Transcript Slide Presentation - Curriculum for the Hospitalized Aging Medical

CHAMP
Early to Bed, Early to Rise:
The Adverse Consequences of Bed Rest
Deón Cox Hayley, DO
University of Chicago
Objectives
What you want to teach, ie goals
and their explicit content
What you want students to begin
doing as a result of the learning in
this module
How you expect to teach students
to know/do, ie specific teaching
methods
Poor functional outcomes associated
with hospitalization in the elderly
Recognize the serious
consequences of bedrest
Power point lecture with
pictures/graphics
Specific organ pathophysiology
associated with prolonged bed rest
Identify certain consequences as
potentially preventable and be able
to explain these to trainees.
Case based lecture
Most hospitalized patients should not
be on complete bedrest.
Change physician’s perception of
writing an order for physical therapy
as fulfilling their obligation to help
patients get out of bed
Discuss exceptions to indications
for getting out of bed
•Brainstorm ways to broaden the
approach to getting people out of
bed.
Outline--Adverse Effects of Bed Rest
1. Case
2. History of use
3. Elderly as important sub-group
a. special concerns
4. How Bed Rest affects:
a. Function
b. Individual organ systems
5. Summary
Get people out of bed!
Patient G.J.
78 y/o female
Admitted to sub-acute rehabilitation (in
NH)
HPI: s/p surgical repair of traumatic
right knee fracture then dislocation
PMH: OA, DM, HTN, bipolar disease
Soc Hx: Husband does most IADLs,
independent in ADLs and ambulatory
Exam:
• Gen: flattened affect
• Obese
• Long leg cast on right
(thighankle)
Function:
• On admission
– NWB on right leg, transfer on left
leg
– Needed assistance of 2
• Goal
– Get back to previous status at
home
Knee fracture
pain
constipation
narcotics
urinary retention
Bed rest
weight gain
worsened DM
delirium
weakness
poor motivation
incontinence
pressure sores
IMMOBILITY
Follow up
• Discharged home, walking with a walker
Sick role model
• Doctor authority
• Hospital disorienting, threatening to older
patients
• Study of elderly hospitalized patients
showed that 72% didn’t ambulate in the
halls at all.
Mahoney J. Wisc Med J. 1999.
Practice of using bed rest
Dramatically decreased:
1. OB
2. Surgery
a. General
b. Orthopedics
3. Cardiology
a. Post-MI
b. CHF
Still too much in general medicine
For if the whole body is rested much more than
is usual, there is no immediate increase in
strength. In fact, should a long period of
inactivity be followed by a sudden return to
exercise there will be an obvious deterioration.
-Hippocrates
Chadwick J, Mann Wm. The Medical Works of Hippocrates. Oxford,
UK: Blackwell, 1950 p. 140.
Review of literature on the utility of
bed rest
• 39 trials of bed rest for 15 different conditions (n=
5777)
• 24 trials investigating bed rest following a
medical procedure
– no outcomes improved significantly
– 8 worsened significantly
• 15 trials investigating bed rest as a primary
treatment
– no outcomes improved significantly
– 9 worsened significantly
Allen C et al. Bed rest: A potentially harmful treatment needing
more careful evaluation. Lancet 354:1229-33, 1999.
Why are the elderly more at risk?
1. Co-morbidities
2. Decreased reserve
What do we know about the adverse
effects of bed rest?
1. Effects on total functioning
2. Effects on individual organs/systems
• Elderly admitted to the hospital:
– At discharge, 31% deteriorated in ADLs
– At 3 months, 51% had either died or worsened in
functional status
Sager MA, et al. Functional outcomes of acute medical illness and
hospitalization in older persons. Arch Intern Med 156:645-52, 1996.
• Continued decline in function after
hospitalization
– 2 days post-hospitalization, 65% lost ability to walk
– At discharge, 2/3 did not improve in function
10% deteriorated further
Hirsch et al. The natural history of functional morbidity in hospitalized
older patients. JAGS 38:1296-1303, 1990.
• One month post-hospitalization
– 59% were not back to baseline
• Risk Factors for functional decline:
–
–
–
–
age
cognitive impairment,
low social activity,
pre-hospitalization functional impairment.
Innouye S et al. A predictive index for functional decline in hospitalized elderly medical patients. JGIM 8:645-52. 1993.
Sager MA. Hospital Admission Risk Profile (HARP): Identifying older patients at risk for functional decline following acute
medical illness and hospitalization. JAGS 44:251-7, 1996.
Hansen K et al. Risk factors for lack of recovery of ADL independence after hospital discharge. JAGS 47(3):360-5. 1999.
Pathophysiology--organ systems
Man was designed … to function more or less
in the upright posture in earth’s gravitational
environment. Thus, the deconditioning that
occurs during bed rest would be viewed as a
departure from the optimal posture.
- Greenleaf J.
CV
1. Change in hemodynamics
2. Orthostatic incompetence
3. Changes in peripheral circulation
Browse NL: The Physiology and Pathology of Bed Rest.
Springfield, Illinois, Charles C. Thomas Publisher, 1963.
CV
1.
Eleven percent of circulating blood shunted
to the central circulation initial  in
cardiac output and stroke volume
2.
With increased time in bed, HR increases
daily
3.
Cardiomegaly, mild though progressive
Chobanian AV et al, The metabolic and hemodynamic effects of prolonged
bed rest in normal subjects. Circulation 49:551, 1974.
Orthostasis
• Prolonged bed rest twice the usual fall in
SV and CO with standing.
• Pooled blood in lower extremities
increased HR and alpha- adrenergic
response
• Symptoms occur early and are profound
Hung J, et al. Mechanisms for decreased exercise capacity after bed
rest in normal middle-aged med. Am Jour Card. 51;344-8. 1983.
CV response to activity after bed rest
1.
Aging cardiac dilatation maximum
heart rate
2.
Immobility adrenergic system upregulation and  reserve to increase CV
signals in response to initial exercise
Respiratory
1. Restrictive impairment
2. Alteration in blood flow
Pulmonary Blood Flow
1.
Highly perfused areas become
posterior
V:Q ratio changes
2.
Blood flow changes (central
circulation and  tissue hydrostatic
pressure) pulmonary edema
Muscle
• Rapid loss of strength
– 5% per day
– 50% of strength lost in first 3
weeks
• Leg strength loss more quickly than
arms
• Atrophy twice as fast if muscle
shortened
Muller LA: Influence of training and of activity on
muscle strength.Aron Physics Med Rehab 51:449, 1970.
Skeletal
• Bone loss 0.9 % per
week
• Both increased
absorption as well as
cessation of new bone
formation
Wheldon GD: Disuse osteoporosis: Physiological aspects. Calcif
tissue Int 36:5146, 1984.
Joint changes
• Joint loading important
to keep healthy cartilage
• Fibrosis and ankylosis
• Decreased lubrication
• Diminished cartilage
smoothness within one
week
• Osteophyte formation
within two weeks
Gastrointestinal
• Increased risk of
aspiration
• Increased transit
time
– Anorexia
– Constipation
Genitourinary
1. Diuresis 300-600 cc
in first week then
stable
2. Hypovolemia
3. Bladder evacuation
impaired
CNS
• EEG slowing on
young
immobilized
patients who did
not have any other
sensory
deprivations
Skin- break down
1. With age, skin is
less resistant barrier
2. Mechanics of
pressure, friction,
traction and
maceration
• Effects on other systems:
– endocrine
– immune
– sensory changes