Mohammed T. Abou-Saleh

Principles and Practice of Geriatric Psychiatry.Editors: Professor John R. M. Copeland, Dr Mohammed T. Abou-Saleh and Professor Dan G. BlazerCopyright & 2002 John Wiley & Sons LtdPrint ISBN 0-471-98197-4 Online ISBN 0-470-84641-0136RehabilitationRob JonesQueen’s Medical Centre, Nottingham, UKRehabilitation of the older person with psychiatric disorder meansrestoring and maintaining the highest possible level of psychological,physical and social function despite the disabling effects ofillness. More broadly, it also means preventing unnecessaryhandicap associated with illness, preventing unnecessary handicapsecondary to maladaptive responses to illness, and combating thedeadening effects of low expectations of older people amongstpatients, families and society in general. Managing chronic diseaseand disability is the greatest challenge to modern medicine.Within this, the rehabilitation of many older people withpsychiatric disorder looms large—although, of course, many oldpeople with psychiatric disorders respond well to ‘‘curative’’therapy and require little rehabilitation.In fact, rehabilitation is a fundamental and inseparable part ofold age psychiatry. Perhaps for this reason, as with rehabilitationin geriatric medicine 1 , little has been written about the topicspecifically. Some particular techniques, such as psychologicalapproaches with the cognitively impaired, have been welldescribed 2,3 but little evaluated 4 , and evaluative research is muchneeded here.SPECIAL PROBLEMS WITH PSYCHIATRICDISORDER IN THE ELDERLY‘‘Old age’’ may span 30 years or more, posing quite differentrehabilitation problems; but the most major concern is with theold-old. In this group, multiple disability is prominent, with thecomplicating danger of polypharmacy, and physical and mentalill-health interact in complex ways. With this frail population,disentangling the respective influences of ageing, previouspersonality and current ill-health can be exacting. Two-thirds ofthe UK’s disabled population are older people and the true extentof handicap due to psychiatric disorder is probably still notestablished.With depression, especially, there may be restriction of physicalactivity, threatening physical capacity and health. Depressionassociated with stroke disorder 5 or with Parkinson’s disease 6particularly illustrates both the connection between physical andpsychiatric problems and the importance of physiotherapy inpsychiatric rehabilitation.Physical factors are frequently of great importance in dementia.A quiescent individual may become delirious and disturbed atnight through heart failure, obstructive airways disease or eventhe uncomfortable effects of severe constipation. Settling suchproblems may transform the reality of care for a carer and seekingout such therapeutic opportunities is an important part ofrehabilitation. Similarly, in dementia, physiotherapy to promoteand maintain the best possible physical capacity is a key element.Advice and practical aid to carers, such as with lifting andhandling the physically disabled demented person, can be crucial.A judicious mixture of the ‘‘therapeutic’’ (curative) and the‘‘prosthetic’’ (supportive) approaches 7,8 is very necessary in oldage psychiatry. Whilst much functional psychiatric disorder anddelirium can be ‘‘cured’’, and this must be the aim, most olderpeople with dementia need some degree of supportive care at somestage. The poor financial and housing state of many older people,together with the lack of children or spouses to help as carers formany of the old-old, are further complicating factors. Maximizing‘‘participation’’ despite psychiatric disorder needs to be a majorgoal, maintaining as far as possible a role in the family, socialcontact, a range of activities and a minimization of loss ofautonomy or institutionalization. This requires an approach thatembraces psychiatric, medical, rehabilitation, nursing and socialperspectives. Seeking active prevention of disability/reducedparticipation as a consequence of psychiatric disorder is a vitalpart of rehabilitation.SPECIAL PRINCIPLES IN REHABILITATION OFTHE OLDER PERSON WITH PSYCHIATRICDISORDERTable 136.1 summarizes the principles. The first principle is to makethe home the focus of attention. That is where problems have arisenand where they will need to be overcome. Planning for rehabilitationshould begin at the earliest moment; an initial assessment athome by a senior psychiatrist, or other experienced team member, isinvaluable—even if ‘‘home’’ is an institution in the community.Home is also where the carers, and often any social services supportstaff involved, may readily be found. This contrasts with standardmedical rehabilitation, where often no such opportunity exists.Table 136.1 Principles of rehabilitation for the older person withpsychiatric disorderFocus on the homeEnsure comprehensive assessmentEncourage normal functionTreat the treatableAnalyse disabilities and chart progressClarify team goal with patient and carers earlyClarify team goal with support workers earlyTeach what can be relearntAdapt the adaptableCoordinate support and follow-upPromote flexibility and ingenuityPromote realistic optimismPrinciples and Practice of Geriatric Psychiatry, 2nd edn. Edited by J. R. M. Copeland, M. T. Abou-Saleh and D. G. Blazer&2002 John Wiley & Sons, Ltd