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Rehabilitation of the elderly patient: a multi-agency task

Iain B McIntosh
General Practitioner
St Ninian's Trustee
Dementia Services Development Centre
Stirling University

Greater life expectancy is producing an increasingly elderly population. More than 16% of UK inhabitants are over 65,(1) and many will live to a considerable age. The majority remain relatively well, but declining health in the old inevitably brings an increased workload to primary healthcare. Overtaken by illness, infection and disability, they will overburden medical, residential care, nursing home and hospital facilities unless vigorous steps are taken towards prompt rehabilitation (defined as a planned programme that ensures the patient progresses to, or maintains, the maximum degree of physical and psychological independence).
Proactive intervention and speedy provision of medical aid and medication may delay a decline in health, while prompt attention to loss of skills and ability can minimise any potential loss of independence. Quick provision of qualitative medical support and a return to self-care is a benefit to the patient, the practice and the state. 
Ageist ­attitudes, positive or covert age discrimination and the excuse of limited resources all too often blunt management response, with the result that those most dependent on good-quality care are least likely to get it.(2) It has been shown that elderly people who are ­encouraged and supported to retain active independence experience fewer psychological problems and are able to cope more effectively with other related crises.(3) 
Declared government and professional policy decrees that people should be maintained in their homes for as long as possible, a commitment that demands the enlightened, proactive input of services and rehabilitation resources - a prerequisite for optimal retention and maintenance of the individual's function and ability to carry out the normal activities of daily living. Primary care professionals cannot divorce themselves from the provision of supportive and remedial services and the need to ensure their seamless application. An attitude lamenting the inadequacy of community support services should be replaced by a demand for the needs to be met. Remedial services initiated in the secondary care sector have to be maintained in the community, and are a wasted endeavour if not continued in the patient's home. This can be undertaken adequately only with the integrated support of an extended primary care team actively involved in rehabilitation, continuing assessment and the global appraisal of patients' health, mental and social status, and physical function.
The extended primary care team comprises:

  • The family doctor.
  • A community nurse.
  • A physiotherapist.
  • An occupational therapist.
  • A social worker.
  • A hospital liaison officer.

The prime objective of management after a stroke, an operation, a fall, infection, disablement or trauma is to minimise its effect on the patient, diminish the after-effects, and allow the patient to regain and maintain function, so that they may remain in their own home and within their local community. Intervention must be prompt, consistent, continued and supervised. It will involve multi-agency and interagency input. Community care is an amalgam of health (rehabilitation and nursing) and social (housing adaptation and functional aids) services, with the elderly disabled being the major care recipients, people who suffer from the triple jeopardy of old age, infirmity and inadequate, unglamorous services with low public visibility.(4) Only the GP is in the position to be able to overview the global care scene, and bridge gaps with help from the extended team. Cooperation, liaison and good working relationships can ensure a comprehensive, seamless response. 
The task is facilitated if a practice elderly surveillance programme exists. Baseline annual health status ­assessments, organised around the current contractual, yearly, over-75-year-old health check can provide a profile of wellbeing and function and can indicate and note decline. As a continuing record of health status, they can help promote proactive intervention and assist immediate response to change in need, illness and hospitalisation. A shared-care plan should be devised in conjunction with involved health and social work carers. Hospitalisation should not bring support hiatus, but be bridged for continuity of treatment from community physiotherapists and occupational therapists. Before discharge, there should be an agreed, shared hospital/community management plan to provide continuing patient care.
After a stroke, a fractured hip or a bad fall in the home or on a ward, there is immediate need for physiotherapy to negate the threat of spasticity, muscle loss and diminished function.(5) This depends on prompt assessment of current physical status and retained abilities. Physiotherapy and the provision of functional aids to maintain existing function and recover lost skills are urgently required. Delayed response will not only slow the return to normal function but result in permanent loss of prowess, inability to carry out the instrumental activities of daily living and perhaps institutionalisation. 
Whoever is providing round-the-clock attention must be aware of the need for the patient to live in "the recovery pattern" and maintain correct "positioning". Mismanagement, procrastination in active rehabilitation and failure to access support services can make the patient a burden upon the state and condemn them to an inferior quality of life. Medical science may not fail them, but the willingness of health professionals to respond expeditiously to their ­functional needs certainly can.


  1. Fry J. General ­practice; the facts. Oxford: Radcliffe Memorial Press; 1993.
  2. Fallowfield L. The quality of life. London: Souvenir Press; 1990.
  3. Hall CM. Ageing and family processes. J Fam Counselling 1976;4:28-42.
  4. Young J. Community care waiting lists and older people. BMJ 2001;322:254.
  5. Johnstone M. Home care for the stroke patient. Edinburgh: Churchill Livingstone; 1987.

Age Concern (England)
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British Geriatrics Society
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Disabled Living Foundation
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London W9 2HU
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