IMMOBILITY

Look at a patient lying long in bed. What a pathetic picture he makes? The blood clotting in his veins; the lime draining from his bone; the scybala stacking up in his colon; the flesh rotting from his seat; the urine leaking from his distended bladder; and the spirit evaporating from his soul (Asher-1947) Common pathway and result of many disease Often cant be prevented but complications can be Small improvement in mobility can result in very significant improvement in lifestyle and caregiver aid e.g improvement from a 2 person transfer to a one person transfer may be very significant

A competen Approach to the immobile patient requires A systemic review of all the possible causes Specific attention to all the possible complications An organized response to each of them Time course of Physiologic changes during bed rest 0 - 3 days Urinary Diuresis Urinary calcium loss Decreased plasma, interstitial and extracellurer fluid volume Decreased calf blood flow Glucose intolerance Decreased G accelerance tolarance Time course of Physiologic changes during bed rest 4 - 7 days Creatinuria Negative N2 balance Tilt table intolerance Time course of Physiologic changes during bed rest 8 - 14 days Decreased red cell mass Decreased leukocyte phagocytosis ability Time course of Physiologic changes during bed over 15 days Peak hypercalciuria Secondary increase in auditory threshold Decreased G tolerance Clinical Result Cardiovaskular decreased left ventrikular function, orthostatic hypotension Haematological increased clotting, decreased red blood cell mass Musculo-skeletal decreased strenght (3% per day), decreased bone (vertebrae 0,9% per week) Metabolic : negative nitrogen balance, decreased glucose tolerance Neurological : sensory deprivation Anecdotal : constipation, psychological state Total inactivity result in a loss of muscle strenght of >>3% per day muscles of ambulation especially at rest Negative calcium balance lumbar spine mineral context decreases by 0,9 % /week for 4 weeks Recovery took 4 months Common causes of immobility in the elderly Musculo- skeletal -Arthritis

-Osteoporosis with fractures -Fractures (hip and or femur) Neurological: Stroke, parkinsons disease, cerebellar dysfunction, neuropathy-fear of falling Cardiovaskuler severe Congestive Heart Failure: -Severe CAD (freguent agina) -Severe Peripheral Vaskular Disease (freguent Claudication) Pulmonary Disease COPD (Chronic Obstructive Pulmonary Disease) Sensory factors imparied vision Fear both instability and a fear of falling (Gait impairment) Enviromental enforced immobility Inadequate aids of mobility -as a treatment -fear of litigation Other -deconditioning -depression -drug side effects: antipsychotic induced rigidity pain malnutrition

The Milieu interview and aging instability of homeostatic control mechanism well ilustrated by complications of mobility Complucation of immobility Skin : pressure sores Musculo skeletal Atrophy, contractures - shortened Achilles tendon walking on tip toes, osteoporosis CVS (Cerebro Vaskulae Syndrom): orthostatic hypotension, venous thrombosis and embolism Respiratory : atelectasis lead to infection and hypoxia aspiration pneumonia Gastrointestinal : anorexia, constipation Genitourinary urinary infection, stones-due to hypercalciurea, incontinence-urinary retention Psychological: sensory deprivation, depression, dementia;delirium Document Extent and duration of disability Underlying medical conditions Review medications to avoid IATROS Asses psychological factory: -depression, -fear Asses environment: - overhead trianglel, - Bedside commode Examination should consist of Skin exam : presence of pressure sores CVS exam : intravaskuler volume Muskulo skeletal exam: muscle tone and strenght, testing of ROM, foot deformity and lesions Neurological Exam : focal weakness, haemianopsia, neglect of 1 side, apraxias Document level of mobility Assess regulary : bed mobility, bed to chair (transfer), wheel chair mobility, standing balance, gait Physical activity in old age (Editorial Lancet Dec 1986): Concept of threshold for indepence a small improvent in the persons mobility can have a huge impact on the persons quality of life Max O2 uptake, muscle mass & power, decreased by 1 % 1 year in normal aging At age 85 2 weeks in bed may result in problems with dressing and undressing Healthy 80 year old : maximum quadriceps contraction to rise from a low armless chair (or from toilet), -IE after 1 week of bed rest, a healthy 80 year old will not be able to get up from a toilet seat

Basic Principles of Rehabilitation in the elderly Treat : underlying discuses, makespesific diagnosis, prevent Set realistic goals : emphasize functional independence, enchance Utilize a team approach motivation both patron & caregiver(s)

Objectives: relieve pain; evaluate maintance & improve; evaluate and improve strenght, endurance, motor skull; evaluate and improve gait and stability; assess the need for teaching and use of aids

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 (Asher- 1947).]