Older Patients, Wiser Care
The Patient Claimed He Was Getting Worse In Rehab. Could He Be Right?
Last updated:January 08, 2010
The case: "If I don't get out of there, I'm going to die."
Those were Mr. Z's actual words. He's not a drama queen, so I took him seriously. He was talking about the convalescent home where he'd been staying since being discharged from a hospital three weeks earlier for diverticulitis (a common inflammation of the colon, which can cause bad belly pain). At age 85, he'd otherwise been doing fairly well. Despite pretty bad congestive heart failure, he'd been proud of his ability to get out of bed on his own and take his four-wheeled walker for a jaunt through the mall.
But a week in the hospital left him feeling weak, so the hospital doctor had offered Mr. Z. a choice: He could return home and have a physical therapist visit him there -- or he could go to skilled nursing facility for "short-term rehabilitation."
Mr. Z. opted for the skilled nursing facility. He figured that he'd get more physical therapy there and would be able to build up his strength faster.
Somehow, though, things hadn't gone well. Instead of getting better, he'd gotten worse. He wasn't sure he was getting the right medications. He couldn't get the attention of a nurse when he needed it. He couldn't sleep, because his roommate had the TV on all night. And the physical therapist, he said, was "terrible."
After a few weeks, Mr. Z. felt scared. He asked to go home, but the facility staff told him he wasn't strong enough. He started to worry that he was going to die there.
The challenge: When someone's getting worse instead of better
Rehabilitation, or "rehab," is the process of gaining back one's strength and abilities. Older people often need rehab after the ordeal of a hospital stay, and Medicare will usually pay for it. It's possible to get rehab at home, through a home health service. But many people opt for an inpatient rehab facility (often located within a skilled nursing facility, typically a nursing home), which can provide more intensive physical therapy and more medical monitoring overall.
Unfortunately, although many wonderful rehab facilities exist, others end up feeling like a clichéd "terrible nursing home experience." This isn't surprising, given that rehab often takes place in nursing homes, where quality can range from excellent to spotty.
Mr. Z. didn't know what to do. It didn't help that like many older people, he had no family in the area to visit him and help monitor his care. (Mr. Z. had been paying to live in a board-and-care home for the past several years.) And no one had told me, his primary-care physician (PCP), either that he'd been hospitalized or that he'd continued on to rehab. Most hospitals aren't good at communicating with PCPs; Mr. Z. hadn't thought to tell me himself.
The solution: Sometimes, it's the comfort of home
Fortunately, Mr. Z. insisted that the rehab facility arrange transportation to his regularly scheduled follow-up visit with me. He looked terrible: pale, thin, and unhappy.
We got him out of the rehab facility that very day. Although Mr. Z. was much weaker than his usual self, he was still able to get around with his walker. The manager of his board-and-care, bless her heart, was willing to take him back. We arranged for a nurse, physical therapist, and occupational therapist to start seeing Mr. Z at home.
"But they say I'm not well enough to go home," Mr. Z. said, worriedly.
Well, that's what staff at facilities say sometimes. It's understandable that they'd be concerned about a frail older person who's getting worse instead of better. But often there are more options for high-quality rehab care at home than people realize, such as the variety of professionals we enlisted to come and visit Mr. Z. And sometimes it's the comfort of home that provides an added measure of strength to boost a recovery.
Why? Nobody really knows for sure. But have you ever had the experience of feeling better physically when you're also feeling good mentally and emotionally? Most of us do. Perhaps the varied stresses of a new environment were just too much for Mr. Z. Or perhaps his particular facility or physical therapy program truly were lousy.
In the end, I didn't spend too much time trying to figure out why inpatient rehab wasn't working for Mr. Z. It works for many. But in this case, he wasn't improving "“ even though he wasn't so sick that he absolutely couldn't leave. It made good sense to give the comfort of home a try.
Mr. Z came back to see me a week later. And I was relieved to see that indeed, he was finally starting to look, and feel, better.
My prescription for caregivers:
Know that inpatient rehab doesn't always work better than home rehab. It can be a very individual thing.
If you or your loved one feels like things are getting worse instead of better in a rehab facility, trust that intuition. Get help. A second opinion from a doctor outside the facility can be a good start, especially if it's a doctor who already knows you or your loved one.
Be persistent about asking what kinds of help would be needed to make home rehab successful (such as visits from a physical therapist, a nurse, and so on).
Make sure you keep the primary care doctor in the loop about changes in treatment, progress, and medications.
Don't expect the hospital to take care of this important step.
Has inpatient rehab worked in your experience? Or have you found that you or loved one did better once you got home?
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