Immobility

Dr. DoHA RASHEEDY ALY

Lecturer of Geriatric Medicine

Department of Geriatric and Gerontology

Ain Shams University

Bed rest benefits in acute

conditions • Reduces oxygen needs

• Decreases pain levels

• Helps in regaining of strength

• Uninterrupted rest has psychological and

emotional benefits

"Bed is Bad"

Unfortunately!!!!!!

• the health-care system tends to

promote immobility in patients.

• Patients are frequently restrained by

either physical restraints, chemical

restraints (sedatives), or treatment

restraints (IV, oxygen, catheters).

• Deconditioning occurs at a faster rate

than reconditioning.

• Immobilization – physical restriction of

movement to body or a body segment

• Deconditioning – decreased functional

capacity of multiple organ systems

AGE-RELATED CHANGES IN MOBILITY

• Normal gait is dependent on the integrity

and interaction of three components:

1. Locomotion.

2. Balance.

3. The ability to adapt to the environment

Walking speed

• The gait is 20% slower natural velocity is

secondary to reduction in stride length and

that cadence (steps per minute) is well

maintained.

• Reduced gait speed has been advocated

as a marker of frailty

Gait initiation

• Gait initiation is well preserved in healthy

older people.

• Abnormalities of gait initiation are a

sensitive but not specific sign of disease

processes in older people, such as

Parkinson’s disease, multiple cerebral

infarcts

Rising from a chair

• Reduced range of motion in the hips,

pelvis, knees, and spine is common with

aging and impedes the initial shift of the

total body center of mass over the feet.

• Weakness of the hip girdle muscles is

also a frequent finding in older people, a

manifestation of deconditioning, and those

affected may need to use their arms to

help themselves upwards.

CAUSES

• Physical.

• Psychological.

• Environmental.

Physical

• Musculoskeletal disorders

Arthritis‘

Osteoporosis

Fractures (especially hip and femur)

Podiatric problems

Other (e.g., Paget's disease)

• Neurological disorders

Stroke

Parkinson's disease

Other (cerebellar dysfunction, neuropathies)

• Cardiovascular disease

Congestive heart failure (severe)

Coronary artery disease (frequent angina)

Peripheral vascular disease (frequent claudication)

• Pulmonary disease

Chronic obstructive lung disease (severe)

• Acute and chronic pain

• Deconditioning (after prolonged bed rest from acute illness)

• Malnutrition

• Severe systemic illness (e.g., widespread malignancy)

• Drug side effects (e.g., antipsychotic-induced rigidity,

Sedatives and hypnotics, by causing drowsiness and ataxia,

blurred vision by anticholinergic, postural hypotension

diuertics , vasodilators)

• Sensory factors Impairment of vision

Psychological

• Fear (from instability and fear of falling)

• Depression

Environmental causes

• Forced immobility (in hospitals and nursing

homes)

• Inadequate aids for mobility.

• Poor lightening.

Effects of Immobility

• Phisiologically

– No body system is immune to affects of

immobility

– Effects depend upon a client’s health, age,

and degree of immobility

COMPLICATIONS

• Decreased mobility and increased bed-

rest adversely affect almost every system

of the body.

• Prolonged inactivity or bed rest has

adverse physical and psychological

consequences

Skin

Pressure ulcers

Musculoskeletal

Muscular deconditioning and atrophy

Contractures

Bone loss (osteoporosis)

Cardiovascular

Deconditioning

Orthostatic hypotension

Venous thrombosis, embolism

Pulmonary

Decreased ventilation

Atelectasis

Aspiration pneumonia

Gastrointestinal

Anorexia

Constipation

Fecal impaction, incontinence

Genitourinary

Urinary infection

Urinary retention

Bladder calculi

Incontinence

Metabolic

Altered body composition (e.g.,decreased

plasma volume)

Negative nitrogen balance

Impaired glucose tolerance

Altered drug pharmacokinetics

Psychological

Sensory deprivation

Delirium

Depression

Skin

• Trauma to fragile skin, including ecchymosis

and skin tears, occur when elders need

more assistance getting up and down;

• Immobility threatens healthy skin integrity

and can become severe enough to result in

pressure ulcers; The first sign of this is

redness that won't blanch

• .

Pressure Areas

Musculoskeletal

• Muscle: disuse atrophy "if you don't use it, you'll

lose it," Loss of muscle strength, Muscle atrophy (begins after 1 day of

immobilization. 1-3%/day Muscles may lose half of their bulk after 2

months)

• Bone: increased bone resorption (osteoporosis)

Increased risk of fracture, dorsal kyphosis, and chronic

back pain 1% loss of vertebral mineral content per week)

• Joints: • Immobilization can induce cartilage degeneration.

The body attempts to repair joints through cartilage

proliferation, osteophyte formation, and fibrofatty

infiltration of the joint cavity.

• Contractures (contributing factors include spasticity,

improper bed positioning, and maintaining the limb in

a shortened position) Muscles, CT that cross two

joints are at increased risk for contractures.

development of contractures, further impaired

mobility, resulting in more joint tightness and

contractures.

• Joint stiffness and pain :if joints are not given

adequate full range of motion. The stiffness is due to

tightness of the muscles and tissues surrounding the

joints.

Genitourinary

Decreased voiding (stasis)

↓ • Increased post-void residual volume, retention

• Increased risk of urinary tract infections

• Increased risk of calculus formation

Venous thrombosis, embolism

venous stasis + increased blood coagulability+

decreased plasma volume

Cardiovascular

↑ heart rate (1 beat/

minute every 2 days) 2ry to increased sympathetic activity

↓

decrease in diastolic filling time 1)•

and a decreased systolic ejection

time2).

1) decreased coronary

blood flow and

decreased O2

available to cardiac

muscles

2)↓ CO, SV

• Orthostatic hypotension (begins after 3

weeks of bed rest ) due to:

1. excessive pooling of blood in the lower

extremities

2. decreased circulating blood volume

• 20 days of bed rest may lead to a 25%

decrease in stroke volume and a 20%

increase in heart rate.

Gastrointestinal

• Constipation

– weakening of the abdominal wall muscles,

leading to difficulty in raising the intra-

abdominal pressure sufficiently for defecation

– loss of privacy and embarrassment if toilet

assistance is needed.

– Bowel irregularity may produce abdominal

discomfort, as well as cause loss of appetite.

Endocrine • Decreased basal metabolic rate (which can lead to diuresis, natriuresis,

and fluid shifts(↓plasma volume)

• Negative nitrogen balance

• Glucose intolerance

• Hypercalcemia (symptoms of hypercalcemia include anorexia, abdominal

pain, nausea, malaise, headache, polydipsia, polyuria, lethargy,and

coma). Symptoms may occur within 2–4 weeks.

• Decreased parathyroid hormone

• Increased plasma renin activity

• Increased aldosterone secretion

• Altered growth hormone production

• Altered spermatogenesis and androgen secretion

• Altered circadian rhythm

• Urinary loss of:

– Nitrogen – (begins day 5-6, peaks at 2 weeks)

– Calcium – (begins day 2-3, peaks at 4-6

weeks)

– Phosphorus

• Reversible post mobilization

Pulmonary

• ↓strength of respiratory muscles→↓tidal volume , minute volume,

respiratory capacity

• ↑respiratory rate to compensate for decreased respiratory capacity

• ↓ability to clear secretions (cough reflex)

Accumulation of secretions in the lower bronchial tree, which can block airways,

cause atelectasis and increase the risk of pneumonia.

psychological

• Increased immobility may result in a loss

of independence and can cause the elder

client to have a sense of isolation and

even depression as they become less able

to navigate their world

• Behavior disturbances

• Anxiety

• Sleep disturbances

Immobility often cannot be prevented, but

many of its adverse effects can be

• Optimize the treatment of underlying diseases.

• For ulcer prevention: – Proper positioning, change positions at least every two hours

– Air mattress, keep skin dry and clean

• Fowler

• Semi Fowler

• Lateral sim’s position

For contracture prevention

• Do stretching and range-of-

motion exercises to each of the

joints everyday, and several

times a day( active better than

passive).

• Maintain proper body

alignment, therapeutic splints.

• Pain control , treatment of

spasticity.

ROM

Stretching

• Focus on abilities and not disabilities: the

use of assistive devices and making the

home accessible.

Assistive devices

Anticoagulation, elastic stocking, intermittent pneumatic

compression.

Methods of Airway Secretions

Elimination • Oral, nasal, or transtracheal suctioning

• Chest percussion and postural drainage

• Flutter mucus clearance devices

• Mechanical vibration devices to the chest

wall

• Maintain an adequate fluid intake (thick

secretion ,constipation, UTI, renal stones,

dehydration, clotting.

• Nutritional support • High protein, high calorie diet

• Supplemental vitamin C

• Vitamin B complex

• Psychological support.

OCCUPATIONAL THERAPY IN THE MANAGEMNET OF

IMMORBILE OLDER PATIENTS

Medalities 1. Assessment of mobility

2. Bed mobility

3. Transfers

4. Wheelchair propulsion

Assessment of other ADL using actual or simulated environments 1. Dressing

2. Toileting

3. Bathing and personal hygiene

4. Cooking and cleaning

Visit home for enviornmental assessment and recommentations for adaptation

1. Recommend and teach use of assisitive devices (cane, crutches)

2. Recommend and teach use of safety devices (e.g., grab bars and railing, raised toilet seats,

shower chairs)