gms | German Medical Science

The Federal Ministry of Health estimates that in 2011 about 1.2 million people are suffering from dementia in Germany. If there is no breakthrough in prevention and therapy, it is assumed that the number of people with dementia will increase to 2.6 million people until 2050. The overall health condition of old people is often affected by the simultaneous occurrence of several diseases and their consequences, age-related changes as well as health-related living conditions and habits. Thus, the treatment and rehabilitation measures have to be individually tailored and combined to the situation of old and needy people.

According to Article 40 of Volume V of the German Social Insurance Code geriatric rehabilitation is an obligatory benefit offered by the statutory health insurance. Nevertheless, patients with dementia in in- and outpatient medical care are often seen as so severely physically and cognitively impaired that they do not receive specific (follow-up)rehabilitation treatments.

According to the International Statistical Classification of Diseases and Related Health Problems (ICD-10) dementia is diagnosed when a decline in memory and intellectual capacity can be proved and activities of daily living (e. g. dressing, eating, personal hygiene) are considerably impaired. Moreover, the areas of orientation, perception, calculating, learning, talking and the ability to judge can also be affected. Corresponding to the ICD criterion dementia is predominant, when the above mentioned impairments appear for at least six months. The severity of dementia is graded in the mini-mental-state-examination (MMSE) or with the mini-mental-state-test (MMST) in low, medium and severe.

Therapies for primary, irreversible forms of dementia aim at an attenuation of the disease as well as an improved quality of life for the patients. They differ in three areas: medication, psychosocial intervention and social intervention.

Geriatric rehabilitation deals specifically with the rehabilitation of aging people. A geriatric patient is a person of old age (mainly 70 years and older) and has at least two diseases which require treatment (above all geriatrics-typical multimorbidity). Rehabilitation starts with an acute event and its objective is to restore, protect or improve the patients’ health. Geriatric rehabilitation is in inpatient and outpatient care. A special form of the outpatient rehabilitation is the mobile rehabilitation. The planning and implementation of the therapy are based on a geriatric assessment. Currently there are only few studies available which deal with the implementation of geriatric rehabilitation among patients with the secondary diagnosis dementia. However, it is well-known that the principle “rehabilitation has precedence over nursing care” has not yet been sufficiently implemented.

• What is the patient-relevant benefit of multimodal and multi-professional rehabilitation programmes for geriatric patients with the secondary diagnosis dementia?
• What is the patient-relevant benefit of unimodal treatments (physio-, ergotherapy, logopaedics) for geriatric patients with the secondary diagnosis dementia?

How cost-effective are these programmes?

Which ethical, socioeconomic and legal regulations have to be considered when implementing such rehabilitation programmes for geriatric patients in Germany?

On the basis of keywords a systematic literature research is done in 31 databases (among others EMBASE, MEDLINE, Cochrane) for the period 2006 until 2011. The important inclusion criteria are geriatric rehabilitation, primary diagnoses stroke and fractures close to hip joints and the secondary diagnosis dementia. 2.074 abstracts are identified. In compliance with the Oxford Level of Evidence two reviewers selected 65 studies. After a thorough examination of the study designs, especially if they deal with dementia as secondary diagnosis, 16 studies are included in the HTA.

13 studies meet the medical criteria for inclusion. The studies are very heterogeneous (number of cases, sampling, intervention, method of measurement, level of evidence). Five studies are from Germany and four studies from the USA. Three studies have a very high or high level of evidence (1A, 1B, 2C), two studies have a medium level of evidence (3A, 3B) and eight studies a low level (4).

Four studies with medium to low evidence examine the primary diagnosis stroke. Two of these studies show positive effects of rehabilitation treatment among dement patients, two studies have inconsistent results.

Four studies comprise the primary diagnosis hip or femoral neck fracture. The study with a very high level of evidence as well as the two studies with very low evidence show that an intense fitness programme is effective among dement patients. The fourth study proves the effectiveness of interdisciplinary early rehabilitation.

Five studies comprise geriatric primary diagnoses, four of them with rehabilitation results which show an improvement among geriatric patients with dementia. The level of evidence of these studies ranges from 2C to 4, successful interventions are physio-, ergotherapy as well as interdisciplinary treatment.

Small cognitive and communicative deficits among patients, the involvement of caring relatives, a good functional condition at the beginning of treatment, the living condition at home and discharge from hospital turn out to be positive for the treatment outcome. Depressions reduce the success of the treatment. The training of cognitive skills during the rehabilitation treatment improves the rehabilitation outcome.

Four studies (two from USA, one from Germany, one from Finland) meet the economic criteria for inclusion, three of them compare the costs of rehabilitation programmes with care measures. Two of the four studies are combined economic-medical studies. One study raises the question of a cost shift from acute clinics to rehabilitation clinics. On the basis of this small number of studies qualitative evaluations are possible. The costs in intervention groups and rehabilitation clinics are higher than in standard care and in-patient care facilities. The conclusions on treatment outcome are inconsistent. It is not possible to make a general statement about cost-effectiveness of multi- and unimodal rehabilitation programmes.

The current data relating to ethical, social and juridical questions, are very poor. One survey with high evidence points out that there is sufficient empirical evidence concerning the successful rehabilitation of dement and cognitively impaired patients and the majority of the authors do not advise against a rehabilitation of this patient group but demand intensified research efforts.

A MMSE score <25 is used in the studies as defining criterion for dementia and synonymously for cognitive impairment. Up to now these patients are often deprived of rehabilitation as the outcome seems to be doubtful. There is a controversial discussion in literature whether cognitive impairment is actually impeding the success of rehabilitation. Therefore, it is questionable to exclude patients with the secondary diagnosis dementia from rehabilitation. Although the studies are very inconsistent, the report concludes that patients who are cognitively slightly and moderate impaired definitely benefit from rehabilitation treatments. However, the progress comparing to cognitively unimpaired patients is possibly slower, the rates of improvement are lower, the baseline and the final level are lower. It is not possible to make statements for patients with severe cognitive impairment as they are often excluded from the studies.

In this context programmes are interesting which focus on the promotion of the cognitive performance. As a consequence patients can live a more independent life and they are particularly sustainable when caring relatives are included in the training programme.

Another aspect is to secure the success of the rehabilitation beyond the treatment period. It is advisable to prepare the patients already during the rehabilitation for the daily routine at home and create potential interim structures which allow the patients to consolidate their acquired skills for the daily life. A long-term approach is very effective with regard to cognitive training units.

The studies show a number of limitations which are the synonymous use of the terms dementia and cognitive impairment and the incomplete and often insufficient description of the rehabilitation measures. Furthermore, the use of different measuring methods makes it more difficult to compare the results, confounders are barely analyzed and subgroup-analyses are missing.

The studies poorly deal with ethical, social and juridical aspects. Therefore, the question arises if it is ethically justifiable to refuse patients with dementia or cognitive impairment as comorbidity the rehabilitation treatment of their primary disease, as it is the pronounced aim of geriatric rehabilitation to provide patients with more independence and quality of life.

The principle “rehabilitation has precedence over nursing care” should be consistently and comprehensively implemented among patients with the secondary diagnosis dementia, as rehabilitation treatments (ergo-, physiotherapy, strengthening of cognitive skill) are effective among patients with dementia. The rehabilitation of the primary disease should be adapted to the cognitive skills of the patients in order to achieve the optimum level of treatment outcome. The research of this topic should be improved.