causes, management of immobility, deconditioning

1. Immobility
Dr. DoHA RASHEEDY ALY
Lecturer of Geriatric Medicine
Department of Geriatric and Gerontology
Ain Shams University

3. Bed rest benefits in acute
conditions
• Reduces oxygen needs
• Decreases pain levels
• Helps in regaining of strength
• Uninterrupted rest has psychological and
emotional benefits

4. "Bed is Bad"

5. Unfortunately!!!!!!
• the health-care system tends to
promote immobility in patients.
• Patients are frequently restrained by
either physical restraints, chemical
restraints (sedatives), or treatment
restraints (IV, oxygen, catheters).
• Deconditioning occurs at a faster rate
than reconditioning.

6. • Immobilization – physical restriction of
movement to body or a body segment
• Deconditioning – decreased functional
capacity of multiple organ systems

7. AGE-RELATED CHANGES IN MOBILITY
• Normal gait is dependent on the integrity
and interaction of three components:
1. Locomotion.
2. Balance.
3. The ability to adapt to the environment

8. Walking speed
• The gait is 20% slower natural velocity is
secondary to reduction in stride length and
that cadence (steps per minute) is well
maintained.
• Reduced gait speed has been advocated
as a marker of frailty

9. Gait initiation
• Gait initiation is well preserved in healthy
older people.
• Abnormalities of gait initiation are a
sensitive but not specific sign of disease
processes in older people, such as
Parkinson’s disease, multiple cerebral
infarcts

10. Rising from a chair
• Reduced range of motion in the hips,
pelvis, knees, and spine is common with
aging and impedes the initial shift of the
total body center of mass over the feet.
• Weakness of the hip girdle muscles is
also a frequent finding in older people, a
manifestation of deconditioning, and those
affected may need to use their arms to
help themselves upwards.

11. CAUSES
• Physical.
• Psychological.
• Environmental.

12. Physical
• Musculoskeletal disorders
Arthritis‘
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)
Coronary artery disease (frequent angina)
Peripheral vascular disease (frequent claudication)
• Pulmonary disease
Chronic obstructive lung disease (severe)

13. • Acute and chronic pain
• Deconditioning (after prolonged bed rest from acute illness)
• Malnutrition
• Severe systemic illness (e.g., widespread malignancy)
• Drug side effects (e.g., antipsychotic-induced rigidity,
Sedatives and hypnotics, by causing drowsiness and ataxia,
blurred vision by anticholinergic, postural hypotension
diuertics , vasodilators)
• Sensory factors Impairment of vision

14. Psychological
• Fear (from instability and fear of falling)
• Depression

15. Environmental causes
• Forced immobility (in hospitals and nursing
homes)
• Inadequate aids for mobility.
• Poor lightening.

16. Effects of Immobility
• Phisiologically
– No body system is immune to affects of
immobility
– Effects depend upon a client’s health, age,
and degree of immobility

17. COMPLICATIONS
• Decreased mobility and increased bed-
rest adversely affect almost every system
of the body.
• Prolonged inactivity or bed rest has
adverse physical and psychological
consequences

18. Skin Genitourinary
Pressure ulcers Urinary infection
Musculoskeletal
Urinary retention
Muscular deconditioning and atrophy
Bladder calculi
Contractures
Bone loss (osteoporosis) Incontinence
Cardiovascular Metabolic
Deconditioning Altered body composition (e.g.,decreased
Orthostatic hypotension plasma volume)
Venous thrombosis, embolism Negative nitrogen balance
Pulmonary Impaired glucose tolerance
Decreased ventilation Altered drug pharmacokinetics
Atelectasis
Psychological
Aspiration pneumonia
Gastrointestinal
Sensory deprivation
Anorexia Delirium
Constipation Depression
Fecal impaction, incontinence

19. Skin
• Trauma to fragile skin, including ecchymosis
and skin tears, occur when elders need
more assistance getting up and down;
• Immobility threatens healthy skin integrity
and can become severe enough to result in
pressure ulcers; The first sign of this is
redness that won't blanch
• .

20. Pressure Areas

21. Musculoskeletal
• Muscle: disuse atrophy "if you don't use it, you'll
lose it,"
Loss of muscle strength, Muscle atrophy (begins after 1 day of
immobilization. 1-3%/day Muscles may lose half of their bulk after 2
months)
• Bone: increased bone resorption (osteoporosis)
Increased risk of fracture, dorsal kyphosis, and chronic
back pain 1% loss of vertebral mineral content per week)

22. • Joints:
• Immobilization can induce cartilage degeneration.
The body attempts to repair joints through cartilage
proliferation, osteophyte formation, and fibrofatty
infiltration of the joint cavity.
• Contractures (contributing factors include spasticity,
improper bed positioning, and maintaining the limb in
a shortened position) Muscles, CT that cross two
joints are at increased risk for contractures.
development of contractures, further impaired
mobility, resulting in more joint tightness and
contractures.
• Joint stiffness and pain :if joints are not given
adequate full range of motion. The stiffness is due to
tightness of the muscles and tissues surrounding the
joints.

23. Genitourinary
Decreased voiding (stasis)
↓
• Increased post-void residual volume, retention
• Increased risk of urinary tract infections
• Increased risk of calculus formation

24. Venous thrombosis, embolism
venous stasis + increased blood coagulability+
decreased plasma volume

25. Cardiovascular
↑
1) decreased coronary
blood flow and
heart rate (1 beat/ decreased O2
minute every 2 days) available to cardiac
2ry to increased sympathetic activity muscles
↓
decrease in diastolic filling time 1)•
and a decreased systolic ejection
2)↓ CO, SV
time2).

26. • Orthostatic hypotension (begins after 3
weeks of bed rest ) due to:
1. excessive pooling of blood in the lower
extremities
2. decreased circulating blood volume
• 20 days of bed rest may lead to a 25%
decrease in stroke volume and a 20%
increase in heart rate.

27. Gastrointestinal
• Constipation
– weakening of the abdominal wall muscles,
leading to difficulty in raising the intra-
abdominal pressure sufficiently for defecation
– loss of privacy and embarrassment if toilet
assistance is needed.
– Bowel irregularity may produce abdominal
discomfort, as well as cause loss of appetite.

28. Endocrine
• Decreased basal metabolic rate (which can lead to diuresis, natriuresis,
and fluid shifts(↓plasma volume)
• Negative nitrogen balance
• Glucose intolerance
• Hypercalcemia (symptoms of hypercalcemia include anorexia, abdominal
pain, nausea, malaise, headache, polydipsia, polyuria, lethargy,and
coma). Symptoms may occur within 2–4 weeks.
• Decreased parathyroid hormone
• Increased plasma renin activity
• Increased aldosterone secretion
• Altered growth hormone production
• Altered spermatogenesis and androgen secretion
• Altered circadian rhythm

29. • Urinary loss of:
– Nitrogen – (begins day 5-6, peaks at 2 weeks)
– Calcium – (begins day 2-3, peaks at 4-6
weeks)
– Phosphorus
• Reversible post mobilization

30. Pulmonary
• ↓strength of respiratory muscles→↓tidal volume , minute volume,
respiratory capacity
• ↑respiratory rate to compensate for decreased respiratory capacity
• ↓ability to clear secretions (cough reflex)
Accumulation of secretions in the lower bronchial tree, which can block airways,
cause atelectasis and increase the risk of pneumonia.

31. psychological
• Increased immobility may result in a loss
of independence and can cause the elder
client to have a sense of isolation and
even depression as they become less able
to navigate their world
• Behavior disturbances
• Anxiety
• Sleep disturbances

32. Immobility often cannot be prevented, but
many of its adverse effects can be
• Optimize the treatment of underlying diseases.
• For ulcer prevention:
– Proper positioning, change positions at least every two hours
– Air mattress, keep skin dry and clean

33. • Fowler
• Semi Fowler
• Lateral sim’s position

34. For contracture prevention
• Do stretching and range-of-
motion exercises to each of the
joints everyday, and several
times a day( active better than
passive).
• Maintain proper body
alignment, therapeutic splints.
• Pain control , treatment of
spasticity.

35. ROM

36. Stretching

38. • Focus on abilities and not disabilities: the
use of assistive devices and making the
home accessible.

39. Assistive devices

40. Anticoagulation, elastic stocking, intermittent pneumatic
compression.

41. Methods of Airway Secretions
Elimination
• Oral, nasal, or transtracheal suctioning
• Chest percussion and postural drainage
• Flutter mucus clearance devices
• Mechanical vibration devices to the chest
wall

43. • Maintain an adequate fluid intake (thick
secretion ,constipation, UTI, renal stones,
dehydration, clotting.
• Nutritional support
• High protein, high calorie diet
• Supplemental vitamin C
• Vitamin B complex
• Psychological support.

44. OCCUPATIONAL THERAPY IN THE MANAGEMNET OF
IMMORBILE OLDER PATIENTS
Medalities
1. Assessment of mobility
2. Bed mobility
3. Transfers
4. Wheelchair propulsion
Assessment of other ADL using actual or simulated environments
1. Dressing
2. Toileting
3. Bathing and personal hygiene
4. Cooking and cleaning
Visit home for enviornmental assessment and recommentations for adaptation
1. Recommend and teach use of assisitive devices (cane, crutches)
2. Recommend and teach use of safety devices (e.g., grab bars and railing, raised toilet seats,
shower chairs)