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Key Features

  • Although common in older people, reduced mobility is never normal and is often treatable if its causes are identified

  • Bedrest is an important cause of hospital-induced functional decline

  • Among hospitalized medical patients over age 70, about 10% experience a decline in function, and those who experience critical illness are at particularly high risk

Clinical Findings

  • Deconditioning of the cardiovascular system occurs within days and involves

    • Fluid shifts

    • Decreased cardiac output

    • Decreased peak oxygen uptake

    • Increased resting heart rate

    • Postural hypotension

  • More striking changes occur in skeletal muscle, with loss of contractile velocity and strength

  • Pressure injuries (formerly pressure ulcers), deep venous thrombosis, and pulmonary embolism are additional serious risks

Diagnosis

  • Laboratory tests should be directed by the history and physical examination

  • For a simple geriatric functional screening instrument, see eFigure 4–1

eFigure 4–1.

Simple geriatric screen. PT, physical therapy; DIAPPERS, delirium, infection, atrophic urethritis or vaginitis, pharmaceuticals, psychological factors, excess urinary output, restricted mobility, stool impaction; PVR, postvoid residual; GDS, Geriatric Depression Screen; APS, Adult Protective Services; OT, occupational therapy; BMI, body mass index; MMSE, Mini-Mental State Exam. (Adapted, with permission, from Lachs M et al. A simple procedure for general screening for functional disability in elderly patients. Ann Intern Med. 1990 May 1;112(9): 699–706 and Moore AA et al. Screening for common problems in ambulatory elderly: clinical confirmation of a screening instrument. Am J Med. 1996 Apr;100(4):438–43.)

Treatment

  • Skin, particularly areas over pressure points, should be inspected at least daily

  • If the patient is unable to shift position, staff should do so every 2 hours

  • To minimize cardiovascular deconditioning, patients should be positioned as close to the upright position as possible, several times daily

  • To reduce the risks of contracture and weakness, range of motion and strengthening exercises should be started immediately and continued as long as the patient is in bed

  • Whenever possible, patients should assist with their own positioning, transferring, and self-care

  • For patients at high risk for venous thromboembolism, antithrombotic measures should be used

  • Avoiding restraints and discontinuing intravenous lines and urinary catheters increase opportunities for early mobility

  • Graduated ambulation should begin as soon as possible

  • Advice from a physical therapist is often helpful both before and after discharge

    • Prior to discharge, physical therapists can recommend appropriate exercises and assistive devices

    • After discharge, they can recommend safety modifications and maintenance exercises

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