s12

Geriatric Rehabilitation. 3. Physical Medicine andRehabilitation Interventions for Common Disabling DisordersRand.otph L, Roig, MD, Gregory M, ll/orsowiczt MD, MBA, Deborsh G. Stewart, MD, David X. Cifu' MD

ABSTRACT. Roig RL, Worsowicz GM, Stewart DG, CituDX. Geriatric rehabilitation. 3. Physical medicine andrehabilitation interventions for common disabling disorders.Arch Phys Med Rehabil 2004;85(Suppl 3):Sl2-7.

This self-directed learning module highlights physical med-icine and rehabilitation (PM&R) interventions for commondisorders that cause disability in older adults. It is part of thestudy guide on geriatric rehabilitation in the Self-DirectedPhysiatric Education Program for practitioners and trainees inPM&R and geriatric medicine. This article specifically focuseson PM&R interventions for arthritides, fractures, cardiovascu-lar disorders, peripheral vascular disease, amputations, pulmo-nary disorders, cancer, stroke, traumatic brain injury, Parkin-son's disease, spinal cord injury, peripheral neuropathies, anddiabetic complications.

Overall Article Objective: To summarize the physical med-icine and rehabilitation interventions for commonly disablingconditions of older adults.

Key Words: Disabled persons; Geriatrics; Rehabil itation.@ i004 by the American Acaclemy oJ'Physical Medicine and

Rehabilitation

3.1 Educational Activity: To dilTerentiate the nonphar-macologic management approach lbr gait instabil ityin a 72-year-old avid gardener with degenerative ar-thrit is, comparing it with inflammatory arthrit is.

/r\ STEOARTHRITIS (OA) IS THE MAJOR disease that\rl l i*itr activit ics in eldcrly persons. By age 60, 100% havehistologic changes of degeneration, 40Yo report arthritis' and10% have activity limitations.L Arthritis management focuseson reducing the risk for functional dependency. Regular exer-cise does not exacerbate pain or accelerate disease progres-sion.2 In fact, evidence suggests that appropriate exercise canDrevent and treat some arthritic disabilities.3'a Exercise pro-grams should be specifically tailored to the patient and shouldinclude him/her in creating the plan' Early patient involvementoptimizes safety and increases compliance. The plan shoddinitiatty focus on the patient's most important functional prob-lems. As these improve, a more generalized fitness programcan be added.2 The few contraindications to exercise, such asacute and unstable cardiovascular conditions, are usually tem-porary.s Although our patient's gait instability requires safety

From thc Dcpartmcnt of Physical Medicinc and Rchabilitation, Northlak€ Reha-

bilitation Profcssionals, Hammond, LA (Roig); Department of Physical Medicine and

Rchabilitation, University of Missouri, Columbia, MO (Worsowicz); Brooks Hcalth

System Administration, Jacksonville, FL (Stewart); and Dcpartment of Physical

Medicine and Rehabilitation, Virginia Commonwealth University/Medical College of

Virginia, Richmond, VA (Cifu).

ll-o commercial party having a direct financial interest in the rcsults ofthe research

supporting this article has or will confer a benefit upon the authors(s) or upon any

organization with which the author(s) is/are associated-Reprint requests to Randolph L. Roig, MD, Northlake Rehab Professionals' 2l0l

Robin Ave, Stc 3, Hammond, LA 70403-5773, e-mail: rroig@aol com'

0003 -999 3/04/8507 -9220$30.00 / 0doi: 1 0. 1 0 1 6/j.apmr.2004.03.007

Arch Phys Med Rehabil Vol 85. Suppl 3' July 2004

planning, it is actually an indication for an exercise program.

Approximately 20% of falls are caused by gait instability, aproblem that can be rectified through strength and balancetraining programs.6

ResearchT into high-intensity, progressive-resistance trainingin oatients with rheumatoid arthritis (RA) showed no increasein ihe number of painful or swollen joints and showed reducedself-reported pain scores, fatigue scores, 5O-ft (15.24-m) walk-

ing times, and balance. Low-load, high-repetition, resistivemuscle training increased self-reported functional capacity and

was a clinically safe form of exercise in persons with functional

class 2 and 3 RA (mean duration, 10'5y).8Compared with range of motion exercise, aerobic exercise,

such as walking or aquatics, in both RA and OA patients, is

reported to inciease aerobic capacity and 50-ft walking time

while decreasing depression and anxiety.e No dif ferenceexisted between the groups for f lexibi l i ty, number of cl ini-

cal ly act ive joints, duration of morning st i f fness, or grip

strength.eReiearch on OA has revealed risk factors, some of which are

preventable. After increased age, obesity is the -strongest risk

iactor for kncc arthri t is, By losingjust 4.5kg (101b), a person

can reduce his/her r isk of developing symptomatic OAby 50%.

In addit ion to obesity, quadriceps weakness, poor propriocep-

t ion, heavy physical act ivi ty, lack of estrogen replacement

therapy (in women), and knee injuries are all preventable risk

factori in the deveiopment of symptomatic OA. A variety of

nonpharmaceutical treatments have proven efl'ective in manag-

ing OA: quadriceps strengthening, aerobic exercise programs,

ed-ucation'and soiial support, well-cushioned and customized

footwear, canes and assist ive devices, icing, and heating pads't

3.2 Ctinical Activi ty: To analyze the chal lenges faced by

an 8O-year-old woman with multiple fractures after a

motor vehicle crash.

Motor vehicle crashes (MVCs) that injure older adults, un-

like the high-speed collisions typical of young adults, are most

commonly-low-speed collisions. Despite this lowered velocity

at impaci older adults are more likely to die as a result of

iniuries sustained in MVCs. Collisions that are not initially

falal but that do result in severe trauma are 6 times more likely

to cause intracerebral lesions than severe chest, abdominal, or

pelvic injury in people over age 70 compared with crash

suryivors younger than 40 Years.roAppropriate exercise for the given fracture is vital to recov-

ery.'The^most studied fracture in the elderly is the proximal

femur. Rehabilitation of hip fractures and joint replacements

has been well described and is a cornerstone of the field'

Reviews are abundant.rr In addition to functionally based in-

patient, outpatient, and home health rehabilitation programs,

additional fo"ut on lower-extremity strength training is also

beneficial. Progressive high-intensity quadriceps training pro-

duces increaseJ extensor power and reduced disability in these

patients.12 People with acute hip fractures. who performed a

iaily, home-baied program of weight-bearing exercises for I

mont'h showed signiflcantly greater quadriceps strength in the

PM&R INTERVENTIONS FOR COMMON DTSABUNG DTSORDERS, Roig s13

affected (hip-fractured) leg and had greater walking velocitythan nonexercisers. The exercisers also improved their weight_bearing ability and (subjectively) reporGd reduced risk offalls.13 For proximal femur fracture, inpatient rehabilitationmay be especially useful. A delay in transfer to a rehabil i_tation ward is associated with a disproportionate increase intotal hospital stay for patients over the age of 75.ra lnpatients with known primary tumor or acute fracture afterminor trauma, the possibility of a pathologic fracture shouldbe considered.r5

Emotional health is extremely important in predicting recov_ery of functional ability 1 year after a bodily insult such as hipfracture, and studies have suggested that reducing depressivesymptoms and increasing positive affect may aid recovery.16 Aserious fracture in an elderly women may cause severe anxietyand fear of impending death. Long-tenn management of anx_iety includes education, exercise, and empowerment (involve_ment in her rehabilitation plan). Instruction in exercise, nutri_tion, and osteoporosis education was shown to reduce bothdepression and anxiety in a 4-day outpatient program for el_derly patients.tz

The social impact of multiple fractures and a lengthy healingprocess are also severe. Valuable social roles involvins thifamily, community, and workplace may be lost at least tem_porarily. Failure to function in social rolcs can lead to isolationand great stress. Efforts to preserve social roles or to redefinethem in mcaningful ways are part of rchabilitation for multiplel ractures.rT

At tent ion to prevent ion of vcnous thromboembol ism(VTE) is also vital. Trauma, hip tiactures, and major ortho_pedic surgery all present high risk for VTEs (25%_50%\.which is even higher with increasing age. Evidence strongiysupports use of prophylaxis, which most doctors reoortusing, but studiesrs show that only one third of high_iistpatients actually receive prophylaxis in the hospitat. tteappropriate prophylaxis for VTE after hip fracture or iointreplacement is fu l l ant icoagulat ion wi th warfar in ( in terna_tional normalized ratio, Z-2.5) or appropriate dosing oflow-molecular-weight heparin (LMWH). Althoush consid_erable regional variation exists, studiesre show tf,at appro_priate use of warfarin or LMWH reduces risk of death-afterhip fracture. Intermittent compression devices and compres_sive stockings have limited efficacy for VTE but are usefulfor cdema management. Aspirin hai not proven effective forVTE prevention and should have no role. Vena cava fi l tersare expensive, and, although they reduce early pulmonaryemboli, they do not prevent recurrent VTE.20 bespite ade_quate thromboprophylaxis, patients undergoing suigery forhip fracture remain at significant risk to develop proximaldeep vein thrombosis, which prolongs rehabil i iation timeand increases mortality rates. Recent research2r supports useof Dop_pler sonography to screen patients receiving prophy_laxis. However, the economic cost-benefit analysis of thispractice is unclear.

During her rehabilitation, skin breakdown may result frompressure, shearing forces, friction, and moisture. preventivemeasures can significantly reduce the incidence of pressureulcers. Succes.sful management should address these etiologicfactors as well as the general condition of the patient. Riskfactors include prolonged immobilization, circulatory distur-bances, poor nutrition, and sensory deficits-all potential ef_fects of fractures in the elderlv.22

3.3 Clinical Activity: To design an exercise program foran 85-year-old retired executive, with a historv ofmyocardial infarction, who now has claudication inthe lower extremities.

Cardiovascular disease (CVD) rehabilitation in elderly per_sons can be a particularly challenging. In older patienti withunderlying heart disease, acute vigorous physical ixertion maytrigger sudden death or myocardial infarctjon, particularly inpeople not accustomed to such activity. Adequate ,....ningand evaluation are important to identi! and cbunsel patientiwith underlying CVD before they begin exercising. Foi exam_ple, the American College of Sporti Medicine iecommendsthat men over 40 and women over 50 undergo exercise stresstesting before starting a vigorous exercise program.23 Further-more, fall risk must be considered when preJcribing aerobicexercise.2a With these concems, primary

-care cliniiians are

often hesitant to prescribe exerciie for ilderly patients withCVD. By individualizing the exercise prescription for eachpatient, risks can be greatly reduced. Our patient with inter_mittent claudication, for example, should bi instructed to ex-ercise to pain tolerance, with only very gradual increase in exer_cise duration, with an emphasis on duration, not intensity.2s. After myocardial infarction or coronary artery bypais graft_ing, a submaximal exercise test can be performed ior fulrtherrisk stratification before hospital dischargi. This test is not usedfor exercis.e prescription.2a_ Based on the patient,s recovery,wound healing, and medical status, a symptom_limited exerciiestress test should be performed after 6 weeks. Test results willbe helpful in prescribing an aerobic cxercise program.24.26 Jntnc ctdcrly parlent, dyspnca. with or wirhout angina, may be asymptom of myocardial ischemia. Seventy percent of patientsover the age of 70 years may have abnormil stress teits withasymptomatic ischemia. The treadmill exercise test may not bean option for the elderly patient because of preexisting lo*.r_extremity disability, balance, or tolerance issues. Modificationsfor.exercise testing and chemical stress tests (eg, persantine-thallium stress test) should be considered.24,26. Physical activity and exercise may ameliorate disease anddelay functional decline in the geriatric population. Exercisecan improve body composition, diminish falls, increaseshength, reduce depression, reduce arthritis pain, reduce risksfor diabetes and coronary artery disease iCaO),'and improvelongeviry.2s Physiologic studies consistently rupport exerciselnrervenrlons. hor.example, peak oxygen uptake (Vorpeak) islhe

mo:l powerful predictor of cardiac and all-cause mo.tuiltyror cardlac patrents. A person's Vorpeak increases with aerobitconditioning and thus im-proves prognosis after cardiac insult.27

l ne very hrgh rates of both disability and recurrent coronaryevents seen in older patients with CAD can be reduced witirexercise. Disability rates are particularly high in women and inall persons older than 75 years. Despite-the high levels ofdisab^ility in older patients with CAD, physicians aie less likelyto refer these patients than younger paiients to cardiac rehabil_itation programs.28 The Americin Heart Association and theAmerican College of Cardiology recently released secondaryprevention guidelines to help- physicians. Contemporary pro_g,1lT: ,lo.ur on all aspects of seiondary prevention inciudingcllnrcal assessment and monitoring, supervised exercise, nutriltional counseling, smoking cessation iupport, stress manage_ment, and.o.ther healthy behaviors. poor-compliance with car_olac rehabltltatton is a multifactorial problem in the elderly, butseveral studies indicate that the most important predicior ofparticip-ation is specific and direct endorsement from the phy_sician.2e

Arch Phys Med Rehabil Vol 85, Suppl 3, July 2004

s14 PM&R INTERVENTIONS FOR COMMON DISABLING DISORDERS. Roig

3.4 Clinical Activity: To design a rehabilitation programfor a 75-year-old woman with newly diagnosed lungcancer and chronic obstructive pulmonary disease,who complains of shortness of breath after ambulat-ing I block.

Chronic obstructive pulmonary disease (COPD) is a majorcause of hospitalization, morbidity, and decreased function inthe elderly.3o Functional limitations caused by dyspnea andsubsequent anxiety can lead to progressively decreased activityand further functional disability. Essential components of suc-cessful rehabilitation programs include appropriate medicalmanagement, necessary oxygen supplementation, education onbreathing techniques, exercise training, nutritional evaluation,and psychosocial and stress (depression, anxiety) management.Oxygenation at rest and during exercise must be monitored forthe need for oxygen supplementation. Oxygen supplementationmay be required with exercise to achieve muscle-training ef-fects. In general, low-dose oxygen supplementation is appro-priate to maintain arterial oxygenation at no less than 88%saturation. However, because people with COPD on oxygensupplementation have a propensity to retain carbon dioxide andthus potentially diminish their respiratory drive, their arterialcarbon dioxide levels must be closely monitored. Exerciseprograms increase endurance, decrease perceived dyspnea, in-crease quality of life (QOL), and increase self-efficacy.3o

Cancer is becoming an increasingly common diagnosis inpatients requiring rehabilitation services. It is essential to giveattention to the disease's effects (both end organ and systemic),the patient's prognosis, the cancer treatments and their poten-tial side effects, and the patient's goals if one is to design anappropriate rehabilitation program. Reviews3r'32 on the man-agemcnt of oncologic rehabil itation issues have been pub-lished.

Inpatient and outpatient puhnonary rehabilitation programsrequire the coordination of multiple professionals workingwithin the interdisciplinary team model. Inpatient pulmonaryprograms have been shown to incrcase a patient's walkingdistance, decrease required oxygen supplementation (both dur-ing the day and at night), increase QOL, increase knowledge ofthe disease process, and decrease future rehospitalization.33Bcnefits of outpatient programs include an increase in Vo,maximum, improved endurance as measured by better perfor-mance in the l2-minute walk test, an increase in cardiac workcapacity, increased forced vital capacity, a decrease in dyspnea,and improved function in activities of daily life (ADLs)'34

3.5 Educational Activity: To justify a rehabil itation pro-gram for a 75-year-old widow with parkinson's dis-ease in an assistedJiving center. Contrast your rec-ommendations if she had been newly diagnosed with astroke, traumatic brain injury, or spinal cord injury.

The efficacy of inpatient and outpatient interdisciplinaryrehabilitation services for older adults with new onset of dis-ability from stroke, traumatic brain injury (TBI), or spinal cordinjury (SCI) has been shown, and age-specific differences inrehabilitation outcomes have been examined in these diag-noses. However. the influence of Parkinson's disease (PD) as aconcurrent morbidity on outcome after a new neurologic insulthas not been specifically studied. Specific therapy interven-tions, intensity and duration ofservices, treatment settings, andgoal setting must to be modified in accordance with the severityof the PD.

PD is a progressive neurologic disease resulting from areduction in the release of dopamine within the striatum of the

Arch Phys Med Rehabil Vol 85, Suppl 3, July 2004

basal ganglia. In the older adult population, lYo suffers fromPD, which has aprevalence of 128 to 187 per 100,000 and anincidence of 20 per I 00,000 in the United States. Symptoms arevaried and include tremor, rigidity, bradykinesia, akinesia,postural abnormalities, hypokinetic dysarthria, and dementia.Rehabilitation interventions are diverse and depend on theclinical findings. A critical review35 of the exercise therapyliterature supports the efficacy of several different tlpes ofphysical and occupational therapies for improving ADLs, in-dependence, and walking ability (walking speed, stride length)but not for neurologic symptoms or QOL. A descriptive re-view36 of the speech and language pathology similarly supportsthe efficacy of speech therapy for improving voice and speechfunction. Education regarding appropriate dietary modifica-tions and swallowing techniques (eg, chin tuck, head position-ing) has also been reported to assist in dysphagia with PD.36There is no available literature that critically examines thespecific efficacy of interdisciplinary rehabilitation services (in-patient or outpatient) on functional limitations because of PD.

Stroke occurs most commonly in the older adult, with nearly75Yo of all strokes occurring in people at or over the age of65years. A person's risk for stroke doubles with each decade oflife after age 55. Stroke rehabilitation has been shown toimprove outcomes while decreasing morbidity and mortality:compared with their younger cohorts, older adults requirelonger lengths of rehabilitation stays, show slower and lessoverall functional improvements, and need nursing homeplacement at discharge more frequently.3T

Unlike their younger cohorts, older adults sustain the major-ity of TBIs and SCIs in domestic fblls. Older adults withconcomitant PD are at an extremely high risk for falls. Thef-actors that contribute to fall risk also predispose the elderly tomotor vehicle, pedestrian, and recreational accidents, all ofwhich may result in TBI or SCI. The dccrease in reaction timeand speed of ambulation commonly seen in the older adultadditionally predisposes them to MVCs and pedestrian MVCs,respectively. Strategies for injury prevention include consistentprimary physician care to manage medical morbidities, regu-late mcdications, and provide ongoing education. Additionally,focused rehabilitation interventions can be used to maximizephysical abilities (gait, balance, strength), procure adaptive andassistive devices (canes, walkers, handicap parking stickers),and provide education. Finally, efforts to reduce violenceagainst older adults are necessary to prevent this increasingcause of injury.

Most of our knowledge about outcomes of older adults withTBI or SCI comes from studies involving all age groups. Theseinvestigations report the strong associations between increasingage and mortality. Injury severity-matched analyses of datafrom the National Institute on Disability and RehabilitationResearch Traumatic Brain Injury Model Systems and theModcl Spinal Cord Injury Systems projects reveal age-specificdifferences in older adults.:8 These analyses show that in olderadults with traumatic central neurologic injuries, improvementsin neurologic and functional status and successful return tohome are common and achievable with rehabilitation. An in-jury severity-matched investigation in TBI revealed that peo-pte SS yeais and older had twice the rehabilitation length ofstay (LOS) and costs, half the rate of functional recovery'greater cognitive impairment at discharge, and twice the nurs-ing home placement rate of people who were 50 years andyounger. At discharge, the level of physical impairment wascomparable for the 2 groups. The association between age andoutcbme is quite complex and appears closely related to injuryseverity as measured by the patient's score on the motor

PM&R INTERVENTIONS FOR COMMON DTSABUNG DISORDERS, Roig s l5

Glasgow Coma Scale, duration of coma, duration of posttrau-matic amnesia, history of alcohol intake, postinjury

'behavior

(eg, presence of depression and/or agitation), and a variety offormal and informal social support factors.38

Injury severity-matched investigations in SCI3e-4r revealedthat subjects 55 years and older with paraplegiaal had increasedrehabilitation LOS and less functional recovery and efficiencvthan subjects who were 50 years and younger. No differencesin acute care LOS, nursing home placement or neurologicrecovery were noted. Subjects 55 years and older with tetra-plegiaao had an increased nursing home placement rate, adecrease in neurologic recovery, and a decrease in functionalrecovery and efficiency than subjects who were 50 years andyounger. No differences in rehabilitation and acute care LOS ornursing home placement were noted.

3.6 Clinical Activity: To evaluate an 80-year-old diabeticman who has complaints of bilateral lower-extremitynumbness.

Age-related changes of skin, muscle, and the peripheralneryous system (PNS) can make the diagnosis of a concurrentperipheral neuropathy challenging. These systems undergo a"normal" decrement in function with the aging process. Theseage-related changes can be observed clinically, anatomically,and e,lectrophysiologically. Normal changes of skin integriti,muscle atrophy, and weakness may be difficult to distinguishfrom foot deformiry, pain, skin ulceration, and decreased mo-bility associated with a peripheral neuropathy. Electrophysi-ologic studies demonstrate slowed nerve conduction and'de-creased motor- and sensory-evoked responses in the elderly.The aging PNS is more susceptible to neuropathies caused bytoxins, drugs, nutritional deficiencies, alcohol use, RA. carci-nomatous disease, and other causes of peripheral neuropa-thY.dz'+t

Evidence of callus formation, tight heel cords, hammer toes,and muscle imbalances of the foot must be assessed. Clinicalfindings of decreased ankle jerks, decreased vibratory sensa-tion, atrophic skin changes, muscle weakness (proximal greaterthan distal), and muscle atrophy may be parr of thJagingprocess. However, absence of Achilles' and patellar reflexes,alteration in lower-extremity vibratory sensation, and de-creased great toe position sense may be abnormal signs, indic-ative ofa-concomitant peripheral neuropathy and noijust signsof normal aging. Electrodiagnostic studies consistenf with ne-ripheral neuropathy have been found in elderly patients witir 2of the 3 clinical findings of absent Achilles' reflex, abnormalvibratory sensation, or altered position sense in the lowerextremities. This distinction between normal agins and anunderlying peripheral neuropathy is important for Jlari'fl,ing thediagnosis.+a Associated peripheral vascular disease (PVDiandrts severity must also be recognized because it will affectactivity tolerance and future wound healing. Full evaluation ofPVD and its treatment have been documented.+s

Treatment plans must include appropriate medical manage_ment, proper skin care, and appropriate footwear. Frequent skininspections and hygienic nail care by the patient or his/hercaregiver should be done on a regular basis. Footwear modi-fications, such as extra-depth shoes with custom inserts (toappropriately distribute plantar weight-bearing surfaces) and/ortoe box adjustments (to accommodate hammei toes). should beevaluated. Diabetic foot care and education is critiCal becausetl% o! people with diabetes will develop some type of footulcer. People with diabetes with chronic ulcers have a 70oh to80oh rate of requiring an amputation. people with diabetes are15 to 17 times more likely to require imputation than the

general population and have a 3-year survival rate of 25%o to50% at the time of amputation. People who undergo an ampu_tation will require extensive rehabilitation r.*1..1.ae,+z

Proper treatment and management of diabetic-related lower_extremity amputation impacts the amputee and the entire healthcare system. The US Department of Health and Human Ser_viceshas published in Healthy people 2010 its goal ofdecreas-ing diabetes-related lower-extremity amputation from 41.0 to18.0 per 10,000 diabetic persons by the year 2010. The WorldHealth Organization and the International Diabetes Federationhave set a goal of reducing diabetes-related amputations by50% over 5 years.az

3,7 Clinical Activity: To design rehabilitation interven-tions for a 70-year-old hypertensive woman withknown CAD presenting to your office with shoulderpain.

Concurrent morbidity or comorbidity is the presence ofmult iple pathologic condit ions in the same patient. Such con-ditions- as arthritis (50%-64%), hyperteniion (41%-4go/o),heart disease (19%-25%), cancer (l7Yo-23%\, and diabeteiq.l]imr (12%-I3o/o) are more common in people over the ageof 70 years.48 Selected medical management bf common co-morbidities is covered in a review by Lin and Armour.ae lnmanaging geriatric patients, it is imperative to account for theimpact of comorbidity. The presence of comorbid conditionsaffects the degree of disability, likely outcome or prognosis,and the therapeutic options available. Comorbidity correlateswith disabi l i ty and the more comorbid condit ions a patient has,the greater the severity of the disabilitY.to In addition to thenumber of chronic condit ions, the severity of the condit ion isalso. pivotal in predict ing disabi l i ty. LOS for hospital izedstroke patients in the Copenhagcn Stroke Study did not corre-late with comorbidity.sr Howevcr, other investigatorss2 showedthat charge per hospital day is affccted by mcdical comorbidi-ties. In stroke patients, comorbidities are associated with olderage, more days from onset to rehabilitation admission, andmore severe functional imoairment.si

Comorbidity is also an important determinant in the formulaused for the rehabilitation prospective payment system imple-mented by Centers for Medicare and Medicaid Servicei inJanuary 2002.Each of the rehabilitation impairment categoriescan be further de{ined by 3 tiers, which characterize the bi.rrdenofcare, by accounting for comorbidities and other factors suchas age and functional measures. Utilization review processes,such as InterQual,sa also use comorbid conditions as necessarycomponents for certain diagnoses to qualifo for various levelsof care.

Providing a rehabilitation prescription for geriatric patientsnecessitates factoring in the primary diagnosis, co.orbid con_ditions, effects of aging and disuse, as well as social factors.which can affect outcome.

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Arch Phys Med Rehabil Vol 85, Suppl 3, July 2004