Promoting Mobility in Hospitalized Elderly Patients
By Jaimie Lazare
Fall prevention measures often include keeping older adult patients in bed for most of their hospital stay. In-hospital mobility programs, however, provide a safe way to get elderly patients up and moving in order to stave off the negative effects of bed rest.
It's no secret that bed rest is a health hazard for older adults because it leads to functional decline resulting from decreased muscle strength and power.1 When patients get out of bed and walk, the movement helps to circumvent these effects and allows patients to maintain their prehospitalization mobility.2 Yet geriatric patients continue to spend most of the duration of their hospital stays in bed. To address the poor outcomes of bed rest among older adults, University of Alabama at Birmingham (UAB) Hospital-Highlands opened its Acute Care for Elders (ACE) in 2008.
Encouraging Patients to Get Moving
Falling is a major concern when caring for older adults. So elderly patients usually remain in bed for most of their hospital stay; however, bed rest while in the hospital leads to sequelae such as delirium and muscle mass loss. Research shows that when elderly patients are discharged, they tend to fall because they've become deconditioned during their hospital stay, Brown says. "One of the things that we're doing at UAB is that the nurses are, on admission, looking at activities of daily living before people came into the hospital," Brown says. If they're seeing a discrepancy, the nurses inform the physicians because the patient may be someone for whom physical therapy is needed sooner rather than later. "For every day we let patients lie in bed, they're losing muscle mass and the ability to get back up on their feet," she says.
As health care providers, it's important to encourage people to try to get back up to their previous levels of mobility because what we see, unfortunately, is that as many as one-third of older adults experience a decrease in their function when they come into the hospital, and they don't all recover, Brown says. "So if we can get them up and moving, we may be able to reduce the number of older adults who end up discharged from the hospital less functionally able than they were before they became sick," Brown explains.
The Value of Baseline Function
Everything in geriatric patients' lives is determined by what patients can do functionally, physically, and cognitively, Middlebrooks says. "It's essential to understand a patient's baseline function; however, determining what a patient was capable of doing before being admitted to the hospital is challenging," she says.
Patients tend to say they're a lot more independent than they really are "because they have this fear of losing their independence," she says. To assess each patient's baseline and progress, interdisciplinary team rounds take place daily on the unit. Middlebrooks, who oversees the meetings, says that all of the various disciplines are providing feedback; the pharmacist reports on inappropriate medications, the team decides whether patients require physical therapy or occupational therapy, the geriatrician puts in orders, and the nurses report on patient progress.
"In addition to interdisciplinary rounds, we do bedside shift reports. The nurse is obtaining a report in the room with the patient and the family involved," Middlebrooks says. This is an integral aspect of care on the unit because the nurses set goals for the patients to get out of bed. If a goal is for a patient to take 10 more steps than the number of steps taken the previous day, family members are involved and can hold both staff and the patient accountable to ensure that those goals are met, she says.
Mobilizing the Staff to Assist Patients
Middlebrooks adds that the training provides information on the importance of mobility in geriatric patients and prevention of medical issues such as delirium and muscle mass decline. "The staff receives training from physical therapists in the hospital. They teach people how to use gait belts appropriately, and here on our unit we have a gait belt and a walker in every room," she says.
There's also simulation training in which actors role play as either a patient or family member. During the simulation training, the staff work to determine how to communicate with patients and family members, especially when there's pushback from caregivers who don't want a patient getting out of bed because they believe that their loved one should be resting or may be at risk for falling.
The Geriatric Scholar Program is a specialized program at UAB. Initially it was designed to educate nurses on geriatric care, but it has been expanded to include all disciplines throughout the hospital. The various teams are trained in geriatrics, taking what they have learned and teaching it to their peers, Middlebrooks says. The program focuses on geriatrics-based projects—one of which underscores the importance of function. "There's a whole team working to make sure that every member of the hospital [staff] understands the importance of baseline vs current function not just for the geriatric patient but for every patient who comes to the hospital," Middlebrooks says.
"One of the things we are actually in the process of doing now is working on our documentation of mobility," Brown says. "We are trying to integrate into our medical records a place where nurses can document how much someone is actually walking or not walking that's easily accessible for physicians, social workers, and physical therapists." UAB's interest in improving the documentation of mobility underscores the potential for it to improve the health of older adults and help to reduce the length of stays and readmissions, she says.
In addition to focusing on documentation, team members are going to different units to work with the nurses to make sure they feel comfortable walking with patients, Brown says. "Our focus is to ensure that gait belts are available in every room. We have done this on our unit and are planning to expand this throughout the hospital," she says.
While there are plans to expand the mobility program to the rest of the hospital through training, Brown notes that because geriatricians understand the negative impact that bed rest can have on older adults, it's up to them to motivate other disciplines on the importance of elder patients staying mobile during and after their hospital stay.
— Jaimie Lazare is a freelance writer based in Brooklyn, New York.
2. Brown CJ, Foley KT, Lowman JD Jr, et al. Comparison of posthospitalization function and community mobility in hospital mobility program and usual care patients: a randomized clinical trial. JAMA Intern Med. 2016;176(7):921-927.