Instituting Cognitive Rehabilitation in Post-Acute Care
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Instituting Cognitive Rehabilitation in Post-Acute Care
Hospital length of stay is dramatically shorter today than in the past. As a result, many older adults require post-acute care in order to regain lost functioning brought on by acute illnesses. While the emphasis in post-acute care is primarily physical rehabilitation, over two-thirds of older adults admitted to these facilities have at least one delirium symptom.1 Recent evidence supports the strong relationship between the resolution of delirium and functional recovery following hospitalization.2 Little clinical attention, however, has been given to older adults’ need for cognitive rehabilitation following hospitalization.
This article reviews the problem of delirium in post-acute care and its impact on functional recovery following hospitalization. We describe a cognitive rehabilitation program that has been successfully implemented in a skilled nursing setting as part of a total program to prevent and/or treat post-hospital delirium. In long-term care facilities, the program requires collaboration between the medical director, nursing staff, and recreational therapist to maximize functional recovery, and potentially reduce the cost of care for older adults who have suffered an acute illness. We list strategies for achieving program effectiveness through interdisciplinary collaboration.
Delirium in Post-Acute Care
According to the Diagnostic and Statistical Manual of Mental Disorders (4th edition), delirium is a common, though frequently unrecognized and untreated, neuropsychiatric syndrome in older adults that is characterized by a sudden decline in attention and cognition.3 Delirium frequently accompanies acute medical conditions and carries a high rate of morbidity and mortality; among hospitalized older adults, mortality can be as high as 76%.4 In a recent review of the state of the science on delirium, Inouye5 notes that delirium typically involves complex interrelationships between a vulnerable patient and exposure to noxious stimuli. The presence of dementia, depression, dehydration, immobility, sensory impairment, multiple comorbidities, and certain classes of drugs are risk factors for delirium.
Recent evidence suggests that the relationship between delirium and dementia is much more important than previously thought. While delirium itself does not seem to cause dementia, its occurrence in hospitalized older adults may herald the onset of dementia. Most cases of delirium occur in persons with dementia,5-7 and 89% of hospitalized persons with dementia will experience delirium.8,9 The two conditions have overlapping clinical, metabolic, and cellular mechanisms, suggesting that delirium and dementia may represent points along a continuum.5 Delirium persists much longer in the post-hospital period than previously recognized, and may reflect underlying brain vulnerability in older adults with very-early-stage dementia.5
Because hospital length of stay is now considerably shorter than in the past, studies indicate that between 16% to 23% of older adults may be discharged with delirium,1,10 shifting the care and cost of care for these individuals to post-acute care facilities. Older adults who are admitted to post-acute care with delirium experience more complications, re-hospitalizations, and death compared to those without delirium.11 Additionally, older adults whose delirium resolves more slowly, or never at all, regain no more than 50% of their pre-hospital functioning, while those whose delirium resolves within two weeks of admission to post-acute care recover all of their pre-hospital functioning.2
Cost of care is disproportionately higher in older adults with delirium. In a retrospective study of 76,688 community-living older adults, the majority of the initial delirium claims occurred in acute-care stay or emergency room visits.
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