Deconditioning due to hospitalisation
A combination of two historic papers and one new paper has provided evidence on deconditioning in older people during hospitalisation.
Functional decline as a result of admission to hospital has been well documented since 1944. Older people are at much higher risk of deconditioning than their younger counterparts.
This research focus summarises two historic papers, which are early studies on deconditioning, and one recent study that records the incidence of iatrogenic disability during hospitalisation. It provides an evidence base for the recent popular #EndPJparalysis campaign initiated by Brian Dolan. Professor Dolan's campaign encourages patients to get up, get dressed and get moving while in hospital to speed their recovery and reduce their length of stay. It is seeing positive early results, as it also empowers patients to manage their own health.
Hospital-associated deconditioning and dysfunction
A paper published in 1991 in the Journal of the American Geriatrics Society described hospitalisation as a ‘devastating’ event for an older person. This was conceptualised as stemming from three discrete processes: the illness itself, adverse effects of treatment and general effects of deconditioning.
The paper explained that studies from the Space Programme found the effects of deconditioning in younger people were mostly reversible, but older people had considerably more difficulty recovering.
The cardiovascular and musculoskeletal systems are the most likely to be adversely affected by bed rest. Bed rest induces cardiovascular changes due to alterations in fluid balance, with haemodynamic consequences. There is a loss of body fluid from plasma volume by about 600mL, and altered fluid distribution due to posture. This loss of orthostatic competence causes an increase in falls, fear of being upright and reduced exercise tolerance. In the laboratory these effects are ameliorated by positioning and proper oral hydration.
The paper described a daily loss of 1.5% of lower leg muscle strength, which means a 10% loss of strength with a single week of bed rest. For an older person who is on the cusp of being unable to climb the stairs at home, or even get out of bed, this loss of strength may mean the difference between dependence and independence.
The paper urged the consistent use of assessing, monitoring and anticipating changes in patients’ functional status to develop strategies to reduce hospital-associated functional decline in older people.
Hoenig H, Rubenstein L (1991) Journal of the American Geriatrics Society. 39, 2, 220-222.
Functional impact of ten days of bed rest in healthy older adults
Kortebein and colleagues published a seminal paper in 2008 that reported a study involving 11 older participants, older than 67, who underwent ten days of enforced bed rest. Although this study would not gain ethical consent today, it found that in healthy older adults, ten days of bed rest resulted in a substantial loss of leg strength and aerobic capacity.
This was independent of the usual multiple factors associated with a hospital admission that may result in functional decline, such as surgery or illness. The debilitating effect of the ten days of bed rest continued well into the week after participants were able to move around and return to their normal activities. This may be directly or indirectly (for example, due to fatigue) attributed to the decline in aerobic capacity and lower leg muscle function.
The paper asserted the value of tailored rehabilitation for anyone after a period of reduced activity.
Kortebein P, Symons T, Ferrando A et al (2008) The Journals of Gerontology. Series A, Biological Sciences and Medical Sciences. 63, 10, 1076-1081.
Preventable iatrogenic disability in elderly patients during hospitalisation
A French study involving 503 patients of 75 years and over reviewed the frequency, causes and preventability of disability induced by a hospital stay. The study included all patients with a minimal length of stay of two days, and a minimal loss of 0.5 points in the Katz Activity of Daily Living Score between admission and discharge. Previous studies have focused on age, dependence, cognition and presence of frailty as indicators of functional decline. This study focused on separating the disease process from the specific experience of ‘hospitalisation’.
It found that 60 (12%) of the 503 inpatients developed iatrogenic disability. Of the 60 cases, 49 (82%) were judged to be potentially preventable by a review panel of eight specialists.
The main causes of developing disability were excessive bed rest and lack of physiotherapy, as well as overuse of incontinence pads and catheterisation.
The paper concluded that healthcare professionals need better education in the specific needs of older people in hospital, and should consider hospital-associated disability as an outcome of care.
Sourdet S, Lafont C, Rolland Y et al (2015) Journal of the American Medical Directors Association. 16, 8, 674-681.
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Compiled by Esther Clift @EstherClift, consultant practitioner trainee in frailty, Health Education England (Wessex)