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In rehabilitation - The Role of the Physician in Geriatric Medicine in the Ageing Society

Age and Ageing, Nov, 1994 by G.P. Mulley

In 1935, Mariory Warren [1], the mother of British Geriatrics, took over the care of 714 chronic patients, over half of whom were bed-bound. She assessed them in detail and introduced a number of innovations: the wards were painted bright colours, the lighting was improved; more space was created between the beds, special equipment was bought. Rehabilitation methods were applied. The results were remarkable: an observer commented that the bedridden could be put on their feet again and that many of the results achieved in Warren's Unit would seem miraculous to hospitals where similar methods had not been tried. As patients got better, were discharged or died, turnover improved and fewer wards were needed for older people.

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In the 1930s, the average length of hospital stay of a sick old person was 260 days [2]; by 1947 this had fallen to 52 days. Today most ill old people spend less than 3 weeks in hospital. These astonishing achievements have taken place largely because of the vision and determination of pioneering geriatricians and the energy and commitment of their successors. The principles of geriatric medicine are now well known and widely practised; these include: early referral of sick old people; comprehensive assessment by a multidisciplinary team guided by a committed clinician, who has a holistic view of the patient and family; optimal medical management; and an interest in apparently mundane health issues (constipation, incontinence, pressure sores, confusion). An essential component of successful geriatric medicine is rehabilitation.

The World Health Organization defines rehabilitation as an active process by which those people who are disabled by injury or disease achieve a full recovery, or, if full recovery is not possible, realize their optimal physical, mental and social potential and are integrated into their most appropriate environment [3]. Rehabilitation is therefore the restoration of the total person to his or her fullest capacity. How is this achieved? There are several elements which are examined in turn, emphasizing developments and current practice, and ascertaining how standards can be monitored, maintained or improved.

Attitudes

The stereotypical view of the traditional hospital consultant is of a somewhat aloof person who is omniscient and omnipotent and who stipulates what should be done to patients. The doctor who is successful in geriatric rehabilitation will exhibit different characteristics: the capacity and eagerness to be an active listener; an interest in the whole person, seeing patients as unique individuals and not as `cases'; an appreciation that patients and their relatives are at the centre of things--that they should help set the agenda and be actively involved in all aspects of care. The doctor will ensure that patients have time to discuss things that matter to them in a sensitive way (the traditional ward-round where a large entourage surrounds the patient and where others on the ward can hear all that is being said is not the best way to achieve this). There will be time in the day when the consultant is available for discussion with informal carers. Perhaps copies of clinic letters will be sent to the patient; this will encourage correspondence to be written in plain English and allow patients to assimilate more than they might in a conventional clinical encounter.

The doctor will not be judgemental: if a patient appears to be `poorly motivated' the physician will recognize that this is a symptom, the causes of which must be carefully sought. The patient and family will see their doctor as an ally and friend, one who eases their anxieties, enables them to achieve the highest possible levels of well-being and independence, who is interested in those small details which can make such big differences, and who will help them overcome bureaucratic and other obstacles that might be in their path.

Teamwork

Rehabilitation is complex and to be effective requires a skilled team. At the centre are the disabled patient and his/her family [4]. The professional members will know what skills their co-workers have; they will be flexible (inter-professional rivalry and border warfare have no place here) and mutually helpful. For example, the doctor may suggest a particular gadget to an occupational therapist, who may in turn be the first person to recognize that the patient is depressed. The nurses are of supreme importance: they will have a detailed knowledge of the disabled person and will put many rehabilitation techniques into practice throughout the day.

As team leader, the consultant geriatrician should listen carefully to the views and observations of therapists, nurses, social workers and others and ensure that quieter members are encouraged to contribute to the case discussion. Communication between members of the team not only occurs at formal case conferences: informal discussion on and off the ward is augmented by communication sheets in the medical case notes. Here all involved in patient care can write what has been discussed with the patient, family, or a person from the community team.

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In rehabilitation - The Role of the Physician in Geriatric Medicine in the Ageing Society

Age and Ageing, Nov, 1994 by G.P. Mulley

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