- 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.#
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;
- 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.