Information package: Older adults as clients of Kela rehabilitation
One of Kela’s responsibilities is to provide access to rehabilitation and to offer financial assistance during it. This text looks at the participation of persons 65 or over in Kela rehabilitation.
Kela has a statutory obligation to offer access to vocational rehabilitation, intensive medical rehabilitation and rehabilitative psychotherapy. In addition, Kela can offer access to, and provide compensation for, rehabilitation on a discretionary basis within a budget allocated yearly by Parliament. Rehabilitation services offered on a discretionary basis are usually not subject to any age limits.
For persons aged 65 and over, rehabilitation is most commonly arranged in the public sector by social welfare and healthcare organisations.
Rehabilitation for those aged 65 and over is typically provided on a discretionary basis
The rehabilitation that persons aged 65 and over can get through Kela is mainly of the kind offered on a discretionary basis. In 2021, discretionary rehabilitation services were provided to 6,527 persons aged 65 or over. This was equal to 0.5% of the population of the same age. One fourth (24%) of the recipients of discretionary rehabilitation services were aged 65 or over.
In that age group, rehabilitation courses were the most common type of rehabilitation, being attended by 67% of all recipients. Seventeen percent participated in adaptation training courses, and another 17% received multidisciplinary individual rehabilitation services.
The average age of rehabilitation clients at the end of the year was 75 years. The majority (60%) were women. However, men were more likely to receive rehabilitation on account heart and cerebrovascular diseases.
The number of rehabilitation clients increased in the 2010s
The number of recipients of Kela rehabilitation aged 65 or over increased in the 2010s across all types of rehabilitation.
The number of clients undergoing multidisciplinary individual rehabilitation increased more than five-fold. The number of persons enrolled in rehabilitation and adaptation training courses nearly tripled. The biggest increase in absolute terms was seen in the number of persons enrolled in rehabilitation courses.
The increase in the number of older rehabilitation clients may be attributable to the fact that the age group has grown. The increase in the number of rehabilitation course enrollees could also be explained by a number of other reasons, such as greater diversity of course options.
Rehabilitation courses for persons over 65 with multiple illnesses were organised in the 2000s as a development project. They formed a basis for so-called IKKU courses for older persons with multiple illnesses. In 2013, more courses were organised for family caregivers, including ones that could be attended both by the caregiver and the person they are caring for. In addition, courses for persons aged 68 and over with specific diagnoses were arranged in the 2010s. Kela has carried out research and development on rehabilitation for older adults since the beginning the century.
In 2015‒2017, the Finnish Parliament released less funding than in previous years for discretionary rehabilitation services, which led to a decrease in the number of rehabilitation clients. The beginning of the COVID-19 pandemic in 2020 also reduced the number of clients. There have been estimates that most of the unmet demand for rehabilitation due to COVID-19 had to do with discretionary rehabilitation services. Such services were typically provided at the service providers’ premises and not as telerehabilitation, for instance.
Musculoskeletal diseases are the biggest cause of rehabilitation need among older adults
Among persons aged 65 and over, musculoskeletal diseases were in 2021 the most common reason for seeking access to Kela rehabilitation. Thirty percent of clients received discretionary rehabilitation services on account of musculoskeletal diseases. The second and third biggest diagnostic categories were circulatory diseases (23%) and diseases of the nervous system (18%). For example, 537 persons aged 65 or over received rehabilitation on account of movement disorders, 483 persons on account of cerebrovascular diseases, and 408 on account of heart disease.
Among all recipients of Kela rehabilitation, mental and behavioural disorders are the most common reason for seeking rehabilitation. In the 65 and over age group, discretionary rehabilitation services on account of mental and behavioural disorders were provided to 248 persons (4%).
Among those aged 65 or over, musculoskeletal diseases were the most common reason for attending a rehabilitation course (35% of attendees), followed by diseases of the circulatory system (30%) and diseases of the nervous system (11%). This was the same distribution as for all rehabilitation services. As for adaptation training courses, diseases of the nervous system were the most common reason for participation (38% of participants).
Kela also provides access to rehabilitation for such groups as family caregivers and older persons with multiple illnesses. In 2021, rehabilitation courses for family caregivers of an adult family member or other loved one were attended by 952 persons aged 65 or over, while IKKU rehabilitation courses for older adults with multiple illnesses were attended by 1,538 persons.
Major differences between wellbeing services counties in rehabilitation participation rates
An analysis of wellbeing services counties in 2021 revealed several differences in the rehabilitation client population aged 65 or over.
The highest participation rates in discretionary rehabilitation were seen in the Keski-Pohjanmaa, Pohjois-Savo, Kainuu, Etelä-Savo and Satakunta wellbeing services counties (more than 9 persons per 1,000 inhabitants aged 65 or over). The lowest participation rates were observed in the Åland Islands and in the Itä-Uusimaa wellbeing services county (less than 2 persons per 1,000 inhabitants aged 65 or over).
The average age of the clients at year-end was highest in the Keski-Pohjanmaa (77.0 years), Etelä-Savo (76.6 years) and Etelä-Karjala (76.5 years) wellbeing services counties. Women were more likely than men to participate in rehabilitation throughout the country.
In nearly all regions, musculoskeletal diseases were the most common reason for seeking rehabilitation. However, in the Etelä-Karjala and Pohjois-Savo wellbeing services counties, circulatory diseases were the most common reason, while in the Päijät-Häme wellbeing services county, diseases of the nervous system were the principal reason. In the Etelä-Savo wellbeing services, musculoskeletal diseases and diseases of the nervous system were equally common as reasons for receiving rehabilitation services.
Rehabilitation courses for older adults with multiple illnesses can help participants have a positive attitude towards their situation
Kela provides access to so-called IKKU rehabilitation courses for older adults with multiple illnesses. They are aimed at persons aged 68 and over with several diagnosed conditions.
A total of 1,538 persons attended IKKU courses in 2021. Their average age at the end of the year was 79.6 years. Most participants (67%) were women.
Compared to the general population, women were overrepresented among those who applied to IKKU courses in 2018, and their average age was higher. Women were twice more likely than men to apply for rehabilitation. The application rate was highest among those aged 75 to 89 years. Compared to the overall population aged 65 and over, there were more surviving spouses and fewer married individuals. It appears that IKKU courses are more commonly attended by persons who live alone. Also, persons in the middle income quartiles were overrepresented among the applicants.
Applications to IKKU courses also showed regional differences. The highest application rates in 2018 were seen in the Itä-Savo and Kainuu hospital districts (with more than 4 applicants per 1,000 inhabitants aged 65 and over), while the lowest rates were found in the Kanta-Häme and Etelä-Karjala hospital districts (fewer than 0.5 applicants per 1,000 inhabitants aged 65 and over).
According to a study looking at the implementation and performance of IKKU courses, various musculoskeletal diseases, along with heart and circulatory diseases, were the most common diagnoses among the participants.
Participants who took an active approach to their situation and had a productive relationship with their care provider were more likely to take the initiative to apply to a rehabilitation course. Among the perceived benefits of the courses were that they helped the participants become more active and engaged at home and in other environments and adopt a more positive attitude to their situation and their future prospects.
Rehabilitation courses for informal caregivers can support the participants’ mental wellbeing
Kela provides access to rehabilitation courses for informal caregivers. There are courses for couples and ones that informal caregivers can attend by themselves.
Participants are usually women and tend to be older themselves. In 2021, 89% of participants (952 persons) attending rehabilitation courses aimed at those caring for an adult family member or loved one were aged 65 or over. In the over-65 age group, the majority of participants (70%) were women.
Several studies have looked at the benefits of rehabilitation courses for informal caregivers.
A 2019 evaluation of the benefits of Kela rehabilitation found that rehabilitation courses for individuals and couples improved the informal caregivers’ quality of life and their level of satisfaction with their own health. In addition, informal caregivers experienced fewer symptoms of depression.
According to a study examining the implementation of rehabilitation courses, informal caregivers saw the courses as a welcome break in their demanding everyday lives. They offered the participants a chance for rest and relaxation and strengthened their mental resources. For example, the courses reinforced the participants’ role as caregivers, gave them more confidence to step away from that role for a time, and encouraged them to look after themselves.
Participants wished that they had had a chance to attend the rehabilitation earlier.
A Kela development project trialled an online programme (OMApolku) based on acceptance and commitment therapy for informal caregivers aged 60 and over . Informal caregivers had fewer depressive symptoms, their quality of life had improved, and their resilience (their ability to process difficult thoughts and feelings) had increased since participating in the online programme. They hoped that the online programme would be complemented by face-to-face meetings at the beginning or between individual stages of the programme. Since 2021, online rehabilitation has been a part of the rehabilitation courses for informal caregivers at which the clients are not accompanied by the person they are caring for.
The Carers of Older People in Europe (COPE) index is a tool for assessing the strain and need of support experienced by informal caregivers. It consists of 15 questions focusing on informal caregivers’ experiences. The questions can be used to support the discussions that professionals and informal caregivers have about the care relationship. The questionnaire also lends itself for use as a screening method when carrying out an assessment of the strain and need of support experienced by informal caregivers. The COPE Index questionnaire and instructions for use may be downloaded from the TOIMIA database.
Rehabilitation courses for stroke survivors can help them adjust to the changes brought by their illness
Kela provides four separate rehabilitation courses for adults who have had a cerebrovascular accident, or stroke: a rehabilitation course for persons having suffered a stroke, a communication course, a gait training course and a course focusing on arm and hand movement.
Sixty-six percent (315 persons) of those who participated in discretionary rehabilitation courses with a cerebrovascular focus in 2021 were aged 65 or over, and more than a half (58%) were men.
According to a study looking at the implementation of rehabilitation courses, courses were likely to be useful for participants who had had adequate and uninterrupted access to healthcare or other types of rehabilitation before attending a Kela rehabilitation course. The professionals concluded that for some of those who attended a Kela rehabilitation course, the time between the onset of their illness and the start of the rehabilitation had been too long.
The participants and their family members said that the courses helped the participants adjust to the changes imposed by their illness, including its symptoms and concomitant functional impairment. A greater focus on the conclusion of the course and a decision to arrange a follow-up period would help to carry over the benefits of the rehabilitation to the clients’ daily lives.
At-home training supports older people’s mobility
A randomised comparative study looked at the impact of physical exercise at home and at the day centre on the rehabilitation of persons with memory disorders . At-home rehabilitation slowed down the deterioration of the participants’ functional status and improved their executive functions. Additionally, those who participated in at-home rehabilitation suffered fewer falls and their risk of death decreased. Group rehabilitation was not found to have any effect on the participants’ functioning but it did reduce the number of falls they had. No effects were observed in the informal caregivers’ wellbeing and quality of life.
Informal caregiver spouses found that the physical exercise had a positive impact on their memory-impaired spouses’ mobility, mood, activity levels and memory functions. The participants showed commitment to both forms of rehabilitation, to at-home rehabilitation more so than to group rehabilitation.
The KaukoIkä research project looked at the effects of at-home physical exercise on the rehabilitation of persons with a hip fracture or living with frailty.
According to a randomised comparative study, at-home exercise reduced the prevalence of frailty among persons with a hip fracture. Among frail persons, at-home exercise reduced their anxiety over the risk of falling and their depressive symptoms. Exercise was not found to have any effect on other measured variables, such as the number of falls, nutritional status or social support, or the burden or need of support experienced by their family members.
According to a study that focused on the practice of physical exercise at home, persons with a hip fracture or living with frailty were more successful than average in reaching the goals set for the rehabilitation. Persons with a hip fracture reported that at-home exercise had improved their mobility and reduced their use of assistive devices or allowed them to use more conservative ones. Further, they managed their daily activities, such as household chores, more effectively.
Frail individuals reported that the exercise had increased their muscle power and improved their balance and mobility. Additionally, they used assistive devices less, managed their daily activities more effectively, and their mobility improved thanks to the exercise.
Both groups felt that the home visits made by physiotherapists and the social aspects of the training had a positive impact for example on their mood. Many participants wished to see the guided training continue.
