Rehabilitation for disability how to do it? Kaisu Pitkl Professor - - PowerPoint PPT Presentation

Rehabilitation for disability – how to do it?

Kaisu Pitkälä Professor University of Helsinki Helsinki University Hospital

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CONFLICT OF IN INTEREST DIS ISCLOSURE

I have no potential conflict of interest to report

Outline

• Definitions
• Rehabilitation
• Functioning, disability
• Active agency
• Prerequisites for effective rehabilitation
• Examples of evidence-based rehabilitation models
• Take home message

Definitions

What is rehabilitation?

• Rehabilitation is a process of change between a person and his/her
• environment. The aim is to promote person’s functioning and well-

being.

• Focus is on
• Person’s mastery and self-efficacy
• Empowerment
• Influence on environment
• In practice it is restoring, maintaining – AND often slowing down the

deterioration of person’s functioning

• It is more than physiotherapy –> cognitive, psychological and social

rehabilitation

What is fu functioning?

• Functioning is a person’s ability to manage daily tasks
• Dependent on intrinsic capasity + environmental possibilities
• Functioning can be
• Physical (ADL, IADL)
• Psychological (cognition, mood, mastery, well-being)
• Social (loneliness, social isolation, social activity)

Jette & Badley 2006, Jyrkämä 2007

Pathology Physiological damages Activity limitations Disability

Diseases e.g. osteoarthritis stroke, myocardial infarction dementia Sarcopenia, Damage in brain Heart failure, Cognitive decline Slow walk, Shortness of breath, Decline in executive functioning Difficulties perfoming ADL and IADL tasks

Development of disabilities

Environmental factors:

• Care of diseases, rehabilitation
• Social ja physical environment
• support

Risk factors Personal characteristics, e.g.:

• coping, life style
• Psychosocial resources

Nagi  Verbrugge & Jette, Soc Sci Med 1994; See also ICF ; WHO 2001

What is disability?

TIME Physical functioning

Sudden loss of functional abilities Effect of rehabilitation is seen fast

Acute rehabilitation using expertice Natural courses of the disease

Rehabilitation

”Catastrophic disability” – e.g. stroke

TIME

Progressive disability  Effect of rehabilitation is seen slowly

”Natural course” Rehabilitation without good adherence Rehabilitation with ideal adherance

Rehabilitation

Progressive disability – e.g. frailty Physical functioning

From functioning and disability to active agency

• Functioning is seldom a person’s permanent characteristic –

it is dependent on environment, social support, expectations, motivation etc.

• Too often we focus on problems, functional limitations,

disabilities – whereas older people show their best in

• ptimistic and resource-oriented rehabilitation

Jette & Badley 2006, Jyrkämä 2007

What is active agency dependent on?

ACTIVE AGENCY

What is expected and demanded?

• Cultural expectations

Intrinsic capacity Demands of physical and social environment What does the person want?

• motivation, needs,

priorities Possibilities?

• technology

(Jyrkämä 2007)

Too oft ften the older person is.. ...

• Bystander and passive object for rehabilitation
• We talk about her problems over her using language

she does not understand

• Older person does not internalize the goals of

rehabilitation – and she should work for the goals!

Routasalo et al. Scand J Caring Sci 2004;18:220-8 Rosewilliam et al. Clin Rehab 2011 Rose et al. Pat Educ Councel 2017

Prerequisites for effective rehabilitation

Base for effective rehabilitation

• Evidence-based rehabilitation models, geriatric

expertice, right target group

• Older person’s motivation
• Patient involvement in goal-setting (Levach et al. Cochrane 2015)
• Older person’s empowerment and support on self-

management skills

• Patient centeredness
• Optimism, resource-oriented approach

Older person’s own concerns

Comorbi- dities

Voima- varat Disease

Omat toiveet ja tavoitteet

Possibilities for prevention

Risks for complications

Elämän kulku, tarina

Sopeutu- minen

Caregiver coping

Other symptoms

Social Network + support Asuminen ympäristö Physical functioning Cognition Psycholog. functioning Social functioning Geriatric giants Status, nutrition Drugs Devices Services

CGA

Resources

Own wishes and aims

Life narrative

Coping

Living environment

Nursing home Good functioning, “Third age” Independent, home-dwelling

Target groups

Multimorbid geriatric patients Independent, home-dwelling elderly at risk

Examples of evidence-based rehabilitation

Geriatric expertice is effective

Comprehensive geriatric assessment (CGA)

• CGA has been tested in 29 trials evaluating 13,766

participants in nine countries (Ellis et al. 2017)

• Patients more likely to be at home and alive at 3-12mo (RR 1.06)
• Postpones nursing home admissions (RR 0.80)
• Complex interventions with expertice in older people tested

in 89 trials (n=97984)(Beswick et al. 2008)

• improves physical function
• maintains independent living, reduces nursing home admissions

Baztán JJ et al. BMJ 2009; 338: b50; Ellis G et al. Cochrane 2017, Beswick et al. BMJ 2008

Rehabilitation with expertise in catastrophic disabilities

• Stroke rehabilitation units superior in patient outcomes
• ver usual wards (Stroke trialists collaboration Cochrane 2013)
• 28 trials (N=5855) lower mortality in 12mo (OR 0.87)
• lower odds of death or dependecy or admission to nursing

home at 12mo (OR 0.79)

• Orthopedic geriatric rehabilitation superior over usual

care (Bachmann et al. BMJ 2010)

• Improves phycial functioning
• Lower risk for nursing home admission (RR 0.72)
• Lower risk for mortality (RR 0.84)

EXERCISE – FOR EVERYBODY!

Strong evidence

• 121 RCTs on progressice resistance strength training (N=6700) (Liu & Latham

Cochrane Database Syst Rev 2009):

• Improves physical disability (33 trials)
• Improves functional limitations (24 trials)
• Improves muscle strength (73 trials)
• Reduces pain in osteoarthritis
• Multicomponent group exercise reduces falls (N>60 000) (Gillespie et al.

Cochrane 2012, Cameron et al. Cochrane 2012)

• Aerobic physical activity may improve executive function, process of speed,

attention (Angevaren et al. Cochrane 2008, Kallio et al. 2017)

• Physical activity improves mood(11 trials) (Blake et al. Clin Rehab 2008)
• Effects can be seen in all levels of care and in all subgroups . It is never too

late to start.

EXERCISE IN DEMENTIA

FINALEX –trial (Pit

itkala et t al.

• l. JAMA In

Intern Med 2013)

• Home-dwelling pts with AD, N=210  1-year training in 1. groups 2xwk 2.

tailored home training 2x/wk 3. control

Time, month

Baseline 3 6 12

LS mean change from baseline in FIM motor

• 20
• 15
• 10
• 5

5 10 Controls Group rehabilitation Home rehabilitation Decline Improvement p=0.80 p=0.040 p=0.0049

Time, month

Baseline 3 6 12

LS mean change from baseline in Clock Drawing test

• 2
• 1

1 2 Controls Group rehabilitation Home rehabilitation Decline Improvement

Prevents disability Improves cognition

P=0.022

Group exercise Home exercise Cont- rols P value No of falls/ year 101 83 171 <0.001

Exercise reduced falls

Number of falls per years

0,0 0,5 1,0 1,5 2,0 2,5 3,0 3,5 4,0 4,5 5,0 CDR 0.5-1 CDR 2-3 Control Intervention

Those with advanced dementia benefitted even more than those with mild dementia

Psychosocial rehabilitation

Loneliness predicts cognitive decline, , dis isabilities and and death…

• Participants: lonely older people (RCT; N=235, mean age 80)
• Intervention: psychosocial group intervention to empower older

people and support their active agency. Facilitation of peer support + group dynamics.

• 8/group . 1 day/wk for 3 months
• Contents: art activities, exercise, writing,

interaction

• Results:
• More friends, QOL improved,
• cognition improved
• Use of health services decreased 34% (p=0.020)

Tilvis, Pitkala et al. Lancet 2000, Pitkala et al. J Gerontol 2009, Am J Geriatr Psych 2011

Time (months)

3 6

ADAS-Cog (mean number of errors )

1 2 3 4 5 6 7 8 9 10 11 12

p=0.003 p=0.13

Intervention Control

Risk of death decreased in 3years…

Time, months

6 12 18 24 30 36

Survival, %

60 65 70 75 80 85 90 95 100 Intervention Control

Mortality HR 0.39 (95% CI 0.15 to 0.98) P=0.044

Self-management coaching

Self-management groups for dementia couples

• Closed group of 10 people for 3 mo
• Pts with dementia + spouses separately (=136 couples)
• Caregivers’ QOL improved
• Dementia patients’ cognition

improved up to 9 mo

www.ystavapiiri.fi; Laakkonen et al. JAGS 2016

Nutritional rehabilitation

NuAD Trial (Suominen et al.

• l. JN

JNHA 2015)

• 99 Alzheimer pts + caregivers randomized into two arms
• Tailored nutrition guidance based on assements, in home

visits, food diaries

• Protein intake increased
• Improved HrQOL
• Less falls

Change from baseline

• 0,3
• 0,2
• 0,1

0,0 0,1 0,2 0,3 15D-score Sexual activity Vitality Distress Depression Discomfort and symptoms Mental function Usual activities Excretion Speech Eating Sleeping Breathing Hearing Vision Mobility p=0.007 p=0.63 p=0.24 p=0.26 p=0.048 p=0.42 p=0.72 p=0.35 p=0.49 p=0.41 p=0.27 p=0.046 p=0.006 p=0.18 p=0.045 p=0.47 Intervention Control

HOW TO DO IT? T.H.M.

CGA

Rehabilitation plan and aims Measuring I Validated scales Evaluation of rehabilitation achievements Realisation of rehabilitation Multidiciplinary work Home visit Operations Care of comorbidities,

• ptimizing drugs,

minimizing risks Devices, Environmental changes, Supporting caregivers New goals Involve older person and caregiver Register

• f aims

Measuring II Validated scales

Process of rehabilitation

Take home messages

• Both how and what
• Empower older person and his/her caregiver
• He/she will set the goals because he/she is doing the work
• Effectiveness is dependent on patient’s active agency
• Support patient autonomy and active agency, involve family,

intervene the environment

• Resource oriented care, optimism
• CGA – expertise
• EBM models + right target group

Cognitive decline - Primary prevention – Secondary prevention

Thank you!