Preventing Functional Decline in the Acute Care Setting   14  

Marie Boltz, Barbara Resnick, and Elizabeth Galik

OVERVIEW

As described in Chapter 7, “Assessment of Physical Function,” functional decline is a common complication in hospitalized older adults, even in those with good baseline function (Gill, Allore, Gahbauer, & Murphy, 2010). Loss of physical function is associated with poor long-term outcomes, including increased likelihood of being discharged from a hospital to a nursing home setting (Fortinsky, Covinsky, Palmer, & Landefeld, 1999), increased morbidity and mortality (Rozzini et al., 2005), increased rehabilitation costs, and decreased long-term functional recovery (Boyd, Xue, Guralik, & Fried, 2005; Boyd et al., 2008; Volpato et al., 2007). The immobility associated with functional decline results in infections, pressure ulcers, falls, and nonelective rehospitalizations (Gill, Allore, & Guo, 2004).

The promotion of function is a basic gerontological tenet, and functional recovery is perceived by older adults as a quality outcome of hospitalization (Boltz, Capezuti, Shabbat, & Hall, 2010). Moreover, older adults expect that an acute care stay will not result in functional decline but instead promote the resumption of normal roles and activities post-hospitalization. Although the acute care setting, with its focus on correcting the admitting medical problem, typically prioritizes nursing tasks, such as medication administration, coordination of care, and documentation over the promotion of function as a clinical outcome, there is growing awareness of the need to attend to the functional status of the hospitalized older adult (Nolan & Thomas, 2008; Resnick, Galik, Wells, Boltz, & Holtzman, 2015). This chapter addresses the trajectory of change in physical function during the acute care stay, the factors associated with functional decline, and function-promoting interventions that can potentially modify these factors. Finally, a clinical practice protocol to guide a unit-level approach to function-focused care (FFC; Protocol 14.1: Function-Focused Care Interventions) is provided.

PHYSICAL FUNCTION AS A CLINICAL MEASURE

Functional decline may result from the acute illness and can begin from preadmission and continue after discharge. In a seminal study, Covinsky et al. (2003) evaluated the changes in performing of activities of daily living (ADL) prior to and after hospitalizations of older adults with medical illness. More than one third declined in ADL function between baseline (2 weeks before admission) and discharge. This included the 23% of patients who declined between baseline and admission, and failed to recover to baseline function between admission and discharge, and the 12% of patients who did not decline between baseline and admission but declined between hospital admission and discharge. Older adults aged 85 years and older comprised the age cohort demonstrating the most functional loss, with rates exceeding 50%.

In their examination of the functional trajectory of hospitalized older adults, Wakefield and Holman (2007) also assessed function at baseline, as well as on admission and day 4. The largest change in functional status was a decline in ADL from baseline to the time of admission; ADL did not return to baseline during the first 4 days in the hospital. The older adults whose ADL scores declined during hospitalization (regardless of the baseline status) were more likely than others to die within 3 months of discharge.

The results of these studies demonstrate that ADL status is unstable in a large percentage of older adults during an acute illness (Covinsky, Pierluissi, & Johnston, 2011). Consequently, Covinsky et al. suggest that an older adult’s functional trajectory is a critical “vital sign,” an important prognostic marker, and indicator to guide care delivery and transitional care. Baseline function may serve as a useful benchmark when developing discharge goals. Older adults who have sustained loss of ADL function prior to admission would ideally have rehabilitation as a goal of their hospital care. For those patients who have acquired ADL disability from admission to discharge, aggressive postacute rehabilitation plans could be mobilized with the goal of promoting return to baseline function.

PATIENT RISK FACTORS FOR FUNCTIONAL DECLINE

Intrinsic vulnerabilities to functional decline include prehospitalization functional status (McCusker Kakuma, & Abrahamowicz, 2002; Zisberg et al., 2011), the presence of two or more comorbidities, and having had a hospitalization or emergency room visit in the previous 12 months (Covinsky et al., 2011; McCusker et al., 2002). Symptoms of depression both before and during hospitalization have also been associated with dependence in basic ADL at discharge, and 30 and 90 days after discharge (Covinsky, Fortinsky, Palmer, Kresevic, & Landefeld, 1997). Cognitive impairment, including delirium, increases the risk of functional decline in the older adults during and after hospitalization (Boltz, Resnick, Capezuti, Shuluk, & Secic, 2012; Inouye, Schlesinger, & Lydon, 1999; McCusker et al., 2002).

The aggregate number of geriatric conditions present at hospital admission determines a patient’s individual risk of functional deterioration (Buurman, van Munster, Korevaar, de Haan, & de Rooij, 2011). Polypharmacy, fall risk, use of an indwelling urinary catheter, urinary incontinence, vision impairment, and hearing loss (Buurman et al., 2012) are associated with a high risk of functional decline that persists 12 months after hospitalization. The patient’s fear of falling (Boltz, Resnick, Capezuti, & Shuluk, 2014), self-efficacy, outcome expectations (McAuley et al., 2006), and views on physical activity during hospitalization (Boltz, Capezuti, & Shabbat, 2011; Brown et al., 2007) influence the level of engagement in physical activity and mobility in older adults in general and thus may influence acute care functional outcomes.

THE CARE ENVIRONMENT AND FUNCTION

A social ecological perspective assumes that the physical, social, and organizational environments contribute to patient outcomes, including functional measures (Galik, 2010). The hospital environment, with its emphasis on biomedical interventions for acute medical and surgical problems, is challenged to “fit” the complex physical, social, and psychological circumstances, which predisposes the hospitalized older adult to functional decline. Parke and Chappell (2010) recommend that the older adult–hospital environment fit be viewed through four dimensions: care processes, social climate, policy and procedure, and physical design.

Hospital Care Processes

Hospitalization is associated with significantly greater loss of total, lean, and fat mass as well as strength in older persons. These effects appear particularly important in persons hospitalized for 8 days or more per year (Alley et al., 2010). Hospitalization itself may also pose risks for functional decline because of the deleterious effects of bed rest and restricted activity (Gill, Allore, Holford, & Guo, 2004). Bed rest results in loss of muscle strength and lean muscle mass (Kortebein et al., 2007), decreased aerobic capacity (Kortebein, Symons, & Ferrando, 2008), diminished pulmonary ventilation, altered sensory awareness, reduced appetite and thirst, and decreased plasma volume (Creditor, 1993; Harper, & Lyles, 1988; Hoenig & Rubenstein, 1999). Brown, Redden, Flood, and Allman (2009) describe bed rest and low mobility as an “underrecognized epidemic.” In their study of hospitalized older veterans, they used accelerometers to measure activity level. Despite the fact that the majority was able to walk independently (78%), 83% of the measured hospital stay was spent lying in bed.

Another study (Brown, Friedkin, & Inouye, 2004) that evaluated the outcomes associated with mobility found that bed rest in older adults was ordered at some point during hospitalization in 33% of the patients. Almost 60% of the observations indicated no documented medical reason for the bed rest. Physician’s orders for bed rest were present on the date of bed rest for only 92 (52%) of the 176 observations. Low mobility (defined as having an average mobility level of bed rest or bed to chair for the entire hospitalization) was compared to high mobility (ambulation two or more times with partial or no assistance, on average). The low mobility group had a statistically significant higher rate of ADL decline, new institutionalization, and death. Similarly, Zisberg et al. (2011) found that low versus high in-hospital mobility was associated with worse functional status at discharge and at 1-month follow-up, even in older adults who were functionally stable prior to admission.

Doherty-King, Yoon, Pecanac, Brown, and Mahoney (2014) shadowed RNs for two to three 8-hour periods using hand-held computer tablets to collect data on frequency and duration of mobility events (standing, transferring, walking to and from the patient bathroom, walking in the patient room, and walking in the hallway) that occurred in the nurse’s presence. They found that nurses infrequently initiated mobility events for hospitalized older patients and most often engaged patients in low-level activity (standing and transferring). Other research indicated that illness severity and reason for admission did not explain low levels of mobility, measured by a step-activity monitor (Fisher et al., 2011).

Care processes associated with immobility include physical restraints and “tethering devices,” such as catheters, intravenous lines, and medication, which contribute to delirium and/or cause sedation (Boltz, Resnick, Capezuti, Shabbat, & Secic, 2011; Brown, Roth, Peel, & Allman, 2006). Additionally, there is a tendency for staff to perform ADL for patients who could participate or do it for themselves, placing older adults at risk of loss of self-care ability (Boltz, Resnick, Capezuti, Shabbat, & Secic, 2011). This “doing for” as opposed to promoting functional independence is often associated with a lack of understanding of the patient’s underlying capability (Resnick, Galik, Boltz, & Pretzer-Aboff, 2011). Interprofessional rounds support a functional approach, with the goal of preventing functional decline and discharging the older adult to the least restrictive setting. Key elements to be addressed include functional assessment (baseline, admission, current ADL status, and physical capability), alternatives to the use of potentially restrictive devices and agents, and a plan for progressive mobility and engagement in ADL (Boltz, Resnick, Chippendale, & Galvin, 2014). Additionally, protocols that support delirium prevention and abatement, and optimize nutrition, while minimizing adverse effects of selected procedures (e.g., urinary catheterization) and medications (e.g., sedative-hypnotic agents) contribute to positive functional outcomes (Kleinpell, 2007).

Social Climate

Leadership commitment to rehabilitative values is essential to support a social climate conducive to the promotion of function (Boltz, Capezuti, & Shabbat, 2011; King & Bowers, 2013). Older adults have identified that respectful, encouraging communication and engagement in decision making as important to facilitating independence (Boltz et al., 2010; Jacelon, 2004). Staff education that addresses the physiology, manifestations and prevention of hospital-acquired deconditioning, assessment of physical capability, rehabilitative techniques, use of adaptive equipment, interprofessional collaboration, and communication that motivates are required to support a function-promoting philosophy (Boltz, Capezuti, & Shabbat, 2011; Gillis, MacDonald, & MacIsaac, 2008; Resnick, Galik, Boltz, & Pretzer-Aboff, 2011). Nursing staff have also described the need for well-defined roles, including areas of accountability for follow-through for function-promoting activities (Boltz, Capezuti, & Shabbat; King & Bowers, 2011). Clear communication of patient needs among staff, and dissemination of data (e.g., compliance with treatment plans and functional outcomes) also support these activities (Resnick et al., 2015).

Policy and Procedure

To foster function-promoting care, policies are needed that clearly define staff roles in assessing physical function and cognition and that implement identified interventions. Other supporting policies address identification and storage of sensory devices (e.g., glasses, hearing aids/amplifiers) and mobility and other assistive devices (Boltz, Capezuti, & Shabbat, 2011; Boltz, Capezuti, Shabbat, & Secic, 2011). Indicative of the low priority placed on mobility promotion is the common process of restricting the patients’ ability to walk to tests and procedures within the hospital.

Environment

Acute care environments directly impact patient function and physical activity. The bed is often the only accessible furniture in the room and the height of toilets, beds, and available chairs do not always fall within the range in which transfers and function are optimized (Capezuti et al., 2008). Accessible functional seating and safe walking areas with relevant destination areas promote functional mobility. Adequate lighting, nonglare flooring, door levers, and handrails (including in the patient room) are basic requirements to promote safe mobility (Betrabet Gulwadi & Calkins, 2008; Ulrich et al., 2008). Environmental enhancements to promote orientation include large-print calendars and clocks (Kleinpell, 2007) and control of ambient noise levels, especially in critical care units (Gabo, 2003).

INTERVENTIONS TO PROMOTE PHYSICAL FUNCTION

Support for Cognition

Cognition and physical function are closely linked in older adults. The ability to engage in ADL and physical activity requires varying types and degrees of cognitive capability, including memory, executive function, and visual-spatial ability. Therefore, an appraisal of the older adult’s cognition (baseline, admission, and ongoing) is an essential activity associated with promoting physical function (see Chapter 6, “Assessing Cognitive Function”) in order to develop, implement, and evaluate a plan to promote maximum physical functioning (Coelho, Santos-Galduroz, Gobbi, & Stella, 2009; Yu, Kolanowski, Strumpf, & Eslinger, 2006).

Interventions to prevent, detect, and manage delirium are associated with improved cognition and thus are integral components of a plan to prevent functional decline (Foreman, Wakefield, Culp, & Milisen, 2004). Liberal visiting hours and familiar items brought in from home (e.g., photos, blankets) provide meaningful sensory input, and along with control of excessive noise and attention to sleep hygiene enhance function-promoting interventions (Landefeld, Palmer, & Kresevic, Fortinsky, & Kowal, 1995). Diversional activities, such as TV, movies, and word games, are associated with “keeping the mind active” and engagement in self-care and physical activity (Boltz et al., 2010). For patients with cognitive challenges, including dementia, activity kits that include tactile, auditory, and visual items enhance cognitive integration, perceptual processing, and neuromuscular strength as well as provide solace and an opportunity for emotional expression and relief from boredom. Activity kits can include a wide range of items such as audiotapes and nontoxic art supplies. In addition, items, such as pieces of textured fabric, clothes to fold, tools, and key-and-lock boards are included for the person with more advanced dementia (Conedera & Mitchell, n.d; Glantz & Richman, 2007). For more information, see Chapter 17, “Delirium: Prevention, Early Recognition, and Treatment.”

Older adults with cognitive impairment can benefit from function-promoting interventions with demonstrated improvements in physical and cognitive function (Boltz, Chippendale, Resnick, & Galvin, 2015b). An understanding of the person’s values, past experiences, and relationships supports meaningful communication to motivate them, along with the use of humor and verbal cues (Galik, Resnick, & Pretzer-Aboff, 2009). In addition, teamwork with other nursing staff, rehabilitative staff, medical providers, and families was considered a key component in facilitating self-care and physical activity (Boltz, Resnick, Chippendale, & Galvin, 2014; Boltz, Chippendale, Resnick, & Galvin, 2015a).

In addition, adapted communication techniques are necessary to accommodate receptive difficulties associated with cognitive impairment, including dementia. The ability to participate in ADL is often more preserved than clinicians believe, as activities, such as washing the face, brushing one’s teeth, and walking, rely on psychomotor memory, which is preserved even in those with moderate to severe cognitive impairment. Communicating with short simple verbal requests, visual cues, and modeling the activity can be helpful in promoting independence in ADL (e.g., assist the person to the sink, set them up to brush their teeth, hand them a toothbrush, and model the behavior; Resnick, Galik, Boltz, & Pretzer-Aboff, 2011).

Physical Therapy and Exercise

Interventions, such as physical therapy and individualized, targeted exercise programs as soon as possible post-admission, have all been tested as ways in which physical activity could be increased and deconditioning and functional decline in hospitalized older adults could be prevented. A single-blinded randomized controlled trial was conducted in a tertiary metropolitan hospital involving 180 acute general medical patients aged 65 years or older (Jones et al., 2006). In addition to usual physiotherapy care, the intervention group performed an exercise program for 30 minutes, twice daily, with supervision and assistance provided by an allied health assistant (AHA). In older adults with low admission ADL scores (modified Barthel Index score less than or equal to 48), there was improvement in function among individuals exposed to the exercise interventions versus those who were not. Similarly, an individually tailored exercise program to maintain functional mobility, prescribed and progressed by a physical therapist, and supervised by an AHA, provided in addition to usual physiotherapy care, was associated with reduced likelihood of referral for nursing home admissions (Nolan & Thomas, 2008). Despite the known benefit of staying engaged in function and physical activity when hospitalized, a 2007 Cochrane review (de Morton, Keating, & Jeffs, 2007) concluded that, in general, patient participation in these programs has been poor. Challenges to feasibility and implementation of these interventions include competing care demands (e.g., test schedules), illness severity, short hospital stays, a general unwillingness of patients to consent to or actively participate in exercise interventions, and a persistent belief among patients that bed rest will assure recovery (Brown, Peel, Bamman, & Allman, 2006; de Morton et al., 2007; de Morton, Keating, Berlowitz, Jackson, & Lim, 2007).

Functional Mobility Programs

One of the most common forms of physical activity encouraged in acute care settings are functional mobility programs. Mobility is conceptualized as a continuum progressing from bedbound to independent walking (Callen, Mahoney, Wells, Enloe, & Hughes, 2004). The benefits of interventions aimed at promoting functional mobility have recently received growing attention. A literature review conducted by Kalisch, Soohee, and Dabney (2013) identified benefits of mobility programs in four areas: (a) physical outcomes (less delirium, pain, urinary discomfort, difficulty voiding, urinary tract infection, deep vein thrombosis, fatigue, and pneumonia, as well as increased walking and ADL performance, and ventilator-free days), (b) psychological outcomes (less depression, anxiety, and symptom distress, as well as increased comfort and satisfaction), (c) social outcomes (improved quality of life and independence), and (d) organizational outcomes (decreased length of stay, mortality, and cost).

Tucker, Molsberger, and Clark (2004) demonstrated the feasibility of a “Walking for Wellness” program that consisted of a patient education program, a screening process to identify patients who would benefit from physical therapy, and daily walking assistance from cross-trained transportation staff. Walking opportunities included “walking trails” marked inside the hospital, with markers placed every 10 feet at the baseboard of the hallways providing a measure of walking distance, as well as a visual incentive for patients walking in the halls. Unless otherwise indicated by the medical provider, the goal for participants was to walk in the hallways two to three times a day with trained escorts, nursing staff, family, or friends. Weitzel and Robinson (2004) developed an educational program for nursing assistants on a medical unit that emphasized promoting the functional status of hospitalized elders. Content included therapeutic communication, promotion of functional mobility, skin care, and eating/feeding problems. Discharge destination (home or nursing home) and length of stay were compared for patients pre- and postimplementation. There was a significant reduction in length of stay (2.4 days) and increase in the percentage of patients discharged to the home setting.

The positive association between mobility and shorter lengths of stay was also supported in an acute care for elderly (ACE) unit, where ambulation was measured by a step monitor (Fisher et al., 2011). Patients on the ACE unit who had shorter stays tended to ambulate more on the first complete day of hospitalization and had a markedly greater increase in mobility on the second day than patients with longer lengths of stay.

To address motivational issues, Mudge, Giebel, and Cutler (2008) evaluated a functional mobility program enhanced with cognitive interventions. This research team used an individualized, graduated exercise and mobility program with an activity diary, progressive encouragement of functional independence by nursing staff and other members of the multidisciplinary team, and cognitive stimulation sessions in older adults aged 70 years and older on a medical unit. The intervention group had greater improvement in functional status than the control group, with a median modified Barthel Index improvement of 8.5 versus 3.5 points (p = .03). In the intervention group, there was a reduction in delirium (19.4% vs. 35.5%, p = .04) and a trend toward reduced falls (4.8% vs. 11.3%, p = .19; Mudge et al., 2008).

In patients recovering from hip surgery, functional mobility programs are enhanced with measures to prevent postoperative complications. Siu, Penrod, et al. (2006) and Siu, Boockvar, et al. (2006) found that positive processes related to mobilization (including time from admission to surgery, mobilization to and beyond the chair, use of anticoagulants and prophylactic antibiotics, pain control, physical therapy, catheter and restraint use, and active clinical issues) were associated with improved locomotion and self-care at 2 months post-discharge. Patients who experienced no hospital complications and no readmissions retained benefits in locomotion at 6 months. Olson and Karlsson (2007) demonstrated that interventions focused on skin care, pain control, and progressive ambulation yielded improved functional discharge outcomes. See Chapter 34, “Care of the Older Adult With Fragility Hip Fracture.”

Critical Care Initiatives to Prevent Functional Decline

The geriatric imperative to support physical function has also been recognized in critical care, and studies are emerging that examine mobility promotion in the critically ill patient, including older adults. A study conducted in a respiratory intensive care unit (RICU) examined the feasibility of early mobility as well as its safety in six activity-related adverse events: fall to knees, tube removal, systolic blood pressure greater than 200 mmHg, systolic blood pressure less than 90 mmHg, oxygen desaturation less than 80%, and extubation. There were less than 1% activity-related adverse events; the majority of survivors (69%) were able to ambulate farther than 100 feet at RICU discharges (Bailey et al., 2007).

Nurse-led mobility protocols have increased the rate of ambulation of patients in critical care units. A multidisciplinary team developed and implemented a mobility order set with an embedded algorithm to guide nursing assessment of mobility potential. Based on the assessments, the protocol empowers the nurse to consult physical therapists or occupational therapists when appropriate. Daily ambulation status reports were reviewed each morning to determine each patient’s activity level (Drolet et al., 2013). Similarly, a mobility team (critical care nurse, nursing assistant, physical therapist) in a medical intensive care unit initiated a mobility protocol for patients with acute respiratory failure. The protocol consisted of progressive mobility interventions ranging from passive range of motion for unconscious patients, to active, assistive, and active range-of-motion exercises, to functional activities such as transfer to edge of bed; safe transfers to and from bed, chair, or commode; seated balance activities; pregait standing activities (forward and lateral weight shifting, marching in place); and ambulation. As compared to usual care (passive range-of-motion only), protocol patients were out of bed earlier (5 vs. 11 days, p ≤ .001), had therapy initiated more frequently in the intensive care unit (91% vs. 13%, p ≤ .001), and had similar low complication rates. For protocol patients, the intensive care unit length of stay was 5.5 versus 6.9 days for usual care (p = .025) and the length of hospital stay for protocol patients was 11.2 versus 14.5 days for usual care (p = .006). (The intensive care unit/length of hospital stay was adjusted for body mass index, acuity, and use of a vasopressor.) There were no adverse events during an intensive care unit mobility session and no cost difference between the protocol and usual care costs (Morris et al., 2008).

FFC: A Multimodal Intervention

FFC is a comprehensive, system-level approach that prioritizes the preservation and restoration of functional capability. It is predicated on the philosophy that physical function is as important a treatment goal as correcting the acute admitting problem, and recognizes the multifactorial nature of functional decline (Resnick, Galik, & Boltz, 2013). FFC utilizes a philosophy of care in which nurses acknowledge older adults’ physical and cognitive capabilities with regard to function and integrate functional and physical activities into all care interactions. The components of FFC are:

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