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• Filed under: Features, Article, Clinical

• Keywords: geriatrics, patient interventions, transitions, quality of life, prevention

Make a Move

From: The Hospitalist, March 2008

by Jill Landis, MD

As elderly patients suffering functional decline and immobility face prolonged hospital stays, placement in nursing homes, and increased risk of mortality, hospitalists must focus on one mission: Keep them moving.#1

With today’s emphasis on cost containment and quality assurance, keeping patients moving is one small step toward improving the quality of a patient’s hospitalization.

At the core of elders’ quality of life is independent mobility. When mobility is lost, a patient’s ability to socialize with peers and family, perform activities of daily living (ADLs), and participate in decisions regarding their well-being is severely compromised.

Most hospital admissions begin with the assignment of a patient to a bed. Although acute illness, medications, and a new environment all take their toll on patient functionality, simply putting a patient in recline has a significant impact.

If a young healthy person is ordered to rest for more than 72 hours, muscle mass and strength decrease, gait speed slows, and coordination becomes impaired.#2 If that patient is put to bed for more than 72 hours, organs other than the musculoskeletal system become compromised. Cardiovascular deconditioning with resting tachycardia and orthostatic hypotension, glucose intolerance, venous thromboembolism, hypercalcemia and osteoporosis, constipation and fecal impaction, pressure ulcers, and even depression can occur.3# Imagine then how elderly patients would fare.

Unfortunately, the independence of elderly patients is continually undermined by the same environment that offers treatment and care—the inpatient ward. And staff and patient family members are at fault.#4

Establish a Baseline

Teaching patients to move autonomously requires extra nursing time. Most on the nursing staff find it easier to provide a bedpan rather than assist a patient to the bathroom. When assisted ambulation is offered, patients may resist.

Families may hinder the resumption of mobility by performing tasks for patients instead of encouraging them to do them themselves. Further, changes in mobility are difficult to quantify and communicate due to limited mobility terminology in nursing practice and limited physician time. When a pre-admission functional status is not clearly documented, hospital staff often assumes that the patient’s compromised state is little changed from its baseline.

With so many barriers to patient mobility, obtaining an accurate assessment of a patient’s functional status two weeks prior to admission is key in establishing a plan for helping elderly patients regain mobility.

Ideally, one should speak to the patient as well as someone closely involved with the patient’s care who can verify or clarify the patient’s description of his or her prior activities. Significant information to obtain includes which ADLs the patient can independently perform, how far the patient can ambulate and with what assistive devices, and whether glasses, hearing aids, specially fitted shoes and orthotics, and knee braces are normally required for ambulation.#5

Though no screening tool has been validated as an absolute predictor of inpatient functional decline, lower functional status before admission, cognitive impairment, depression, advanced age, and prolonged length of hospital stay have been associated with loss of independence. Their presence may warrant a more aggressive regimen for regaining mobility.

Set the Stage

Before calling in a transfer to inpatient rehab, there are several steps one can take to maximize the return of function. By optimizing a patient’s functional capabilities during the admission, you enable them to integrate necessary skills into a daily routine—something they’re unlikely to learn at a rehabilitation center. Take these steps:6

• Control pain. Adequate analgesia is imperative for regaining mobility. Opiates and opiate agonists may be necessary for optimal control. Constipation should be expected and treated, and patients should be closely monitored for orthostasis, confusion, and urinary retention;
• Get the patient to a chair with assistive devices nearby. This includes canes, braces, walkers, orthopedic shoes, glasses, and hearing aids;
• Minimize IVs, catheters, and drains. Those that cannot be removed can be taped to minimize their interference with ambulation. Regular clothes, particularly jogging suits, promote ambulation and comfort;
• Coordinate with nursing department so the patient has periods of activity and rest. A walk down the corridor should be followed by a commensurate period of minimal activity, not a two-hour nap;
• Encourage sleep hygiene. Daytime activities can be maximized only when preceded by a restful night’s sleep. Limiting caffeinated beverages, restricting television time, and encouraging relaxing evening activities like reading may be necessary to ensure adequate sleep. Well-rested patients are better equipped to challenge themselves physically during the day and are less at risk for the side effects associated with sleeping medications;
• Give early referral to physical and occupational therapies. Even if the patient can barely tolerate sitting in a chair, a passive range of motion exercises for all joints should be undertaken daily. Additionally, active resistance exercises may be feasible for even debilitated patients if they receive daily assistance and continual encouragement. With persistence, skeletal muscles and the cardiovascular and pulmonary systems will show more endurance.#

Follow Progress

Accurately following a patient’s progress in regaining mobility requires the use of an assessment tool. The Elderly Mobility Scale (EMS) is useful for assessing improvements in mobility of elderly patients receiving physical therapy.

Balance, range of motion, and ambulation are scored initially, and the scores are updated during daily physical therapy. A review of this assessment tool was published in the Journal of Ageing this year, with the authors concluding that the EMS is a valid, reliable scale that can be readily applied during daily clinical work.7# Further, a review in Clinical Rehabilitation found the EMS to be a reliable test of motor function in elderly patients with a range of functional levels.#8 This assessment falls short in its lack of predictive validity in terms of falls or discharge destination.

Elderly patients suffer more hospital-associated falls than those younger than 65. According to a 2000 article from the British Medical Journal, patients older than 65 were seven times as likely to experience a preventable fall while in the hospital compared with younger age groups.#9

Patient factors that contribute to falls include age-related changes in postural control, impaired gait, decreased visual acuity, medications, the presence of acute and chronic diseases that affect sensory input, the central nervous system, and coordination. Osteoporosis is also an important factor—pathologic fractures often precede a fall. Environmental factors include poor lighting, obtrusive furniture, slippery floors, loose floor coverings, and bathrooms without handrails or grab bars.

The items most commonly included in fall risk-assessment tools include:10

• Comorbid patient characteristics or conditions associated with falling, such as cognitive impairment;
• History of a fall;
• Mobility impairment;
• Incontinence;
• Medications affecting balance/cognition and polypharmacy;
• Sensory deficits; and
• Advanced age.

The presence of more than three of these items identifies a patient at high risk for falling. But calculating a fall assessment includes not only identifying relevant risk factors, but also performing a focused physical exam. In ambulatory patients, the timed “get up and go” test is a useful predictor of falls. The patient is observed as she rises from a chair, walks 10 feet, then returns to the chair. If the patient requires more than 16 seconds to complete the task, he or she is at greater risk for a fall.

Early Intervention

While management depends on the underlying etiology of the fall, some generally acceptable practices are effective:

• Maintain a safe physical environment. Making sure spills are cleaned up quickly and walkways are kept free of obstruction is as important as maintaining adequate lighting in all areas where older adults will walk;
• Avoid use of restraints. Though restraints are often employed to prevent falls, they have not proved effective in medical trials. It has been demonstrated that their use increases the injury associated with falls, and several restraint-reduction projects have demonstrated that restraints can be removed without a significant increase in falls or injuries;
• Deal with medication side effects. The side effects of CNS altering drugs, and drugs affecting postural blood pressure, balance, and gait should be expected and addressed. Polypharmacy should be minimized;
• Watch patients closely. High risk patients should be positioned by the nursing station so that their visibility to the staff is maximized; and
• Promote mobility. There has been considerable research demonstrating the positive effect of exercise on reducing fall risk among community-residing older adults. While no study to date has addressed the impact of exercise in the hospital-based community, improved balance, mobility, and flexibility have been documented in nursing home residents receiving aggressive physical therapy. TH

Dr. Landis is a frequent contributor to The Hospitalist.

References

1. Hoogerduijn JG, Schuurmans MJ, Duijnstee MS, et al. A systematic review of predictors and screening instruments to identify older hospitalized patients at risk for functional decline. J Clin Nurs. 2007 Jan;16(1):46-57.
2. Callen BL, Mahoney JE, Wells TJ, et al. Admission and discharge mobility of frail hospitalized older adults. MedSurg Nursing 2004:13(3):156-163. 
3. Resnick NM, Marcantonio ER. How should clinical care of the aged differ? Lancet 2002; 350:1157-1167.
4. Watters JM, McClaran JC, Man-Son-Hing M. The elderly surgical patient. ACS surgery: principles and practice. Medscape 2005.
5. Miller KE, Zylstra RG, Standridge JB. The geriatric patient: a systematic approach to maintaining health. Am Fam Physician. 2000;61(4):1080-1098.
6. Rydwik E, Frändin K, Akner G. Effects of physical training on physical performance in institutionalized elderly patients with multiple diagnoses. Age Ageing. 2004 Jan;33(1):13-23.
7. Kuys SS , Brauer SG. Validation and reliability of the Modified Elderly Mobility Scale. Australas J Ageing 2006; 25(3):140-144.
8. Spilg EG, Martin BJ, Mitchell SL, et al. A comparison of mobility assessments in a geriatric day hospital. Clin Rehabil. 2001 Jun;15(3):296-300.
9. Thomas EJ, Brennan TA. Incidence and types of preventable adverse events in elderly patients: population based review of medical records. BMJ 2000;320(7237):741-744
10. Gray-Miceli DL, Capezuti E. A nursing guide to the prevention and management of falls in geriatric patients in long-term care settings. Medscape; May 19, 2005.