Deconditioning and Its Prevention

Deconditioning (functional decline) is the loss of the ability to perform basic activities of daily living, attributed primarily to the effects of immobilisation by forced bed rest, immobilising devices (catheters, drips), restraint use, and lack of encouragement of independence in self-care.

Immobility is defined as restriction of time spent out of bed or chair by medical orders, restrictive devices, chemical restraints (antipsychotics), lack of mobility aids, or lack of human assistance and encouragement.

Functional decline occurs in one-third to one-half of hospitalised older patients; as many as one-third of older inpatients are restricted to bed or chair rest during admission.

A systematic review of 30 studies found that between 15% and 76% of hospitalised elders show diminished performance in at least one ADL at discharge; of these, only half recover function by three months, and for many the loss of independent living is permanent.

Functional decline is regarded as a profound marker of morbidity and mortality. Just ten days of bed rest in healthy older adults produces measurable functional impairment (Kortebein).

Medical: musculoskeletal (arthritis, osteoporosis, hip and femoral fracture, foot problems), neurological (stroke, Parkinson's disease, neuropathy, normal-pressure hydrocephalus, dementia), cardiovascular (severe heart failure, angina, claudication), severe COPD, acute and chronic pain, malnutrition, and severe systemic illness.

Sensory: impaired vision, reduced kinaesthetic sense, reduced peripheral sensation.

Iatrogenic and environmental: forced immobility in hospitals and nursing homes, inadequate mobility aids, cluttered or uneven surroundings, poorly designed chairs and beds, stairs.

Psychological: depression, apathy, lack of motivation, fear of falling, and the health belief that rest is beneficial to recovery.

Drugs: sedatives and hypnotics (drowsiness, dizziness, ataxia, delirium), typical antipsychotics (rigidity), and antihypertensives causing orthostatic hypotension or bradycardia.

Caregiver-driven dependency: well-meaning staff and families who bathe, dress and wheel patients who could do these things themselves — "the hospital breeds dependency".

Skin: pressure ulcers (risk multiplied by immobility plus low serum albumin). Musculoskeletal: muscle atrophy and loss of strength and endurance, reduced fibre size and capillarity, contractures, disuse osteoporosis with increased bone resorption and reduced formation, degenerative joint disease, hypercalcaemia.

Cardiovascular: deconditioning, reduced plasma volume, orthostatic hypotension, deep vein thrombosis and pulmonary embolism. Respiratory: reduced tidal volume, atelectasis, aspiration pneumonia.

Gastrointestinal and genitourinary: anorexia, constipation, faecal impaction and incontinence, urinary retention, urinary infection, bladder calculi, functional incontinence.

Metabolic: negative nitrogen and calcium balance, impaired glucose tolerance, altered body composition and altered drug pharmacokinetics. Psychological: sensory deprivation, delirium, depression and anxiety.

Reduced bone mass from decreased weight-bearing increases the likelihood that a fall will cause serious injury; balance and coordination problems increase fall incidence itself.

Risk factors for functional decline in hospitalised elders (Kane): age 75 and above, cognitive impairment (missing more than 15 of the first 21 MMSE items), dependence in two or more IADLs before admission, presence of a pressure sore, baseline functional dependency, and a history of low social activity.

Prevention begins with the bed rest order: careful consideration is warranted before prescribing bed rest, and mobility should be assessed for the ability to move in bed, transfer and ambulate safely, including the need for assistance and assistive devices.

Promote mobility actively: nursing staff should encourage and assist position change in bed, transfer to a chair and ambulation; organised group walks on the ward at set times provide diversion and involve the patient in recovery; bed and toilet seat height should be matched to the patient's lower leg height to allow safe transfers.

Refer to physiotherapy and occupational therapy for problems; rehabilitation therapists may supply transfer aids — trapeze, transfer pole or bar, or a raised one-quarter or half-length siderail attached near the top of the bed as a bed-mobility device.

Avoid physical restraints and restrictive full-length siderails: research demonstrates restrictive devices can be safely eliminated and are associated with strangulation, asphyxiation and the full spectrum of immobility complications. Avoid unnecessary catheters and infusion lines that tether the patient.

Facilitate observation instead of restraint: nurse high-risk patients near the nursing station, encourage time out of the room, encourage family visits at mealtimes and at night, provide communal dining, and use volunteers or paid companions where family cannot stay.

Multicomponent programmes: the Hospital Elder Life Program (HELP) prevents cognitive and functional decline in hospitalised elders; acute geriatric units staffed by an interdisciplinary team using multidimensional functional evaluation improve outcomes; environmental modification (primary colours, lower windows, better furniture and room design) helps older patients retain function.

Assessment of the immobile patient should cover the perceived cause of immobility, medical conditions and treatments, pain, mood, fear and motivation, nutritional status including protein and 25-hydroxy vitamin D, and both the physical and social environment including caregiving interactions.