Journal of Gerontological Nursing

IATROGENESIS IN THE ELDERLY: Factors of Immobility

Paula R Mobily, PhD, RN; Lisa Skemp Kelley, MA, RN

Abstract

INTRODUCTION

Maintenance of mobility is critical for health, well-being; and quality of life, yet immobility is one of the most common problems for the institutionalized elderly1'2 Immobility may lead to serious physiological and psychological consequences. A multitude of factors that influence the state of clients' mobility are wkhin nursing's realm of practice. This article discusses the iatrogenic factors associated with immobility, the consequences of immobility for the client, and what gerontological nurses can do to prevent or minimize the iatrogenic risks for the institutionaltzed elderly.

Teach us to live that we may dread

Unnecessary time in bed

Get people up and we may save

Our patients from an early grave3

There are many threats to physical mobility for the elderly. Hogue has developed a conceptual model for organizing information relative to the mobility of elderly patients in long-term care facilities.4 Her model proposes that mobility is a consequence of the interaction between the competence of the individual and the resources within the environment. With respect to the competence of the individual, mobility is influenced by biological health, sensory-perceptual capacity, motor skills, cognitive capacity, and ego strength. Resources within the environment include the physical and architectural features, medical regimens for the treatment of disease and disability, policy factors, resident and staff characteristics, and social support availability. It is the environmental factors and resources that contribute to iatrogenic and nursing-induced complications associated with immobility.

Physical and architectural features that restrict mobility include such things as architectural barriers, slickly waxed floors, obstructions in the patient's room or hallways (ie, laundry carts), and lack of assistive devices for ambulation or mobility. Medical regimens, despite their therapeutic intent, often negatively affect mobility. Examples of this phenomenon are bedrest, surgery, physical and chemical (pharmaceutical) restraints, and other treatments that limit mobility, such as IV therapy, indwelling catheters, oxygen therapy, and suction catheters.

Policy factors are closely related to medical regimens. As noted by Hogue, policies determine the balance that exists between individual freedom and institutional order and continuity.4 Policies, then, can affect the individual in terms of the relative lack of environmental choice and control and subsequently affect mobility. Other critical factors include the extent to which nursing and medical care are based on comprehensive functional assessment and on primary and secondary prevention of disability. The Omnibus Budget Reconciliation Act of 1987 (OBRA '87) is very specific with respect to policies related to comprehensive assessment, maintenance of functional abilities, use of chemical and physical restraints, and drug therapy in longterm care facilities. These factors will be addressed in more detail and interventions to prevent iatrogenically induced complications of immobility presented.

Characteristics of other residents in the facility can also influence mobility. Through modeling of the activity level and functional health of other residents, an individual's behaviors and values often change to conform to those of the majority of others within the environment.5"7 Similarly, decreased opportunities for socialization with other residents may inadvertently contribute to the potential for loss of mobility.

Staff characteristics that influence mobility include staffing levels, care patterns, and staff knowledge and abilities. Inadequate staffing levels make it very difficult to promote mobility and institute measures to prevent or minimize the development of impaired mobility or the consequences that follow. Limited availability of physical and occupational therapists, especially in rural settings, or lack of consultation for patients prone to impaired mobility can also be detrimental because these personnel are often instrumental in developing activities and programs to promote mobility and rehabilitation.

Care patterns that promote patient dependence can also inadvertently contribute to loss of mobility and a subsequent decline in functional ability. Nursing staff…

INTRODUCTION

Maintenance of mobility is critical for health, well-being; and quality of life, yet immobility is one of the most common problems for the institutionalized elderly1'2 Immobility may lead to serious physiological and psychological consequences. A multitude of factors that influence the state of clients' mobility are wkhin nursing's realm of practice. This article discusses the iatrogenic factors associated with immobility, the consequences of immobility for the client, and what gerontological nurses can do to prevent or minimize the iatrogenic risks for the institutionaltzed elderly.

Teach us to live that we may dread

Unnecessary time in bed

Get people up and we may save

Our patients from an early grave3

There are many threats to physical mobility for the elderly. Hogue has developed a conceptual model for organizing information relative to the mobility of elderly patients in long-term care facilities.4 Her model proposes that mobility is a consequence of the interaction between the competence of the individual and the resources within the environment. With respect to the competence of the individual, mobility is influenced by biological health, sensory-perceptual capacity, motor skills, cognitive capacity, and ego strength. Resources within the environment include the physical and architectural features, medical regimens for the treatment of disease and disability, policy factors, resident and staff characteristics, and social support availability. It is the environmental factors and resources that contribute to iatrogenic and nursing-induced complications associated with immobility.

Physical and architectural features that restrict mobility include such things as architectural barriers, slickly waxed floors, obstructions in the patient's room or hallways (ie, laundry carts), and lack of assistive devices for ambulation or mobility. Medical regimens, despite their therapeutic intent, often negatively affect mobility. Examples of this phenomenon are bedrest, surgery, physical and chemical (pharmaceutical) restraints, and other treatments that limit mobility, such as IV therapy, indwelling catheters, oxygen therapy, and suction catheters.

Policy factors are closely related to medical regimens. As noted by Hogue, policies determine the balance that exists between individual freedom and institutional order and continuity.4 Policies, then, can affect the individual in terms of the relative lack of environmental choice and control and subsequently affect mobility. Other critical factors include the extent to which nursing and medical care are based on comprehensive functional assessment and on primary and secondary prevention of disability. The Omnibus Budget Reconciliation Act of 1987 (OBRA '87) is very specific with respect to policies related to comprehensive assessment, maintenance of functional abilities, use of chemical and physical restraints, and drug therapy in longterm care facilities. These factors will be addressed in more detail and interventions to prevent iatrogenically induced complications of immobility presented.

Characteristics of other residents in the facility can also influence mobility. Through modeling of the activity level and functional health of other residents, an individual's behaviors and values often change to conform to those of the majority of others within the environment.5"7 Similarly, decreased opportunities for socialization with other residents may inadvertently contribute to the potential for loss of mobility.

Staff characteristics that influence mobility include staffing levels, care patterns, and staff knowledge and abilities. Inadequate staffing levels make it very difficult to promote mobility and institute measures to prevent or minimize the development of impaired mobility or the consequences that follow. Limited availability of physical and occupational therapists, especially in rural settings, or lack of consultation for patients prone to impaired mobility can also be detrimental because these personnel are often instrumental in developing activities and programs to promote mobility and rehabilitation.

Care patterns that promote patient dependence can also inadvertently contribute to loss of mobility and a subsequent decline in functional ability. Nursing staff may actually contribute to impaired mobility through helping activities, such as providing unnecessary assistance with transfers and bathing activities. This may ultimately promote dependence, rather than encouraging the patient to independently do as much as possible.5,8 Finally, the knowledge and abilities of the staff with respect to understanding the hazards of impaired mobility, the iatrogenic and nursing-induced factors associated with impaired mobility, and the interventions necessary to prevent or minimize the adverse effects can be critical.

Impaired mobility, whether self- or other-imposed, can have a number of negative consequences for the older individual. Physiologically, every body system is at risk. Impaired mobility may result in decreased range of joint motion, development of contractures, loss of muscular strength and endurance, loss of bone mass and strength, deterioration of the cardiovascular and respiratory systems, metabolic imbalances, development of pressure sores, and impairment in urinary and gastrointestinal functioning. Psychologically, impaired mobility may result in depression, changes in behavior, and alterations in perceptual ability. Understanding the basic mechanisms underlying each of these consequences, the relative time frame in which they can develop, and the concomitant changes associated with aging provides the basis for interventions aimed at preventing or minimizing them.

CONSEQUENCES OF IMPAIRED MOBILITY

Decreased Joint Range of Motion

Aging produces changes in joint structure. As one ages, the collagen content of connective tissue increases progressively, resulting in an increase in the stiffness of tissue and a decrease in joint mobility.9·10 Ine elderly patient with impaired mobility will race further compromise of joint function. Whenever movement is restricted, metabolic joint activity is altered. These tissues undergo a marked increase in collagen and become dense, and the fibers of the involved muscles, ligaments, and tendons shorten.11 The result is a decrease in the overall flexibility of the joint and a subsequent decrease in joint range of motion.

These changes in joint structure may occur after as few as 5 days of immobilization, with measurable changes in range of motion within a week.12·13 The deterioration progresses with continued immobility and contractures and permanent loss of joint mobility may result. Although all joints can be affected by immobilization, the hip, knee, and ankle are most susceptible due to the effects of gravity, the strength of the flexor muscles, and the difficulty for full extension or range of motion while sitting or in a recumbent position.14 Contractures of the hip and knee make the patient much less stable and therefore prone to falls, which may further restrict mobility.4,15

Loss of Muscular Strength and Endurance

Muscular strength is maintained by frequent maximum tension contractions. Ten to fifteen percent of muscle strength can be lost each week that muscles are resting completely, and as much as 5.5% can be lost each day of rest and immobility.16 The greatest loss of strength occurs during the initial period of immobilization, and results from deficiencies in venous functioning and stasis.17 As muscle strength decreases, there is a concomitant decrease in endurance. When endurance is reduced, activity often becomes limited, thus initiating a cycle that can lead to further decline in strength and endurance and further reduction in mobility. The muscles most affected by immobilization are the antigravity muscles that facilitate locomotion and help maintain an upright position.18 These include the quadriceps, glutei, erector Spinae, and gastrocnemius-soleus muscles.14

Loss of Bone Mass and Strength

When normal weight-bearing and movement is diminished or absent, osteoclastic activity increases, greater resorption of bone occurs, calcium and phosphorous are released, and bones become thin, porous, and fragile. This is commonly termed "disuse osteoporosis." Bone loss increases rapidly from the third day to the third week of immobilization and peaks during the fifth or sixth week.19·20 With ambulation, bone mineral has been found to restore at a rate of only 1% per month,21 underscoring the importance of preventing the initial loss. Elderly patients are especially vulnerable because bone loss resulting from limited mobility is compounded by bone loss resulting from age-related osteoporosis. When bone density is sufficiently compromised, the elderly patient is particularly susceptible to fractures of the hip, spine, and extremities. Fractures further limit mobility and place patients at increased risk for subsequent decline in functional status and development of further complications of immobility.

Detrimental Effects on the Cardiovascular System

Cardiovascular deterioration is another adverse consequence of immobilization, particularly when the period of immobility is prolonged and the extent of limitation is severe, resulting in confinement to bed or wheelchair. When a patient is placed in the supine position, approximately 11% of the total blood volume is redistributed from the vessels of the lower extremities to the thorax. Approximately 80% of this volume enters the thoracic circulation22 and cardiac output increases. As a result, the heart must work harder to circulate this extra volume. Cardiac workload is increased approximately 20% when the body is recumbent, and mis load is doubled in individuals with pre-existing cardiovascular disease.23

An additional and potentially problematic effect of immobilization for the elderly results from initiation of the Valsalva maneuver. The Valsalva maneuver, an increase in intrathoracic pressure produced by forceful exhalation against a closed glottis, is commonly induced in patients with limited mobility. It can result from pushing, pulling, or straining such as occurs when turning in bed, lifting oneself with a trapeze, pushing oneself up in a wheelchair, getting on a bedpan, or straining during defecation.24 With die sustained increase in intrathoracic pressure that results, venous blood flow is greatly inhibited, causing an increase in pulse rate and a transient increase in systemic blood pressure. Because many elderly have pre-existing cardiovascular pathology, the potentially deleterious effects of these phenomenon are increased.

Orthostatic hypotension is one of me most common cardiovascular complications of immobility. In healthy adults, movement from a supine to vertical posture causes a redistribution of blood volume as approximately 500 mL of blood pools in the large vessels of the lower half of the body.25 Venous return is reduced, and central venous pressure, stroke volume, and systolic blood pressure decrease concomitantly.18·2628 Baroreceptors typically elicit sympathetic stimulation to counter these effects; however, during prolonged bedrest, position changes from supine to vertical do not occur and postural reflexes diminish, resulting in orthostatic hypotension when the person attempts to assume a vertical posture.25

Orthostatic hypotension can occur in persons who are immobilized for as little as 1 week, whether the immobilization is supine or sitting.29·30 Orthostatic hypotension is common in the elderly due to age-related changes in the cardiovascular system, multiple chronic diseases, and medications that predispose to hypotension. The addition of immobility can significantly enhance the risk for orthostatic hypotension and the dangerous sequelae of falls and resulting complications. Normal men have been found to require 5 weeks to recover from the postural effects of only 3 weeks of immobility.31 It follows that the elderly would deteriorate more quickly and would take longer to recover cardiovascular efficiency after a prolonged period of immobility.

Immobilization, whether in the supine or sitting position, also reduces the skeletal muscle pumping action and increases the gravitational pull on the vascular system. Both of these phenomena contribute to venous stasis mat predisposes the patient to me development of venous thrombosis. Estimates of the incidence of thrombosis in the immobilized elderly, based on postmortem studies, are 80% to 100%.32 Thrombosis has been found to develop within the first week of immobilization.33 As the period of immobility increases, so does the risk of thrombosis32 and the potentially life-threatening sequelae of emboli.

Respiratory Problems Associated with Immobility

Respiratory function can also be compromised during periods of impaired immobility. In die supine position, the vital capacity of the lungs is decreased by 4%18; secretions increase and expectoration decreases or becomes inadequate, causing pooling. In addition, the cilia become ineffective in propelling mucus from the respiratory tract.34 Pneumonia is a common complication of these factors. In addition, atelectasis may occur due to restricted chest ventilation and poor oxygenation, and inadequate removal of carbon dioxide results. The elderly patient is already at increased risk for development of respiratory complications due to the anatomical changes in the respiratory system and decreased mucociliary clearance that occur with aging.35·36 The risk escalates for elderly patients receiving sedatives or other medications that further compromise ventilatory status.

Metabolic Imbalances

Major metabolic changes resulting from immobility include loss of calcium and development of negative nitrogen balance. As bone resorption occurs during immobility, calcium is mobilized and the serum calcium level increases. If urinary function is compromised, as often occurs with aging, hypercalcemia can result and cause further problems, including anorexia, nausea, vomiting, abdominal cramping, constipation, and lethargy.

Normally, protein synthesis and protein breakdown within the body are in balance. During immobilization, muscle atrophy occurs, resulting in a marked increase in the excretion of urinary nitrogen, reflecting protein breakdown.19 The result is a negative nitrogen balance. Negative nitrogen balance can develop within 5 days following immobilization19 and is important because it represents a depletion of stores for protein synthesis essential for tissue repair. This phenomenon has important implications during immobility due to the potential for tissue injury from prolonged pressure.

Development of Pressure Sores

Development of pressure sores of the skin or muscle can be one of the most serious consequences of immobility, and the elderly are particularly susceptible. It has been estimated that two thirds of all geriatric patients in longterm care facilities have one or more diseases or conditions that create risk factors for the development of pressure sores.37 Age-related changes in the skin and underlying tissues, combined with other factors such as the increased incidence of peripheral vascular disease, increased prevalence of nutritional deficiency and peripheral neuropathy, and the increased incidence of incontinence can quickly interact with the pressure created by immobility to produce tissue injury.

The extent and duration of immobilization are crucial factors in the development of impaired tissue integrity. Once tissue injury has occurred, the impaired body metabolism, particularly with respect to negative nitrogen balance, compounds the problem of healing. In addition, the formation of pressure sores will often result in further immobilization, initiating a spiral of negative sequelae.

Decreased Urinary Function

Urinary complications due to immobility include development of renal calculi and urinary tract infections. These complications arise primarily from impaired renal drainage and changes in urinary calcium levels and pH. Mobilization of calcium from the skeletal system increases the level of urinary calcium. During periods of immobility, especially when the patient is in a recumbent position, drainage of urine from the renal calyces is impaired, increasing the time for precipitation and aggregation of crystalloids. The result is an increased risk of renal calculi. This predisposition for calculi formation is enhanced by the increase in urinary pH, which results from the absence of acidic metabolites from muscle metabolism.18

The potential for development of a urinary tract infection increases during immobility because of the predisposition for urinary stasis in both the kidney and bladder, which in turn allows for bacterial growth. Elderly patients with impaired mobility, and especially those who are incontinent or have decreased cognitive or functional status, may be at even greater risk for development of urinary tract infection due to poor perineal hygiene, which favors enteric perineal bacterial growth.38·39 Urinary tract infection further enhances the potential for development of renal calculi by providing a bacterial nuclei around which stones can form.14

Decreased Gastrointestinal Function

Impaired mobility affects the gastrointestinal system by altering ingestion, digestion, and elimination. Negative nitrogen balance and hypercalcemia can cause anorexia, nausea, and vomiting, which may result in inadequate intake of nutrients. Decreased protein and caloric intake, coupled with altered cardiovascular and respiratory functioning, decrease the exchange of nutrients between cells, reducing cellular metabolic activity and interfering with the body's ability to digest and use nutrients.40

Constipation may become a major problem for the immobilized elderly due to a decrease in intestinal motility, the inadequate ingestion of fiber and fluid associated with anorexia, development of weakness of the muscles used for defecation, the inability to respond to the urge to defecate, and the inability to assume the erect sitting position for defecation, which occurs when patients must use a bedpan. These physiological effects of immobility are often compounded by medications, particularly opiates and anticholinergics, which inhibit normal gastrointestinal function.

Psychological Effects

The patient with impaired mobility is subject to psychological as well as physiological consequences. Impaired mobility is often associated with diminished opportunities for socialization and diminished sensory input from other patients and staff Although patient response is variable, this decrease in sensory input and socialization can cause depression; changes in behavior including hostility, belligerence, withdrawal, confusion, anxiety, apathy, and regression; decreased ability to concentrate and problem solve, altered time perception, increased dependency; and even auditory and visual hallucinations.40"44 These psychological consequences may in turn further impair physical mobility. For example, patients who are depressed often become withdrawn and concomitantly decrease their level of mobility. Also, the deviant behaviors noted above are often less acceptable, and the patient exhibiting these may well be excluded from group activities and opportunities for social interactions that promote mobility.

In summary, the adverse consequences of immobility can be devastating for the elderly client. Recognition and management of the iatrogenic factors contributing to immobility can be crucial in preventing the occurrence of these consequences.

MANAGEMENT OF IATROGENIC RISK FACTORS

Awareness of the impact of physical and architectural barriers can be instrumental in preventing the iatrogenically induced consequences of limited mobility. Attention to environmental restraints can make the resident feel more secure and more inclined to ambulate. Appropriate footwear can promote a sense of stability and security and minimize the risk of falling on waxed floors. Nursing personnel should be alert to physical barriers that restrict active mobility. Removal of obstructions in the resident's room and hallways is a simple, but often overlooked, intervention to promote ambulation. Provision of assistive devices such as handrails, walkers, and canes, as appropriate, can increase independence and the level of ambulation and mobility for many residents.

A period of bedrest can be beneficial in many circumstances. Care must be taken, however, to limit the period of bedrest to meet therapeutic objectives without prolonging me time unnecessarily. Given the speed of onset of complications associated with immobility, it is vital that interventions to prevent these complications be instituted immediately. An overbed trapeze will enable many residents confined to bed to reposition themselves independently and with greater frequency, thereby greatly diminishing the potential for development of many of the adverse consequences of bedrest.

The chief argument for the use of restraints involves patient safety. It is vital that restraints be used only when absolutely indicated and preventive interventions, including periodic removal and range of motion exercises, be instituted immediately and diligently continued. OBRA '87 regulations call for discriminant use of restraints only after alternative methods have been used and found deficient. Pharmaceutical agents, such as tranquilizers and sedatives, are also addressed in the OBRA '87 regulations. These can act as chemical restraints, and awareness of their potential in causing problems relative to mobility is important. Care must be taken to titrate the therapeutic benefits with the potential for untoward consequences with respect to mobility. Ongoing consultation with the physician and judicious use of these drugs is imperative.

Nursing personnel must consider the degree of restraint imposed by treatments such as rv therapy, oxygen therapy, and use of indwelling and suction catheters. Residents receiving these therapies require ongoing interventions to prevent the development of problems associated with the restrictions in mobility. Ambulatory devices or units that allow for greater mobility should be available and used. Consultation with the attending physician may establish parameters for the use of these therapies that at the same time increases mobility for the resident. For example, rather than using an indwelling catheter, clean intermittent catheterization may be a feasible alternative. Similarly, a heparin lock could be used in place of an IV set-up when the IV is used only to administer medications.

As with the other factors previously discussed, institutional policies can actually contribute to impaired mobility. Good nursing practice, along with OBRA '87 mandates, should be beneficial. Long-term care facilities must provide the quality of care necessary to attain and maintain the highest possible mental and physical functional status. Comprehensive assessment on admission and periodic review no less than every 3 months are required. In addition, residents must receive necessary treatments to maintain or improve abilities, and the staff must demonstrate that a decline in abilities is unavoidable and due to the individual's clinical condition. Specifications directly relevant to me topic of impaired mobility include mandates that the client's range of motion must not decline, and that appropriate treatment and services to prevent any further reduction in range of motion, when limited, be instituted. Also, me facility is expected to prevent the development of pressure sores, institute treatment and services to promote healing when they do occur, and prevent new sores from developing. Finally, the new legislation mandates against unnecessary use of restraints and medications.

Because the characteristics of other residents in the environment can influence mobility, efforts should be made to interface, to the extent possible, residents with similar functional abilities and activity levels. Those residents with impaired mobility, but with the potential for improvement, may do better in an environment that promotes interaction with residents at higher levels of function and activity. Again, the importance of consultation with activity, occupational, and physical therapists cannot be overemphasized.

Attention to staff characteristics is critical for preventing or minimizing the effects of immobility. Adequate numbers of staff to provide the necessary care and availability of resources, such as physical, occupational, and activity therapy personnel, can significantly enhance the functional abilities and activity level of residents. Recognition of the nature of care patterns that actually promote dependence and subsequent loss of mobility, as well as knowledge of the causes and consequences of immobility and the level of interventions necessary to prevent or minimize the effects of immobility, is critical. Inservice education programs, interdisciplinary team conferences, and comprehensive and regularly updated care plans can be important sources of information and knowledge.

This article has provided a framework for understanding the iatrogenic and nursing-induced factors associated with impaired mobility, a review of information about the physiological and psychological consequences of immobility, and interventions for preventing or minimizing immobility. The elderly patient presents a special challenge. The consequences of immobility can affect health, well-being, and quality of life, but these can be avoided with astute and vigilant nursing management.

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