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Functional Decline in Hospitalized Older Adults: It’s often a consequence of hospitalization, but it doesn’t have to be.

Graf, Carla MS, RN, APRN, BC

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Carla Graf is a geriatric clinical nurse specialist at the University of California, San Francisco Medical Center. Contact author: carla.graf@ucsfmedctr.org. This article is 10th in a series that’s supported in part by a grant from the Atlantic Philanthropies to the Gerontological Society of America. Nancy A. Stotts, EdD, RN, FAAN (nancy.stotts@nursing.ucsf.edu), a John A. Hartford scholar, and Carole E. Deitrich, MS, GNP, RN (carole.deitrich@nursing.ucsf.edu), are the series editors. The author of this article has no significant ties, financial or otherwise, to any company that might have an interest in the publication of this educational activity.

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Abstract

OVERVIEW: In older adults who are hospitalized, functional decline can occur in a matter of days. This devastating outcome is a common result of the older adult’s “cascade to dependency,” in which normal aging changes—combined with bed rest or immobility—result in irreversible physiologic changes, poor outcomes at discharge, and for many, placement in a nursing home. Routine walking schedules, activities to prevent sensory deprivation, and timely hospital discharge are among the interventions that can help prevent functional decline.

In April 1967 AJN published a collection of articles called “The Hazards of Immobility,” which summarized the physiologic changes that occur in healthy, ill, or injured people who undergo bed rest. 1 The articles described the detrimental effects of immobility on cardiovascular, respiratory, gastrointestinal, musculoskeletal, urinary, metabolic, and psychosocial health. In the foreword, the editors noted that in 1960, the “U.S. Public Health Service reported that disability from immobilization was one of 10 preventable health problems and, with then existing knowledge, such disability could be reduced 50% to 75%.”

Nearly 40 years later, even more is known about the hazards of immobility. Yet the problem remains, especially in older adults. Hospitalization for an acute illness, even a short admission, imposes a degree of immobility on any patient, and in an older adult such immobility can be devastating. Decline can happen quickly. One early study of hospitalized patients over the age of 74 noted that by the second day of admission statistically significant deterioration had occurred in “individual scores for mobility, transfer, toileting, feeding and grooming.” 2Deconditioning is the term used to describe the decrease in muscle mass and other physiologic changes that result from either aging or immobility or both and contribute to overall weakness. Functional decline is the consequence of those physiologic changes—the resulting inability to perform activities that ensure a person’s independence, such as rising unaided from a chair.

Hospital care is often focused on treating acute illness; physical and cognitive functioning—the factors that most affect the patient’s independence and overall prognosis—are often overlooked. 3 For example, mobility regimens (such as scheduled walks) while hospitalized are often initiated only as a patient is close to discharge, when it may already be too late. After two bedridden weeks in the hospital, a patient who is taught a few exercises at the time of discharge will gain little immediate benefit. Indeed, one recent study found that nearly one-third of hospitalized patients 70 years of age and older showed a decline in activities of daily living (ADLs) upon discharge. 4

FIGURE. The hospital...
FIGURE. The hospital...
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The costs are both human and financial. Functional decline leads to increased risk of illness and death, often irreversibly diminishes quality of life, results in less autonomy and greater dependence, and sometimes leads to institutionalization. Functional decline also leads to increased lengths of hospitalization and readmission. 5

To prevent functional decline in hospitalized older adults, nurses must look for risk factors and intervene. As the physician Richard Asher once wrote, “Teach us to live that we may dread unnecessary time in bed. /Get people up and we may save our patients from an early grave.” 6

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HOW SERIOUS IS THE PROBLEM?

In the United States in 2002, “more than 12.5 million people aged 65 and older were discharged from hospitals”; the average length of stay was 5.8 days. 7 Hirsch and colleagues found that functional decline could occur as early as the second day of hospitalization. 2

This highlights the threat evidenced in other studies. In one, a study of 1,279 community-dwelling adults ages 70 and older who were hospitalized for acute medical illnesses, 31% experienced a decline in ability to perform ADLs between preadmission (baseline) and time of hospital discharge. 8 After three months, 51% had either died or had a new impairment in an instrumental activity of daily living (IADL). The authors found that 16% of patients who experienced functional decline during hospitalization died within three months of discharge, compared with 13% of those who improved in functional ability and 7% of those who stayed the same. Three months after discharge, 40% of the original cohort for whom data were still available reported additional disabilities in daily activities.

In another study, Landefeld and colleagues found that 35% of older adults hospitalized in an acute care medical unit experienced a decline in ability to perform one or more basic ADL by the time of discharge. 3 Other investigators have found that patients with the greatest loss in ADLs during hospitalization are most likely to be admitted to a nursing home. 9

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AGING AND OTHER CONTRIBUTORS

There are many complex contributors to functional decline, although much is still not understood.

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Aging and the hospital.

Creditor describes a “cascade to dependency,” a process leading to disability that occurs when a person who has undergone normal aging changes is hospitalized with bed rest. 5 Changes to be expected with aging include

* decline in muscle strength and aerobic capacity.

* vasomotor instability.

* baroreceptor insensitivity.

* reduced total body water.

* reduced bone density.

* reduced ventilation.

* reduced sensation.

* altered thirst, taste, smell, and dentition.

* fragile skin.

Palmer and colleagues developed a conceptual model for older adults, depicting the “syndrome of dysfunction” that occurs when a functional older person is hospitalized. 10 Both acute illness and the hospital environment can contribute to a decline in function. The authors suggest that the hospital environment is designed for the caregiver rather than the patient; high beds, shiny floors, equipment clutter, and a lack of orienting cues, for example, may cause the patient not to walk because of fear of falling. In addition, both acute illness and uncomfortable environments can lead to or exacerbate depression, compounding functional decline. 10, 11

While in the hospital, older adults may be left immobilized in a bed or chair, quickly becoming deconditioned. 5 They may become dehydrated or malnourished from inadequate intake of food and drink or from nothing-by-mouth orders. They are at higher risk for delirium caused by acute illness, the adverse effects of medication, sensory deprivation because of isolation, and lost eyeglasses or hearing aids. These risk factors may lead to falls, dependency, use of restraints, infections, and rejection from family.

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Aging and immobility.

Aging causes an ongoing loss of muscle fiber; consequently, skeletal muscles lose mass and strength. The imposition of immobility on aging muscle may cause significant atrophy that occurs more rapidly than in younger patients, leads to falls and functional decline, and necessitates long periods of rehabilitation. 12 To maintain strength, muscles must contract; without contraction, muscle strength decreases by as much as 5% per day. 5 The antigravity muscles of the leg and back (the muscles primarily responsible for maintaining erect posture) are primarily affected by periods of immobility. In fact, Kasper theorizes that given repeated cycles of atrophy and recovery, an older adult may lose the ability to restore skeletal muscle mass and become permanently disabled. 12

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The cardiovascular system.

The most common cardiovascular changes that accompany aging include blood vessel stiffening, which can raise blood pressure. In addition, valve calcification affects blood flow. Reductions in blood and plasma volume and in total body water, as well as dehydration, may precipitate syncope. 5 Within 24 to 48 hours of bed rest in the supine position, plasma volume decreases by almost 7% or 500mL. 1, 5, 12 Blood pools in the thorax. The body perceives an increase in venous volume; this triggers central blood volume receptors that generate a reduction in antidiuretic hormone secretion and a loss of water and sodium. During periods of inactivity and bed rest, hemoglobin and hematocrit values may initially rise with the corresponding fall in plasma volume, but they fall dramatically during recovery and resumption of activity, leading to the potentially unnecessary treatment of anemia. 12

Cardiac output and stroke volume are affected by changes in body position. Both decrease when the body is supine, due to redistribution of venous blood returning to the heart during periods of bed rest. 13 Olson also describes the Valsalva maneuver occurring as a result of using the muscles of the arms and upper body to change position in bed. 1 She estimates that bedridden patients may perform this maneuver 10 to 20 times per hour, with the possible risk of cardiovascular compromise in predisposed patients. (Note that this is not a problem of deconditioning; it’s an immediate risk created by a sudden increased demand on the heart.)

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The pulmonary system.

Respiratory changes associated with aging include diminished rib cage expansion and increased closing volume and residual capacity; these result in reduced oxygen tension (arterial oxygen pressure). 5 Bed rest may further reduce ventilation by preventing full rib cage expansion and causing stasis of secretions; this can eventually lead to oxygen–carbon dioxide imbalances. 1

Frailty, a word commonly used to describe older chronically ill adults, is thought to contribute to functional decline. While there is no standardized definition of frailty, many consider it a distinct clinical syndrome. Hamerman suggests that frailty can be thought of as an “evolving geriatric functional continuum, in which frailty is a midpoint between independence and death.” 14 Fried and colleagues specify frailty as “a clinical syndrome in which three or more of the following criteria were present: unintentional weight loss (10 lbs. in the past year), self-reported exhaustion, weakness (grip strength), slow walking speed, and low physical activity.” 15 Frailty may encompass concepts such as failure to thrive, anorexia, and sarcopenia, as well as chronic cognitive changes such as dementia.

Illness may also contribute to functional decline. A study by Ferrucci and colleagues identified stroke, cancer, congestive heart failure, pneumonia, coronary heart disease, and hip fracture as precipitators of functional decline. 16 Iatrogenic events during hospitalization—including falls, fractures, adverse drug reactions, nosocomial infections, and the consequences of chemical or physical restraint use—occur frequently in older patients and can lengthen hospitalization, produce cognitive changes, and lessen the ability to perform ADLs. 17

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Bed rest orders and immobility.

The effects of bed rest orders were recently examined in a study of low mobility in hospitalized patients ages 70 and older. 4 Slightly more than one-third of the 498 participants had formal bed rest orders. Furthermore, almost 60% of the 80 participants in the lowest mobility group had no documented medical reasons for bed rest. This study demonstrated that low mobility in hospitalized patients independently predicted poor outcomes at discharge, despite illness severity, age, marital status, sex, comorbidities, and preadmission impairment in performing ADLs. Poor outcomes included ongoing decline in performance of ADLs, new institutionalization, and death. This highlights the need for hospital nurses to develop unit standards for mobility regimens and to advocate that physicians or nurse practitioners provide patients with activity orders early in their hospitalization.

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Impaired cognition.

Increasingly, older adults hospitalized for acute care have some form of cognitive impairment, either a chronic condition such as dementia or an acute one such as delirium. (See “Cognitively Impaired Older Adults,”A New Look at the Old, February 2005.) Cognitive impairment has been shown to be a predictor of functional decline in older adults. 8, 18 One study of 2,593 frail older patients followed over the course of one year examined the effects of hospitalization and cognitive impairment on performance of ADLs. 19 The results showed that cognitive impairment contributed significantly to the loss of ability to perform ADLs, and that risk nearly doubled when the cognitively impaired person was hospitalized with an acute illness. This highlights the importance of incorporating safe mobilization plans and self-care activities for patients with cognitive impairments. Nurses can promote these goals by interviewing caregivers about the patient’s abilities and usual routines and developing a care plan that takes these into account.

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ASSESSING FUNCTION

Evaluating functional status can be challenging, especially in the hospital and in patients with acute and chronic conditions. A complete assessment should include not only the performance of ADLs and IADLs but also cognition, vision and hearing, social support, and psychological well-being. Functional assessment can be formal or informal, done in various settings, and performed by a variety of providers. Its purpose is to provide a baseline for ongoing comparison, determine prognosis, and evaluate response to treatment. At discharge, it can identify necessary services.

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In the hospital.

Ideally, given the short duration of hospital stays, functional assessments should be completed at admission, and the patient should be reassessed and his condition documented daily. The initial assessment must include questions about physical and cognitive function, such as: Are you having trouble walking, using stairs, bathing, eating, swallowing, dressing, or managing medications? Do you have any memory problems? Have you had a recent fall? Do you use a walker or wheelchair? Do you climb stairs in your home? These questions—meant to ascertain problems with function—should alert clinicians to the need for interventions that might prevent further decline and help them plan for discharge. The nurse should question the patient (or, when necessary, the caregiver) directly. In community and outpatient settings, such screening is done periodically using instruments that are sensitive to changes occurring over time, such as the Timed Up and Go test. Basic functional screening of older adults usually includes assessment of mobility and the ability to perform ADLs and IADLs.

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Special considerations in functional assessment.

If assessments require demonstration or simulation (such as walking, pivoting, or doing personal care) give the patient adequate time. Safety is always the first priority; stand close to the patient to prevent a fall during testing. This is especially important when a test is timed because the patient may hurry to complete the maneuvers. Patients with pain and fatigue may need to rest frequently and to take medication before testing. Non-English speakers may require a translator.

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Vision or hearing impairment.

If the patient has hearing or vision deficits, assessments should be made while the patient is wearing eyeglasses or hearing aids. If these aren’t available, provide the patient with appropriate adaptive devices such as page magnifiers or hearing amplifiers. With a patient who is hearing impaired, minimize extraneous noise and face him or speak into his good ear.

Cognitive impairment may prevent a patient from understanding or remembering directions. If this is the case, speak slowly, give one-step commands, repeat directions word for word, demonstrate the activity, and give the patient time to respond. Some patients with cognitive impairments cannot give a self-report. It may be necessary to ask a family member or caregiver to report as a surrogate, but such reports should be validated if possible, as family members may under- or overestimate the patient’s abilities. 20

The assessment of cognition is important in differentiating delirium from dementia or depression. It’s also necessary in care planning—for example, to evaluate the need for home care or alternative housing. It can help prevent injuries such as falls that may be caused by impaired short-term memory. Choosing the appropriate instrument depends on the institution, the population being assessed, the goals, the setting, and time and training needs.

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Instruments for functional assessments.

The Katz Index of Independence in Activities of Daily Living, often referred to as the Katz ADL, and the Lawton Instrumental Activities of Daily Living Scale, known as the Lawton IADL, are assessment instruments validated for use with older adults, are easy to use, and have been incorporated into many hospitals’ admission procedures. 21, 22 The Katz ADL assesses level of dependence by measuring the ability to perform six activities: eating, transferring, toileting, continence, dressing, and bathing. The Lawton IADL assesses level of dependence by examining a person’s ability to use the telephone; shop; prepare food; do housekeeping and laundry; and manage transportation, medication, and finances. The Hospital Admission Risk Profile (known as HARP) is an assessment instrument for use with hospitalized older patients that’s quick and easy to use upon admission. 23 HARP identifies upon admission patients at low, medium, and high risk for functional decline by stratifying them by age, baseline IADL status, and an abbreviated Mini-Mental Status Exam. Interventions can then be individualized depending on patient risk. Olsson and colleagues found that using the Reality Comprehension Clock Test in long-term care residents with dementia could identify special problems that can lead to falls. 24

Many instruments exist for assessing function; unfortunately, there is no gold-standard instrument for measuring functional status in hospitalized older adults. 25 Choice of assessment instrument is determined by the setting or institution, should be practical and tailored to the goals of assessment, such as planning for hospital care and discharge; the setting, whether inpatient or outpatient; the ease of use, such as the time needed to assess and train; and the method of assessment, whether it relies on the report of the caregiver or demonstration of the task (see Table 1, page 64).

Table 1
Table 1
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Direct observation is also useful. For example, can the patient feed himself? Can he cut his food without help? Can he use utensils, open a milk carton, reach for items on his bedside stand? Can he sit or stand at the sink to wash his hands and face and brush his teeth, comb his hair? Can he come to a sitting position at the side of the bed, then transfer to a chair or commode? Can he bend over to put on his socks? Deficits should be reported to the team for further testing and addressed in care plans. Care plans should be communicated to other team members—including nursing assistants, families, the patient and his caregivers—to ensure that the patient remains as independent as possible during hospitalization.

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Limitations.

Pearson identifies bias that could result in inaccurate assessments in some of the instruments. 25 For example, both the Lawton IADL and HARP assess a person’s ability to prepare a meal. An older man who is able to cook but has never done so may report that he does not perform this activity—thus misrepresenting his functional abilities. Furthermore, testing may intimidate patients with little or no formal education and those who can’t read or write. Those who fear that test results will lead to changes in their living situation may overstate their abilities. Those with chronic illness or depression may refuse or be unable to participate fully. These challenges can be addressed by using assessment techniques such as testing in stages, establishing rapport before testing, providing information about the goals of testing, observing or having the patient simulate self-care activities while hospitalized, and asking family and caregivers to validate test results.

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INTERVENTIONS

In an observational study Callen and colleagues sought to determine the frequency of hallway walking by hospitalized older adults. 26 They found that the frequency was quite low; in fact, 72.9% of patients considered “able to walk” did not do so during a three-hour period. Among those who walked, the median walking time was 5.5 minutes. Most patients who walked were either alone or with therapy staff; only 9.4% walked with nursing staff, and 18.8% walked with family members.

Why do patients continue to have orders for bed rest, despite evidence of adverse effects? Why don’t hospital nurses make ambulation a focus of their work, given the speed at which functional decline can occur in the elderly? The Callen and colleagues study poses important implications for nurses, physicians, patients, families, and hospital administrators. First, nurses on medical units should establish walking routines for patients—just as nurses on surgical units have established postoperative ambulation routines. Hospital administrators must recognize that hospital-acquired functional decline is a poor outcome and should allocate the resources required to institute ambulation programs. One way to promote this is to establish safe areas so older patients don’t have to navigate equipment and high-flow traffic. In addition, hallways should have railings and, if possible, distance markers to keep patients motivated. Consider placing chairs in hallways so patients know they can safely stop and rest. Finally, more specific orders should be written for activity. Callen recommends that orders be prescribed such as “walk in hall twice a day,” rather than “up ad lib”; bed rest orders should be few. Patient and family teaching should stress the physiologic and psychological benefits of ambulation.

Despite research on the risk factors of functional decline, little is known about interventions to prevent it. While safety concerns discourage high-impact exercise in acutely ill older adults before or after hospitalization, a trial of low-intensity exercise and walking showed no effect on hospital length of stay and only minimal functional improvement one-month after discharge. 27 Mallery and colleagues conducted a randomized, controlled trial to evaluate participation in and adherence with a protocol consisting of resistance training and Pilates exercise versus passive range of motion for 39 older acutely ill hospitalized medical inpatients (exercise group = 19; passive range of motion group = 20). 28 Participation and adherence were lower in the exercise intervention group than it was in the group assigned passive range of motion: in the former, 71% participated and 63% adhered to the program, while in the latter, 96% participated and 95% were adherent. It’s worth noting that this is one of the only studies to use high-intensity exercise in an acutely ill geriatric sample—and that the results demonstrated acceptable levels of participation, adherence, and safety in the intervention cohort (see “Tips for Nurses by Health Care Setting,” above). This study also included patients with mild to moderate cognitive impairment and found no major obstacles to performing resistance exercise in this population.

Programs to prevent functional decline in hospitalized older patients can be as simple as establishing standards for promoting function and self-care or as complex as creating separate geriatrics units.

“Walking for Wellness,” a six-month pilot program, was recently developed at a large acute care hospital to test the feasibility of a daily walking program for older patients. 29 The hospital had noted longer hospitalizations, exercise intolerance, and impaired ambulation that they attributed to older patients’ immobility during admission. After appropriate assessments, trained escorts assisted patients with hallway ambulation two to three times a day, providing patient and family education about the importance of mobility during hospitalization, and making walking opportunities for patients inside and outside of the hospital. One hundred percent of patients, families, physicians, nurses and physical therapy staff were satisfied with the program.

Acute care of elders units were developed and tested in the early 1990s, with the goal of enhancing mobility and cognition in functionally intact older adults. 3 A multidisciplinary team conducts rounds daily and discharge planning begins on the day of admission. Findings have demonstrated shorter length of stay, with less skilled nursing facility placement and improved patient, family, and provider satisfaction without raising costs. 30 However, functional outcomes have been mixed; improvements in the ability to perform ADLs have occurred in some, but not all, studies. 3, 31

The Hospital Elder Life Program (HELP) is a multidisciplinary intervention implemented hospital-wide to prevent cognitive and physical decline, promote independence, assist with transitions, and prevent readmissions. This program also focuses on recognition and management of common geriatric syndromes such as delirium, promoting sleep without drugs, and functional decline. HELP uses a robust volunteer program for patient visits, feeding assistance, early mobilization, and therapeutic activities.

Nurses Improving Care for Health System Elders (NICHE), a creation of New York University’s John A. Hartford Foundation Institute for Geriatric Nursing, is a national program that helps health care institutions to assess current geriatric care and to initiate evidenced-based, age-appropriate nursing interventions. 32 One of the most popular and successful models of this program is the role of the geriatric resource nurse (GRN). The GRN is a unit-based nurse who receives training and mentoring in the care of high risk, frail elders. In turn, she acts as a mentor for other staff on the unit and is responsible for advocating and implementing evidence-based geriatric nursing practices. Hospitals participating in the NICHE program have reported improved patient satisfaction, shorter lengths of stay, and lower costs in caring for older adults. See the online collection of assessment tools called “Try This” at www.hartfordign.org/resources/education/tryThis.html.

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Home care.

Patients who live alone may need more intensive in-home services to maintain their independence. Mahoney and colleagues found that people who lived alone and received in-home services following medical discharge were less likely to improve functionally than were those who lived with others. 33 Likewise, the former group had more nursing home admissions within 30 days of hospital discharge. This study highlights the importance of social support in maintaining community independence and the need for individualized discharge planning.

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Instrumental Activities of Daily Living

* Use of telephone

* Shopping

* Food preparation

* Housekeeping

* Laundry

* Transportation

* Medication administration

* Handling finances

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Functional Decline: How is Your Facility Doing?

Questions to evaluate your preventive efforts.
Is the environment elder friendly?

Attributes include nonglare floors; handrails and distance markers in hallways; shower chairs, raised toilet seats, and grab bars in bathrooms; low beds (if necessary), large clocks, and calenders in the room.

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Are you taking appropriate steps to prevent sensory deprivation?

Use of hearing aids, eyeglasses, and dentures is essential, and, when appropriate, provide alternatives such as amplifiers and magnifiers. Encourage family involvement and use of items from home such as robes, blankets, or pictures. Provide newspapers, music, television, puzzles, and word and math games. Consider an animal-assisted therapy program.

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Are you promoting self-care activities?

Activity routines should be specific, for example, 50 feet of hallway walking twice a day. Include rest periods in the schedule. If feasible, start the routine at admission. Post instructions in the room as a reminder. Patients should be out of bed for meals, walking to bathroom, and in the hall as tolerated. If necessary, provide assistive devices such as walkers, and refer the patient to physical and occupational therapy.

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Are you providing sufficient patient support and education?

The benefits of exercise and ambulation, the hazards of functional decline, the use of assistive devices, fall prevention, the patient’s routine—it’s crucial that both the patient and family understand these topics. Provide ample information and make time to answer questions. Coaching and providing positive feedback can motivate patients to continue walking. If staff value these activities, patients and families are more likely to value them as well.

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Is your patient safe?

Avoid using physical restraints or sedatives. Alternatives include low beds, and camouflage devices to hide IVs, tubes, and drains. Fidgeting devices and diversional activities are also helpful. Remove Foley catheter and IVs as soon as medically feasible. Review medications for geriatric dosing and possible side effects.

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“A New Look at the Old” Online

A series of Webcasts designed to improve multidisciplinary care.

Further explore the topics presented in the series “A New Look at the Old” by going online; over the course of the series 15 free Webcasts will run, created through a collaboration of AJN, the Gerontological Society of America, and Trinity Healthforce Learning, and sponsored in part through a grant from Atlantic Philanthropies. The most recent Webcast was “Dementia Focus: The Person Behind the Disease” and a new program will premier in January. For information on the schedule or to view previous Webcasts, go to www.nursingcenter.com/AJNolderadults. This Web site includes a forum for comments and questions about the Webcasts or articles in this series.

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Tips for Nurses by Health Care Setting

Hospital

Don’t delay discharge when the patient is clinically fit. A study of hospitalized patients 65 years and older found that delayed discharge was associated with “decline in basic activities of daily living” and the “need for skilled nursing.” 1

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Nursing Home

Keep walkways and floors free of obstacles. Even walking around objects can cause problems. Brown and colleagues recently reported that the concentration required by healthy older adults presented with an obstacle to negotiate while walking was significantly greater than that required for “steady-state gait in this age group.” Such fractured attention can lead to falls, especially for those with cognitive decline. 2

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Ambulatory Care

Encourage older adults to walk for at least a block or two a day—or even farther, if they’re already out the door. A recent study (titled in part, “Just Get Out the Door!”) found women 65 years and older who were functionally limited had significant benefits from just a short amount of regular walking. Their functional decline decreased at a significantly lower rate than that of women who didn’t walk. 3

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Home Care

Emphasize function in addition to treatment of disease. At the conclusion of the study comparing restorative care to usual care in older adults receiving home care, patients receiving restorative care were more mobile and more likely to remain at home. Included in the restorative care treatment plan: “combinations of exercise and training; behavioral changes; environmental adjustments and adaptive equipment; counseling and support; training and education of patient, family, and friends; and medication adjustments.” 4

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