1. IMMOBILITY
By,
SAGAR SHARMA

5. • Immobility
• Immobility is a common pathway by which a host of
diseases and problems in older individuals produce
further disability. Immobility often cannot be
prevented, but many of its adverse effects can be.
Improvements in mobility are almost always possible,
even in the most immobile older patients. Relatively
small improvements in mobility can decrease the
incidence and severity of complications, improve the
patient's well-being, and make life easier for caregivers

6. • CAUSES
• Many physical, psychological, and
environmental factors can cause immobility in
older persons . The most common causes are
musculoskeletal, neurological, and
cardiovascular disorders. Pain is a common
pathway by which these disorders result in
immobility

7. • TABLE 10-1 COMMON CAUSES OF IMMOBILITY IN OLDER
ADULTS
• Musculoskeletal disorders
Arthritides
Osteoporosis
Fractures (especially hip and femur)
Podiatric problems
Other (e.g., Paget's disease)
Neurological disorders
Stroke
Parkinson's disease
Other (cerebellar dysfunction, neuropathies)
Cardiovascular disease
Congestive heart failure (severe)

8. • Coronary artery disease (frequent angina)
Peripheral vascular disease (frequent claudication)
Pulmonary disease
Chronic obstructive lung disease (severe)
Sensory factors
Impairment of vision
Fear (from instability and fear of falling)
Environmental causes
Forced immobility (in hospitals and nursing homes)
Inadequate aids for mobility
Acute and chronic pain
Other
Deconditioning (after prolonged bed rest from acute illness)
Malnutrition
Severe systemic illness (e.g., widespread malignancy)
Depression
Drug side effects (e.g., antipsychotic-induced rigidity)

9. • COMPLICATIONS
• Immobility can lead to complications in almost every
major organ system . Prolonged inactivity or bed rest
has adverse physical and psychological consequences.
Metabolic effects include negative nitrogen and
calcium balance and impaired glucose tolerance;
diminished plasma volume and altered drug
pharmacokinetics can result. Immobilized older
patients often become depressed, are deprived of
environmental stimulation, and, in some instances,
become delirious. Deconditioning can occur rapidly,
especially among older people with little physiological
reserve.

10. • COMPLICATIONS OF IMMOBILITY
• Skin
Pressure ulcers
Musculoskeletal
Muscular deconditioning and atrophy
Contractures
Bone loss (osteoporosis)
Cardiovascular
Deconditioning
Orthostatic hypotension

11. • Venous thrombosis, embolism
Pulmonary
Decreased ventilation
Atelectasis
Aspiration pneumonia
Gastrointestinal
Anorexia
Constipation
Fecal impaction, incontinence
Genitourinary

12. • Urinary retention
Bladder calculi
Incontinence
Metabolic
Altered body composition (e.g., decreased plasma
volume)
Negative nitrogen balance
Impaired glucose tolerance
Altered drug pharmacokinetics
Psychological
Sensory deprivation
Delirium
Depression

13. • ASSESSING IMMOBILE PATIENTS
• Several aspects of the history and physical examination are important in
the assessment of immobile patients . Useful historical information
includes the extent and duration of disabilities causing immobility, the
underlying
•
medical conditions that influence mobility, and a review of medications in
order to eliminate iatrogenic problems contributing to immobility. Pain
should be routinely assessed as it may be a major contributing factor.
Standardized pain assessment tools have been recommended for this
purpose (AGS Panel on Persistent Pain in Older Persons, 2002).
Psychological factors, such as depression and fear, may contribute to
immobility and may make recovery difficult. They should, therefore,
receive special attention

14. • ASSESSMENT OF IMMOBILE OLDER PATIENTS
• History
Nature and duration of disabilities causing
immobility
Medical conditions contributing to
immobility
Pain
Drugs that can affect mobility
Motivation and other psychological factors
Environment
Physical examination

15. • Skin
Cardiopulmonary status
Musculoskeletal assessment
Muscle tone and strength (see Table 10-4)
Joint range of motion
Foot deformities and lesions
Neurological deficits
Focal weakness
Sensory and perceptual evaluation
Levels of mobility
Bed mobility
Ability to transfer (bed to chair)
Wheelchair mobility
Standing balance
Gait
Pain with movement

16. • EXAMPLE OF A GRADING SYSTEM FOR MUSCLE STRENGTH IN
IMMOBILE OLDER PATIENTS
• GRADE OBSERVED STRENGTH
• Normal 5
• Good 4 Muscle produces movements against gravity and can
overcome some resistance
• Fair 3 Muscle produces movements against gravity but
cannot overcome any resistance
• Poor 2 Muscle produces movements but not against gravity
• Trace 1 Muscle tightens but cannot produce movement, even
after gravity is eliminated
• None 0 Muscle does not contract at all

17. • Most importantly, the patient's mobility should be
assessed and reassessed on an ongoing basis. There
are several levels of mobility as well as important
distinctions within each level. For example, a patient
may be bed-bound but may be able to sit up without
help, or the patient may be able to transfer
independently into a wheelchair, but be unable to
propel the wheelchair. Pain should also be assessed
during mobility because patients may deny pain at rest
but experience considerable pain with movement.
Rehabilitation therapists are skilled in making these
detailed evaluations of mobility and should be involved
in the care of immobile patients.

18. • MANAGEMENT OF IMMOBILITY
• Optimal management of immobile older patients necessitates a
thorough assessment, specific diagnoses, and multimodal
treatment directed at specific diseases
•
and disabilities. This process generally involves a team of health
professionals. Physical and occupational therapists can be especially
helpful in the assessment and management of immobility and
associated functional disabilities, and they should be consulted as
early as possible when the problem of an immobile patient
presents itself. In many patients, mobility cannot be completely
restored and intensive rehabilitative efforts will not be cost-
effective. Specific goals must be individualized, and in some
patients these goals will involve preventing complications of
immobility and adapting the environment to the individual (and
vice versa).

19. • It is beyond the scope of this text to detail the
management of all conditions associated with
immobility in older adults; important general
principles of the management of some of the
most common of these conditions are
reviewed.

20. • Specific diagnoses for these conditions should be made whenever
possible, because the most appropriate treatment(s) of the primary
disorders, as well as associated abnormalities, may differ. For
example, polymyalgia rheumatica is a common condition in elderly
women; its clinical features are often nonspecific—fatigue,
malaise, muscle aches. Because this disorder necessitates
treatment with systemic steroids and is highly associated with
temporal arteritis (a disease that can rapidly lead to blindness if
appropriate treatment is not instituted), it is essential to make this
diagnosis. Older patients with fatigue and symmetrical muscle
aches (especially in the shoulders) should be tested for
sedimentation rate, which will generally be markedly elevated
(approximately 75 percent of patients have values greater than 40
mm/h in polymyalgia rheumatica.

21. • Any symptoms suggestive of involvement of the
temporal artery—headache, jaw claudication,
recent changes in vision—especially when the
sedimentation rate is very high (greater than 75
mm/h) should prompt consideration of temporal
artery biopsy because treatment of temporal
arteritis requires higher doses of steroids than
does the treatment of polymyalgia alone. Patients
with polymyalgia are generally treated with 10 to
20 mg of prednisone in a single dose, whereas
patients with temporal arteritis are treated with
40 to 80 mg of prednisone daily in divided doses.

22. • Another example of the importance of making a
specific diagnosis is the carpal tunnel syndrome. This
disorder may be overlooked when symptoms of pain,
weakness, and paresthesias in the hand are mistaken
for osteoarthritis.
•
Objective weakness, sensory deficit, and atrophy of
intrinsic musculature of the hand should prompt
consideration of performing nerve conduction studies
and surgical therapy to relieve symptoms and prevent
progressive disability. Wrist splints, generally provided
by occupational therapists, are sometimes effective in
relieving the discomfort of this syndrome.

23. • The history and physical examination can be
helpful in differentiating osteoarthritis from
inflammatory arthritides ; however, other
procedures are often essential. Osteoarthritis
itself may be inflammatory in some instances.

24. • Synovial fluid analysis can be especially helpful in
differentiating osteoarthritis from crystal-induced
arthritides such as gout and pseudogout (Table 10-5).
Because clinical examination alone cannot determine
whether an inflamed joint is infected and joint infections
can occur in conjunction with other inflammatory joint
diseases, all newly inflamed joints should be tapped, Gram
stained, and cultured to rule out infection. Failure to
diagnose and treat joint infections can lead to
osteomyelitis, joint destruction, and permanent disability.
• In addition to making specific diagnoses of rheumatological
disorders whenever possible, careful physical examination
can detect treatable nonarticular conditions such as
tendinitis and bursitis.

25. • For example, bicipital tendinitis and
trochanteric bursitis are common in geriatric
patients. Dramatic relief from pain and
disability from these conditions can be
achieved by local treatments such as the
injection of steroids.

26. • 2) An immobile patient as compared to mobile
persons can develop at Night all of the
following except
• A)DVT
• B)Pulmonary embolism
• C)Delusion
• D)Abnormal blood flow at night