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