Promoting Safe Mobility

Abstract

This article is the fifth in a series, Supporting Family Caregivers in the 4Ms of an Age-Friendly Health System, published in collaboration with the AARP Public Policy Institute as part of the ongoing Supporting Family Caregivers: No Longer Home Alone series. The 4Ms of an Age-Friendly Health System (What Matters, Medication, Mentation, and Mobility) is an evidence-based framework for assessing and acting on critical issues in the care of older adults across settings and transitions of care. Engaging the health care team, including older adults and their family caregivers, with the 4Ms framework can help to ensure that every older adult gets the best care possible, is not harmed by health care, and is satisfied with the care they receive.

The articles in this series present considerations for implementing the 4Ms framework in the inpatient hospital setting and incorporating family caregivers in doing so. Resources for both nurses and family caregivers, including a series of accompanying videos developed by AARP and the Rush Center for Excellence in Aging and funded by The John A. Hartford Foundation, are also provided. Nurses should read the articles first, so they understand how best to help family caregivers. Then they can refer caregivers to the informational tear sheet—Information for Family Caregivers—and instructional videos, encouraging them to ask questions. For additional information, see Resources for Nurses.

Figure: A nurse and a family caregiver assist an older adult with ambulation. Photo courtesy of the AARP Public Policy Institute.

Nearly 20% of Americans are family caregivers of older adults,¹ many of whom require assistance with toileting, transfers, and walking. More than half of caregivers help their care recipient use assistive devices for mobility, such as walkers and canes.² However, some caregivers are concerned about using these devices incorrectly and causing harm to the older adult or hurting themselves while providing assistance.² About 60% of family caregivers say they taught themselves to use mobility devices, as opposed to learning from a medical professional.²

Age-related loss of strength and muscle mass, or sarcopenia, negatively affects mobility, increasing the risk of depression, falls, and diminished quality of life.³ When older adults are hospitalized, their mobility is often abruptly restricted, leading to rapid functional decline.^{4, 5} The focus on reducing falls in hospitals—owing to the Centers for Medicare and Medicaid Services no longer reimbursing for fall-related costs—has had the unintended consequence of limiting mobility, thereby causing associated adverse outcomes like delirium and pressure injuries.^6-10

Recognizing the need to address mobility in older adults, The John A. Hartford Foundation and the Institute for Healthcare Improvement, in partnership with the American Hospital Association and the Catholic Health Association of the United States, developed the 4Ms of an Age-Friendly Health System—a framework in which four interrelated elements of care known as the 4Ms (What Matters, Medication, Mentation, and Mobility) are assessed and acted on. The framework can be used to align the plan of care with what matters to the older adult and the family caregiver. In this article, the last in a series on the 4Ms, we review the importance of mobility in older adults and the factors that affect it; discuss how to partner with family caregivers to promote mobility and prevent falls in the hospital and at home; and provide resources for nurses, clinicians, and caregivers.

BACKGROUND

In the 4Ms framework, addressing mobility entails ensuring that older adults “move safely every day in order to maintain function and do What Matters.”¹¹ Mobilizing hospitalized older adults is foundational nursing care, and opportunity exists for nurses to change organizational culture from focusing on fall prevention and immobility to promoting evidence-based practices for safe mobility.¹² One strategy is the use of progressive mobility protocols—interventions that become incrementally more advanced, such as first doing bed exercises or sitting up, then progressing to standing and walking.⁸ Older adults may be fearful of falling and reluctant to engage in mobility interventions.¹³ However, keeping older adults on bed rest may increase their risk of experiencing a fall.^{8, 12}

Hospitalization affects mobility in older adults owing to disease processes, procedures, and, for those who are bedbound, increased risk of deconditioning.^{12, 14} Furthermore, hospital-acquired deconditioning can persist after discharge if not addressed.¹⁵ Declines in mentation—both cognition and mood—may also be exacerbated during hospitalization, especially for those on bed rest, and can heighten the risk of delirium. These mentation changes, in turn, further decrease mobility and increase fall risk and can have negative long-term consequences, including diminished engagement in what matters to the older adult.^15-17

Pain is a frequently reported cause of decreased mobility.¹⁸ Unaddressed pain can lead to withdrawal from valued activities and, eventually, deconditioning and frailty.¹⁸ Cognitive decline can also affect mobility. Individuals experiencing cognitive impairment may have difficulty attending to their environment and thus miss potential slip or trip hazards, and may be unable to regain their balance after a fall.¹⁹ Additionally, medications can contribute to decreased mobility and the risk of falling. Benzodiazepines, neuroleptics, opioids, and some antidepressants have all been associated with increased fall risk.²⁰

Individuals who are mobile during hospitalization demonstrate increased functional status, have shorter lengths of stay, and experience reduced risk of medical complications and death.^{21, 22} It is important for the health care team to weigh the benefits of mobilization with fall risk.⁷ While there is evidence that increased mobility reduces falls among hospitalized older adults,^{23, 24} careful and ongoing assessment is needed to ensure that older adults are safe and ready to ambulate. Nurses play an important role in this assessment, as well as in developing a fall prevention plan for all older adults.²⁵

It is recognized that hospital staff have limited time to adequately address mobility. However, a systematic review by Yasmeen and colleagues found that family and informal caregiver involvement with mobility in the hospital setting improved patients' mobility and engagement in activities of daily living and decreased length of stay.²⁶ Many family caregivers do not feel well equipped to safely engage in mobility activities and worry about making mistakes.^{2, 27} Therefore, caregivers can benefit from mobility training with the health care team, including learning how medication and mentation can impact mobility and how to safely reengage older adults in activities that are important to them following discharge.²⁷

ASSESS MOBILITY

Prior to encouraging ambulation in the hospitalized older adult, it is important to perform a baseline mobility assessment.⁸ This assessment ideally includes the nurse, other health care team members, and the family caregiver. Caregivers can provide critical context, like informing the team about the level of mobility required for the older adult to do what matters to them—such as attend a grandchild's sporting event, go to the zoo, or take walks with a friend.

Nurses can initiate conversations with the caregiver to learn about the older adult's prior level of function, including whether they have noticed if the older adult holds on to furniture when walking at home or has expressed concerns about falling. Asking the caregiver about the older adult's history of falls, the older adult's history of recovery from falls or deconditioning, and any medications that may have affected the older adult's mobility or mentation in the past can yield critical information on baseline mobility. If the older adult has experienced a fall, what was its effect on their confidence level? The caregiver is instrumental in noticing whether the older adult has become more fearful of falling. This fear can result in a lower activity level, leading to depression and decreased quality of life.²⁸

Assessment tools. Mobility assessment tools can help the health care team set a daily mobility goal for the older adult. The Johns Hopkins Activity and Mobility Promotion program, for example, offers reliable and valid assessment tools, including the Activity Measure for Post-Acute Care, which assesses any functional limitations to the individual's capacity for mobility, and the Johns Hopkins Highest Level of Mobility scale, which assesses the individual's current level of mobility.^{29, 30} The Johns Hopkins Mobility Goal Calculator combines the results of these two assessments to generate an individualized daily mobility goal for maintaining or increasing function.^{30, 31}

Other mobility assessment tools commonly used in the acute care setting include the Timed Up and Go test and the Bedside Mobility Assessment Tool 2.0 (BMAT 2.0), both of which provide a baseline mobility assessment nurses can use to determine the older adult's mobility goal.^{32, 33} Additionally, the BMAT 2.0 guides the identification of appropriate equipment to use to promote safe mobility.³³

The inform–activate–collaborate framework is one strategy nurses can use to assess family caregivers' concerns about mobilizing the older adult and to promote safe mobility.²⁶ This framework has been shown to maximize caregiver engagement and promote best outcomes.³⁴ The nurse can inform caregivers of the older adult's condition; activate caregivers by involving them in the older adult's care; and collaborate with caregivers, along with the health care team and the older adult, on the older adult's plan of care.

Inform. First, the caregiver should be informed of any changes in the older adult's condition that occurred during hospitalization, any new medications that were prescribed, any concerns about the older adult's mentation, and how these factors may interfere with mobility. For instance, the family caregiver may worry about mobilizing an older adult who is experiencing pain or is weak. The nurse can acknowledge the caregiver's concerns while also reinforcing the many benefits of mobility. Additionally, the nurse can suggest mitigation strategies, such as offering a nonpharmacological intervention like range of motion exercises combined with a warm compress or acetaminophen, if indicated, 30 minutes before ambulation is planned.

Activate. Next, the nurse should engage with both the older adult and the caregiver to gain valuable information for collaborative goal setting, discharge planning, and ensuring a safe home environment. Ask the older adult about what matters to them, both in the hospital and after discharge. Talk to the caregiver and the older adult about the discharge environment. Will the older adult be going home? What is the layout of the home? What activities will the older adult be engaged in after discharge?

Collaborate. Finally, the nurse should assess the caregiver's level of knowledge, skill, and comfort regarding mobilizing the older adult. Ask the caregiver if there are any assistive mobility devices that might make care at home more manageable. If the older adult is using such a device, does the caregiver feel confident about managing it? Is additional instruction or training needed?

ACT ON MOBILITY

In the 4Ms framework, acting on mobility means using what was learned in the mobility assessment to develop an individualized safe mobility plan in collaboration with the older adult and caregiver. The goal is to maximize functional ability by having the older adult ambulate as often as possible—at least three times per day.¹¹

Mobilizing older adults requires an interdisciplinary team effort including the nurse, nursing assistant, family caregiver, and physical therapist. The nurse is central to promoting mobility and can implement tailored interventions to meet the older adult's daily mobility goal.³⁰ Discussing the goal and mobility interventions with the older adult and caregiver fosters partnership. Using the whiteboard or activity board in the hospital room to document the daily goal is one effective strategy to keep everyone informed and promote progressive mobility.³⁵

Although mobility interventions will differ depending on whether the older adult can walk unassisted, can walk only with assistance, or is on bed rest, the shared message is to encourage older adults to “get moving” to the best of their ability.^{36, 37} For older adults who can walk independently or with assistance, mobility interventions may include walking minimally in their room, such as to and from the door or bathroom; standing up to brush their teeth; and, optimally, walking in the hall three times a day. Encouraging sitting in a chair rather than in bed at mealtimes also promotes mobility; additionally, sitting upright facilitates swallowing, thus decreasing the risk of aspiration.³⁷ If the caregiver is present during mealtimes, the nurse can use this opportunity to model proper transfer techniques and body mechanics while narrating the actions, thereby coaching both caregiver and older adult.

If the older adult is on bed rest, the nurse can engage the caregiver in repositioning the older adult and assisting with range of motion exercises targeting the upper and lower extremities. The nurse can reinforce with the caregiver that frequent repositioning is necessary, especially if the older adult is unable to get out of bed.

Reviewing the hospital's fall risk protocol with the older adult and caregiver can be a teaching moment to promote safe mobility. Providing rationales for the protocol's individualized interventions reinforces their continuation at home. Stressing to the caregiver the importance of maintaining an unobstructed path to the bathroom, keeping the older adult's hearing aids and glasses on, and promoting adequate hydration throughout the day are all interventions to keep the older adult safe and to prevent falls both during the hospital stay and after discharge.

Finally, collaborating with caregivers on home mobility plans—while taking into consideration any concerns they may have about this aspect of their role—facilitates shared decision-making and accountability. Further, teaching caregivers specific skills helps to ensure a smooth transition home.³⁸ Consultations with the physical and occupational therapists can be integral to caregiver training. Physical therapists can discuss proper techniques for mobilization and educate the caregiver on the use of assistive devices, if needed, such as a cane, walker, wheelchair, or gait belt.³⁹ Occupational therapists can discuss mobility considerations for activities of daily living, such as using a bench for bathing or reorganizing the older adult's kitchen to avoid unnecessary reaching for objects.⁴⁰ Other home safety strategies to discuss with the older adult and caregiver include installing grab bars in the bathtub or shower, using night lights, and removing throw rugs, which are trip hazards.⁴¹

RESOURCES FOR CLINICIANS AND CAREGIVERS

Table 1 lists resources and tools for clinicians and caregivers to use in assessing and acting on mobility. These include safety and fall prevention checklists, mobility assessments, and evidence-based programs for older adults that promote fitness and balance, which are foundational to safe mobility. Additionally, nurses can refer family caregivers to the tear sheet, Information for Family Caregivers, which offers tips for addressing safe mobility during and after hospitalization.

Table 1. - Tools for Assessing and Acting on Mobility

Resources	Link
Try This: Age-Friendly Health Systems: The 4Ms	https://hign.org/sites/default/files/2020-06/Try_This_General_Assessment_35.pdf
CDC: MyMobility Plan	www.cdc.gov/injury/features/older-adults-mobility/index.html
CDC: STEADI Initiative	www.cdc.gov/steadi/index.html
CDC: STEADI: Stay Independent	www.cdc.gov/steadi/pdf/STEADI-Brochure-StayIndependent-508.pdf
CDC: STEADI: Check for Safety	www.cdc.gov/steadi/pdf/STEADI-Brochure-CheckForSafety-508.pdf
CDC: Timed Up and Go (TUG)	www.cdc.gov/steadi/pdf/TUG_test-print.pdf
CDC: Preventing Falls: A Guide to Implementing Effective Community-Based Fall Prevention Programs	www.cdc.gov/homeandrecreationalsafety/pdf/falls/fallpreventionguide-2015-a.pdf
NCOA: Falls Free CheckUp	www.ncoa.org/article/falls-free-checkup
NCOA: Evidence-Based Program: Geri-Fit Strength Training Workout for Older Adults	www.ncoa.org/article/evidence-based-program-geri-fit-strength-training-workout-for-older-adults
NCOA: Evidence-Based Program: Stay Active and Independent for Life (SAIL) Program	www.ncoa.org/article/evidence-based-program-stay-active-independent-for-life-the-sail-program
Johns Hopkins Medicine: Activity and Mobility Promotion	www.hopkinsmedicine.org/physical_medicine_rehabilitation/education_training/amp/toolkit.html
Arthritis Foundation: Walk with Ease Program	www.arthritis.org/health-wellness/healthy-living/physical-activity/walking/walk-with-ease
MaineHealth: A Matter of Balance Program	www.mainehealth.org/healthy-communities/healthy-aging/matter-of-balance

CDC = Centers for Disease Control and Prevention; NCOA = National Council on Aging; STEADI = Stopping Elderly Accidents, Deaths, and Injuries.

Box 1: Information for Family Caregivers

Resources for Nurses

• Why Mobility Matters
• https://links.lww.com/AJN/A215

Note: Family caregivers can access these videos, as well as additional information and resources, on AARP's Home Alone Alliance web page: www.aarp.org/nolongeralone.