The importance of senior rehab - the distance between knowledge and action can be a killer…

Senior Rehab is essential in helping those who have suffered a set-back, get back on their feet – often literally.

Maybe it’s part of the human condition that we can know so much and yet act so little.

Nowhere was that more apparent than in a hospital family meeting that I attended yesterday.  The Client, age 88 years, was present with her three children and the social worker. Prior to her hospitalization she had lived independently. In the three weeks she had been in hospital since her heart attack she had barely been out of bed.

This is a huge issue.

Colleen S. Campbell, Geriatric Evaluation & Management Director at the Geriatric Research Education and Clinical Center outlined many of the issues  in her paper; Deconditioning: the consequence of bed rest. 

Deconditioning (disuse) can lead to:

• Muscle weakness and Atrophy.
• A 3% loss in muscle mass within thigh muscles within 7 days
• 3 – 5 weeks of total inactivity can lead to a staggering 50% decrease in muscle strength.
• Disuse Osteoporosis can result from a lack of weight bearing, gravity and muscle activity.
• Within 24 hours of bed rest there is an increase in the resting heart rate of 4 – 15 beats per minute. And a 5% decrease in blood volume. An Increase in Orthostatic hypotension can result.
• Immobility can result in atrophy of the heart muscle
• Seniors who are left in bed are more likely to suffer from Pressure ulcers, decreased appetite, and constipation.
• Psychologically immobility can result in depression, loss of motivation and a feeling of helplessness.
• Increase in Anxiety, fear, and neurosis
• Decreased concentration and impaired judgement
• A life threatening Pneumonia can result from the decrease in all pulmonary function parameters.

In short, seniors who become deconditioned because they have been left to languish in bed are more likely to suffer a loss of independence because of their inability to function.

Now back to our meeting….

The social worker explained that the physiotherapist was stretched very thin (no pun intended) and would not likely be in a position to offer much.

Somehow she didn’t appear to be mortified by this.

The family understood that an application had been made to a rehabilitation setting so that this once semi-independent senior could receive senior rehab and return to her home with assistance.

The social worker corrected this impression by stating that the Social Worker who had originally been assigned was no longer on the case. She added that as the new social worker, she was unaware whether the application had been completed or not. (She then felt it was important to inform us that she worked only part time, did not know this Client at all, and that these things were known to move very slowly….no kidding!)

There was no acknowledgement about the negative impact on the Client, no suggestion as to how things could be moved along any faster or how to improve the outcome of the Client’s hospital stay.

There was also an observation that the Client was not eating or drinking well while in hospital. On more than one occasion she was dizzy, tired and weak (see Deconditioning, above).

Those who had seen the hospital meals felt that the poor quality of the meal was partially to blame. Everyone agreed that this might be an issue – no one suggested how to deal with it. (Family could bring in food, meal choices might include sandwiches or other foods that are more agreeable to the Client’s palate, contact the dietitian, allow client have a meal in the cafeteria each day…something-do something!)

Everyone knows that a prolonged hospital stay with these kinds of conditions is not in the best interest of the Client. Everyone agreed that if the Client did not start moving soon, she might permanently lose the ability to do so.  (Essentially use, it or lose it).

And to top it all off,  there seemed to be an error or miscalculation in the application for rehab itself. The application had been made for aggressive rehabilitation, not the slow stream rehabilitation more suited to the Client’s age and frailty. (The wait for aggressive rehabilitation is longer - the social worker said it could be months!).

We insisted that the social worker check the status of the client application for senior rehab while we waited. She returned and told us that all she needed to do now was touch a button to set the slow stream application process in motion - push the button, push the button!

What if the client had not had the benefit of an experience Registered Nurse advocating for her at that meeting?  Would the button have ever been pushed? Why is a previously independent senior left to languish in a bed? Why is there not more urgency to the whole process?

We absolutely know that a person has to eat, drink and move around in order to improve in their general condition. We absolutely know that a lack of nutrition, hydration and movement are debilitating to anyone – never mind a frail senior.

And yet, the lack of action that we saw with this client appears to be more the norm than the exception.

What you can do:

Remember inaction is a decision (today we are not going to do range of motion exercises with Mrs Smith) – In the hospital setting, a person’s condition can  get better or it can get worse. You can make a difference. Decide to act and ask others to act.

Be informed, know what is going on and why, ask questions. Don’t be shy. If the answers you get don’t seem to make sense, ask someone else.

Oh and did I mention, ACT!

Discharge Prescriptions need to be reviewed

When a Client is discharged from hospital, we always review their discharge prescriptions and compare that list to the medications that they were taking before being hospitalized. Sometimes during the course of a person's hospitalization their medication regimen is changed. Sometimes however, there are oversights, errors or as in this case, Printer problems.

So many times one problem compounds another and the end result is a dangerous mess of mixed up medications that goes unnoticed until a person becomes unwell or experiences a crisis.


Here is a story from our Practice today:

Today we were organizing a client's medications.There were multiple vials of medications strewn throughout the apartment. Some were years old. The client had a dangerous habit of pouring medications from one vial to another vial. The printed directions on the medication vials were not necessarily the most recent instructions and some dosages had, in fact, changed. The client confided to us that she has difficulty opening the vials. We introduced a medication dossette.

Although this client had a recent history of low hemoglobin and she had iron tablets at home by order of her family doctor, the discharge note from the hospital did not mention anemia as one of her pre-existing conditions. Nor did it mention the iron therapy or any follow up that might be required by a person with anemia.  We called the Nurse Practitioner at the hospital who revealed that the client had had a transfusion while in hospital, related to low hemoglobin but that they had been unaware of any history of iron therapy.

An oversight.

This particular client also has diabetes. She is newly diagnosed and is insulin dependent. She has been directed to take her blood sugar readings four times daily and adjust her insulin dose based on the reading. She does not have a chart to reference. She is unsure of what foods she should eat in order to maintain good blood sugar control. She is uncertain as to what she would do if her blood sugar reading was low. She lives alone and is frail.

Another oversight?

The Client received a referral to a dietitian but the period of time between her discharge from hospital and the appointment for the dietitian is 5 months....

During our home assessment we found, candies, white bread and other items that would not normally be found on a diabetic diet. The client's family said that visitors are bringing all kinds of foods to the house when they visit...

Finally, in reviewing the medication  in the discharge note we found a discrepancy.The family doctor ordered a medication to be taken three times daily.  The hospital discharge prescription noted that it was only to be taken once per day. We could not see any reason for the discrepancy.Once again we called the Nurse Practioner to help clarify the prescription. In assisting us, she discovered that the medication dosage should have been one tablet, three times a day and that it was due to a Printer error that the order had been cut off (instead of reading that the meds should be taken with breakfast, with lunch and with dinner, it read only that the drugs should be taken with breakefast. The rest of the message was not included.)

True story.  One of many.

Please check your discharge prescriptions. Ask questions if there seems to be a discrepancy.

Printer problems, errors and oversights happen.