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Keeping older patients active: undoing the adverse effects of lockdown

The challenge of addressing deconditioning, that unwelcome by-product of social distancing

Social distancing and shielding disrupted many activities designed to prevent deconditioning. Restarting them involves some new challenges for nurses

It is much more difficult to motivate patients to be active if they are permanently in nightwear Picture: iStock

While COVID-19 has had devastating consequences in the short term, the implications for some peoples health are likely to be long-standing and substantial.

On our acute medical older peoples ward, which specialises in dementia care, were already seeing the adverse effects of lockdown and shielding on our patients.

Safe discharge programme has been disrupted

With many people unable to enjoy their usual routines, involving day centres and family visits, they are moving around much less at home and rarely going outside.

Alongside reduced physical

Social distancing and shielding disrupted many activities designed to prevent deconditioning. Restarting them involves some new challenges for nurses

It is much more difficult to motivate patients to be active if they are permanently in nightwear
Picture: iStock

While COVID-19 has had devastating consequences in the short term, the implications for some people’s health are likely to be long-standing and substantial.

On our acute medical older people’s ward, which specialises in dementia care, we’re already seeing the adverse effects of lockdown and shielding on our patients.

Safe discharge programme has been disrupted

With many people unable to enjoy their usual routines, involving day centres and family visits, they are moving around much less at home and rarely going outside.

Alongside reduced physical activity, the absence of mental and social stimulation appears to contribute to higher levels of delirium when they come into our care.

To reduce the risk of coronavirus transmission, our own ward project Dayroom to Doorstep, has been on hold, only starting again recently in a very reduced way. Normally, this supports the safe discharge of patients, who gently begin to re-engage with the activities of daily living while still in our care.

‘Understanding what we’re seeing now is helping us predict what we think we’ll see more of in the coming weeks and months. Among the issues we’re recognising is that patients may well start from a much lower baseline than we might previously have expected’

Before the pandemic, we had structured and timetabled activity – knitting, doing jigsaw puzzles, listening to audio books, singing, poetry or art – for those who were well enough. This, as well as sitting down together for lunch each day, was an opportunity to meet others.

Planned daily activities help patients with
dementia keep active and avoid deconditioning

Unintended consequences of visiting restrictions

Routine works well for patients who have dementia or cognitive impairment, tangibly improving their quality of life and helping them become more relaxed and less agitated, as they see hospital as a much less frightening place to be.

It also changes relatives’ perceptions of how unwell they think their loved one is, encouraging them to see that the person can be safely discharged home because they’re already up, dressed and active. In turn, this boosts patients’ confidence about their own capabilities.

Since the pandemic began, many patients can’t understand why things have changed so suddenly, radically and for the worse. With visiting restricted, families can’t even bring in clothes for their relatives, so we’re having to keep patients in pyjamas.

As a result, day and night routines are becoming muddled and patients are becoming much more institutionalised. When someone is wearing night clothes, it’s much harder to encourage them to be active, with the likelihood of deconditioning increasing.

The likelihood is we’re going to see a lowering of baselines

Before the pandemic: taking patient
John Nichols to the day room

Muscle tone can be lost quickly when a person spends much more time in bed, leading to an increased possibility of falls. At the same time, lack of social contact is resulting in anxiety and depression, factors of mental deconditioning.

Understanding what we’re seeing now is helping us predict what we think we’ll see more of in the coming weeks and months. Among the issues we’re recognising is that patients may well start from a much lower baseline than we might previously have expected.

For example, someone who may once have been able to make their own way to our day room may need one-to-one support to get there.

We’re already anticipating how that might affect staffing, and are drawing up a job description for a project facilitator role. This person will play a key part in mobilising our patients once again, getting them up and active while working within the constraints of social distancing.

Activities coordinators should now be viewed as essential to adult nursing care

I’d like to see all hospitals have designated members of staff whose job is to encourage patients to be as active as they can be. Once you have instigators, other staff are inspired to follow.

Even if someone can’t move from their bed, they need interaction, and that’s especially true for older people, who can deteriorate quickly if they’re left staring at four walls.

At the very least, patients should be encouraged to sit up and get dressed, so we can avoid PJ paralysis. This new role could help focus attention, initiating important conversations about how best to help patients.

Most nursing homes have established activity coordinators, but this is a new development on hospital wards for older people. While in the past it may not have been seen as an essential component of adult nursing care, in the light of the effects of the pandemic, it’s time to reconsider.

Mobilising patients is the concern of the whole multidisciplinary team

Since we began our project, our nursing staff have adapted quickly. Now they view getting patients up, dressed and moved to the day room as a completely normal aspect of the day-to-day care we provide.

Importantly, every member of the team – including consultants and therapists, working alongside nursing staff – is involved in suggesting which patients would benefit from taking part in the project. This multidisciplinary approach is firmly embedded, with feedback showing how much staff value it.


Helen Slocombe is a senior sister at Royal United Hospitals Foundation Trust, Bath

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