement (Semlyen, Summers, and Barnes, 1998). Individuals with TBI ages

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, and the same level of

physical impairment at discharge as younger subjects (Cifu et al., 1996; Frankel et al., 2006).

Community Living Centers

Rehabilitation services have been shown in multiple studies to benefit residents of longterm- care facilities. A

comprehensive analysis of 11,150 nursing home residents revealed that when comparing those residents who

did and those who did not receive a variety of rehabilitation services, individuals who received any rehabilitation

services were over 40 percent more likely to return home, which increased by 3.6 percent for each hour ofweekly therapy received. This association was true for all individuals in the cohort, and for specific diagnoses of

individuals, including stroke, hip fracture, congestive heart failure, chronic obstructive pulmonary disease, and

general deconditioning weakness. There was also a weak association between decreased mortality and

rehabilitation (Murray et al., 2003).

Rehabilitation services provided in the VA long-term care programs, or community living centers (CLC), include

functional evaluations, restorative services, and maintenance services. While a range of therapy services are

available, a unique area of concentration is the use of recreation therapy services. Recreational therapy

emphasizes providing meaningful activities to residents, enhancing social interactions, and training in leisure

skills. Recreation and creative arts therapists provide interventions to treat symptoms of depression; programs

to prevent falls and injuries; and therapeutic activities to maintain or improve function. Interventions include

exercise and movement activities; sensory and cognitivestimulation programs; activities to promote social

interaction skills; choice and self-expression; and programs to improve activities of daily living and functioning.


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Within the the VA CLC system, there are currently eight CARF-accredited skilled nursing facilities (SNF) that

provide interdisciplinary rehabilitation services. These settings are reserved for individuals who have either

acuteonset disability or an exacerbation of a chronic disability; are unable to be safely managed at their home,

but who are unable to tolerate or benefit from IRF services; or have insufficient caregiver support that will allow

them to return home after completion of the rehabilitation stay.

Research supports the use of the SNFbased rehabilitation for individuals with orthopedic injury, and those who

would typically benefit from IRF care but may not be able to medically tolerate that care, or have limited

caregiver support. In individuals who have a single-limb orthopedic disability, but no other significant medical

morbidity or disability, there is little evidence that the intensity of either an IRF or a CLC-based skilled nursing

facility provides added benefit to CLC-custodial care (Kramer et al., 1997; Stewart, Miller, and Cifu, 1998).

However, for individuals who have secondary medical or functional limitations (for example, frail older adults)

and an acute orthopedic-related disability, interdisciplinary versus multidisciplinary rehabilitation team care

results in decreased dependency and nursing home placement (Munin et al., 1998). Individual and group

therapy services and PM&R physician consultation are also beneficial for CLC residents with focal or general

debility to optimize long-term independence, prevent a decline in physical and cognitive fitness, and assist in the

healthcare of older adult veterans.

Rehabilitation services are often integrated into the the VA's home-based care programming, particularly

physical and occupational therapy services. Research supports that home-based rehabilitation services for

older adults with stroke, malignancy, and post-surgical debility- including hip fracture-have produced durable

outcomes (longer than 12 months), however, significantly increased caregiver burden has been reported, when

compared to inpatient or nursing home-based care (Corrado, 2001; Crotty et al., 2003; Knowelden et al., 1991;

Tinetti et al., 1999). Optimally, home-based therapy services should be time-limited (no more than eight weeks)

and focus on a return to home independence or a progression toward outpatient services.

The foundation of outpatient rehabilitation services are the functionally based physiatrist and therapy

evaluations and the delivery of treatment to the patient. Rehabilitation providers include physiatrists,occupational therapists, physical therapists, kinesiotherapists, recreation therapists, and speech and language

pathologists. These interventions include general conditioning and strengthening exercises, focused therapeutic

exercises, functional skills training, and leisure skills training. A critical review of the therapeutic exercise-

therapy literature supports the efficacy of all types of rehabilitation services on improving age-related declines in

activities of daily living independence and walking ability (walking speed, stride length) (De Goede et al., 2001).

Importantly, physical activity initiated late in life has a strong effect on longevity; even when accounting for

factors such as smoking, hypertension, family history, and weight gain (Blair et al., 1995; Singh, 2002;

Paffenbarger et al., 1993). An analysis of more than 10,000 older adults demonstrated that there was an almost

two-fold increased likelihood of dying without disability among those most physically active, compared to thosewho were sedentary (Leveille et al., 1999; Morgan and Bath, 1998; Shephard and Balady, 1999). Strengthening

exercises have been shown to have a therapeutic effect in individuals older than 90 years (Agre, Rodriguez,

and Franke, 1997; Buchner, 1997).

Outpatient rehabilitation services have also been shown to improve health and functional abilities in a number of

specific disability groups of older adults, including those older adults with rheumatologic and orthopedic

disabilities, Parkinson's Disease, amputation, pain, and cardiopulmonary disorders. Additionally, focused

interventions to enhance mobility in older adults with no or limited ambulation, to assist these patients in a return

to driving, and to provide adaptive equipment and assistive technology are all employed with success in the VA

system.

Rehabilitative strategies that complement pharmacologic and surgical interventions to improve pain, weakness,

falls, and related functional decline seen with the arthritides (such as osteoarthritis and rheumatoid arthritis)

common to older adults have been shown effective. Outpatient rehabilitation programs to improve strength,


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endurance, and functional skills in osteoarthritis have been shown to work (Fisher et al., 1991).

A key to arthritis programs is educating the patient on achieving a balance between exercise and rest (Oh et al.,

1995). Reductions in disability have been reported with group, individual and home-based exercise programs

(American Geriatrics Society, 2001). A wide range of therapy services are available in VA outpatient settings to

meet the needs of veterans with arthritis and orthopedic dysfunction. These include the nationwide Managing

Overweight Veterans Everywhere weight management program for veterans, general conditioning exercises

offered through kinesiotherapy, aquatic therapy, and therapeutic activities offered through recreation therapy.

Aerobic activity (swimming, aquatic aerobics, dancing) is well-tolerated in patients with rheumatoid arthritis

(Metsios et al., 2008). Reports also 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

(Ettinger et al., 1997; Minor et al., 1989). Isometric exercises result in strengthening without increasing

inflammation in patients with rheumatoid arthritis (Machover and Supecky, 1966). 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 et al., 1997; Mangione et al., 1999).

Across the VA system there are forty clinically active cardiac-rehabilitation programs (thirty-six directed by

PM&R physicians and four directed by cardiologists). These rehabilitation services focus on the assessment,

restoration, and management of health and abilities for veterans with acute and chronic cardiac or pulmonary

disorders. While physician-directed, these programs are primarily provided by the exercise physiologists and

specially certified therapists (primarily kinesiotherapists) to safely optimize cardiac and pulmonary status to

improve function. Cardiac rehabilitation programs have been demonstrated to improve maximal oxygen

ventilation, to improve functional abilities, quality of life, and to decrease medical costs (Glassman, Rashbaum,

and Walker, 2001). Even submaximal endurance activities (for example, 40 percent maximal heart rate) have

been shown to have a training effect in older adults (Shephard and Balady, 1999). Pulmonary rehabilitation has

been shown to improve functional abilities, improve quality of life, and decrease medical costs (Reina-

Rosenbaum, Bach, and Penek, 1997; Stewart et al., 2001).In older adults, adaptive equipment often allows for normal (or near normal) resumption of functional skills after

an acute or chronic disabling disorder. As an example, it typically requires less than $200 of equipment or

modifications to allow an individual with a disability to meet the Americans with Disability Act standards for

access. For this equipment to be judiciously and appropriately used, a rehabilitation professional should be

involved in the assessment of and training with these devices. They may range from simple tools that can be

used to augment activities of daily living, such as specialized eating or grooming devices (weighted or built-up

utensils, long-handled sponges), to modified tools for household chores (reachers, one-handed cutting boards),

to devices for enhancing community reintegration (steering wheel knobs, personal digital assistant, vocalizers).

In general, these devices are recommended by an occupational therapist who will also provide any necessarytraining on them, although at times additional therapy specialists (speech and language pathologist for

communication and cognitive deficits; kinesiotherapist for vehicle modifications) may also be involved. The

devices are made available either directly by the therapist involved or through the prosthetics service.

Interdisciplinary rehabilitation clinics to enhance the mobility of older adults are present in most VA facilities.

These clinics may provide fairly straightforward interventions, such as leg braces, home exercises, or standard

wheelchairs, or more sophisticated interventions, such as motorized scooters or electric wheelchairs. As with all

rehabilitation interventions, these services are best delivered through an interdisciplinary team approach,

particularly when dealing with a challenging disorder or disability, and take into considerations a large number of

patient-specific issues (such as age, specifics of illness and disability, home and community environment,

caregiver support, ease of use of equipment, etc.). Naturally, it is the goal of these programs to provide the most

appropriate equipment or therapy interventions that will foster short- and long-term mobility, are cost-effective,

and will promote overall veteran autonomy. Providing a veteran with equipment or exercises without taking into


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consideration all elements of the veteran and knowledge of the short- and long-term issues of their disability will

not yield the desired effects. The VHA provides this equipment through the prosthetics service.

The privilege of driving is highly valued and is of special importance to older adults. Motor vehicle injuries are a

leading cause of injuryrelated deaths in persons 65 years and older. Per mile driven, the fatality rate for drivers

ages 85 years and older is nine times higher than the rate for drivers ages 25 to 69 years old. Accident rates for

drivers ages 80 to 85 are four times greater than those ages 40 to 45 years.

Drivers older than age 85 are ten times more likely to have an accident than other drivers (Dubinsky, Stein, and

Lyons, 2000). Older adults with mild Alzheimer's Disease, or a Clinical Dementia Rating (CDR) of 0.5, are more

accident prone than alcohol-impaired teenagers, and standards exist for the use of CDR in driving evaluations

in elders (Dubinsky, Stein, and Lyons, 2000). Heart disease, stroke, arthritis among women, dementia,

diabetes, and use of multiple medications have been associated with increased risk of accident (Carr et al.,

2006). The VA rehabilitation services has forty-seven certified drivers rehabilitation programs, predominantly

directed by kinesiotherapists, to provide assessments of driving ability and rehabilitative therapies to assist with

the achievement of safe driving skills. These centers use state-of-the-art clinics and equipment. Direct linkages

to the state department of motor vehicles allows for drivers licenses to be officially certified or modified.

Pain Management and Other Programs

It is a myth that older adults do not feel pain as much as younger people. In the final analysis, age-related

changes in pain perception are probably not clinically significant (Harkins, 1996). Epidemiological studies have

demonstrated that pain is overlooked as a potential cause of disability. Fall risk is increased with pain and

reduced with use of analgesic medications (Leveille et al., 2002; American Geriatrics Society Panel, 2002).

Pain management occurs across clinical settings, beginning with the primary care clinicians and extending to

pain specialists. Rehabilitation service pain care is typically provided in collaboration with other medical

services, including anesthesiology, mental health, and surgery services. These services may include an acute

pain consultation service for hospitalized veterans, interventional pain clinics for therapeutic procedures, and

consultation on acute or chronic medication management, along with musculoskeletal clinics for physician-andtherapy assessment and care. As with all complex services, interdisciplinary care provision is essential to

optimize outcomes (Worsowicz, Brown, and Cifu, 1998). The specific physiologic changes seen in older adults

(such as altered absorption of oral medications, the likelihood of polypharmacy due to co-morbid conditions,

increased sensitivity to centrally acting medications, reduced exercise tolerance) must be taken into account

when developing strategies to manage pain.

In 2000, the VA established six Parkinson's Disease Research, Education and Clinical Centers to provide an

interdisciplinary environment for the care of veterans with Parkinson's Disease and movement disorders.

Rehabilitation services are integrated into these centers to assist in the diagnosis, treatment, and management

of this progressive disease and the accompanying disability.The available literature supports that the interdisciplinary team approach to care, typically provided in an

outpatient setting, results in improved long-term outcomes (Carne et al., 2005; Carne and Cifu, 2006). A

descriptive review of the speech and language pathology research similarly supports the efficacy of speech

therapy on improving voice and speech function, particularly the use of specialized techniques (for example, the

Silverman technique). Education regarding appropriate dietary modifications and swallowing techniques (such

as chin tuck, head positioning) has also been reported to assist in dysphagia with Parkinson's disease (Fox et

al., 2002).

Geriatric amputee rehabilitation care focuses on typical changes seen in older adults that may make both a

return to mobility and function, and prosthesis wearing and use more difficult (such as hand weakness, visual

deficits, skin integrity risks, and decreased cardiac reserve).In 2009, the VHA established an amputation system

of care to offer a tiered system of services, with some level of services available at all the VA medical centers.

This system collaborates closely with the Department of Defense to provide stateof- the-art care, establish a


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national database, promote telehealth programs to reach out to geographically underserved areas, and create a

peer visitation program through the Amputee Coalition of America.

Individuals with amputation vary from older adults suffering dysvascular conditions (for example, peripheral

vascular disease) to those who have returned to activity after incurring limb losses in military conflicts. Patients

are enrolled for a lifetime of rehabilitation care that begins in the preoperative stage and extends on a

continuous basis through the postoperative stages for the life of the veteran. Preventive measures are integral

to the system, and are fostered by established programs such as the Preservation, Amputation Care and

Treatment program, a podiatry service-managed program that monitors intact limbs, provides education

concerning care, and works to prevent future amputations.

Assistive Technology and Sensory Programs

Assistive technology (AT) encompasses areas of intervention that include wheeled mobility, adaptive driving,

adaptive sports and recreation, augmentative and alternative communication, electronic cognitive devices,

adaptive computer access, and electronic aids to daily living (Cook and Hussey, 2008). Assistive technology

may offer particular advantages to older adults with disability. Specialty areas that are being developed include

geriatric and special sensory focused AT.

In 2009, the VHA launched a nationwide AT plan coordinated through four AT centers of excellence, developed

in collaboration with The Center for Assistive Technology at the University of Pittsburgh Medical Center. These

AT centers of excellence have developed a standardized interdisciplinary evaluation process and training

program that will assist each older adult veteran referred with AT needs. The ability to use the VA's existing

high-tech videoconferencing tools for AT with consultation and clinical outreach makes this rehabilitation

intervention a potentially useful tool for older adult veterans who are unable to easily access the VA resources

because of transportation or geographic issues. The selected AT devices for veterans are provided by the VA

prosthetics service. Programs include lending libraries and computer labs for patients to train on multiple

devices, depending on their needs. The CLC AT programs will ultimately include an AT apartment with

computer accommodation, augmentative communication devices, and wheeled mobility.The VA provides a comprehensive system, through collaboration between rehabilitation and other services, of

assessing and managing the declines in special senses (e.g., hearing, vision) that commonly accompany aging.

Audiology provides evaluation and treatment services to veterans with hearing, balance, and tinnitus (ringing in

the ears) problems. Hearing loss and tinnitus account for 10 percent of the total number of service-related

disabilities in the VA (Humes, 2006). In 2009, the VA issued more than 475,000 hearing aids to veterans,

making the VA the largest provider of hearing aids in the United States. The VA also provides cochlear implants

for veterans with severe hearing loss, and assistive listening devices, such as amplifiers, for television and

telephones.

Speech-language pathology provides evaluation and treatment services to veterans with speech, language,voice, fluency, memory, and swallowing problems. The VA estimates that there are more than one million

visually impaired veterans older than age 45 in the United States, with that number likely to increase as the

average age of veterans rises.

The VA's rehabilitation service for the blind provides care management, adjustment counseling for patients and

families, and rehabilitation that encompasses the range of needs from those whose vision loss is just beginning

to interfere with daily activities to veterans who may be suddenly and traumatically blinded. The VA

interdisciplinary clinical programs provide clinical evaluation of vision impairment by each team's eyecare

specialist, and functional assessment of the effect of vision loss. Any needed optical devices are provided, as

well as interventions that may include vision and other sensory training, such as sensory integration, orientation

and mobility training, training in activities of daily living, training in the use of computers and global positioning

systems, and other technologies.

Sidebar


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The VHA provides a broad array of integrated rehabilitation services to meet the diverse needs of the aging

population of veterans.

In older adults, adaptive equipment often allows for normal (or near normal) resumption of functional skills after

an acute or chronic disabling disorder.

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AuthorAffiliation

David X. Cifu, M.D., is National Director of the Physical Medicine &Rehabilitation Program Office for the VHA

and the Herman J. Flax, M.D., Professor and Chairman of the Department of PM&R at Virginia Commonwealth

University in Richmond, Va.

Disclaimer: The views expressed in this article are those of the author and do not necessarily represent the

views of the U.S. Department of Veterans Affairs.

Subject Older people; Hospitals; Subacute care; Cultural differences; Physical therapy; Mortality; Chronic

illnesses; Cochlear implants; Injuries; Disease; Heart failure; Disability; Pain management;

Publication title Generations

Volume 34

Issue 2

Pages 64-73

Number of pages

10

Publication year 2010

Publication date Summer 2010

Year 2010

Publisher American Society on Aging

Place of publication San Francisco

Country of publication United States

Publication subject Gerontology And Geriatrics

ISSN 07387806


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