Interventions to Prevent Functional Decline in Older Adults

Old Age Functional Decline and Nursing Care

 Assessment, promotion, examination,risk factors,social climate and support for functional decline in older adults and geriatric nursing.

Assessment of Functional Decline

    Assessment of 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 to a nursing home setting (Fortinsky, Covinsky, Palmer, & Landefeld, 1999), increased morbidity and mortality (Boyd, Xue, Guralnik, & Fried , 2005; Rozzini et al., 2005). 

    Increased rehabilitation costs, and decreased functional recovery (Boyd et al., 2008; Boyd et al., 2005; Gill, Allore, Holford, & Guo, 2004; Volpato et al., 2007). 

    The immobility associated with functional decline results in infections, pressure ulcers, falls, a persistent decline in function and physical activity and non elective  frequent hospitalizations (Gill et al., 2004).

Functional Promotion as a Gerontological Concern

    The promotion of function is a basic gerontological tenet, and functional status is a key determinant of quality of life for older adults (Boltz, Capezuti, Shabbat, & Hall, 2010). 

    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). 

    Older adults themselves expect that an acute care stay will not result in functional decline but instead lead to the resumption of normal roles and activities posthospitalization (Boltz, Capezuti, Shabbat, & Hall, 2010). 

    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 (Protocol 7.1: Protocol for FFC) is provided.

Physical Function and Clinical Measure

    Functional decline may result from the acute illness and can begin preadmission (Fortinsky et al., 1999) and continue after discharge (Sager et al., 1996). 

    In a large prospective observational study, Covinsky and colleagues (2003) evaluated the changes in performance of activities of daily living (ADL) function prior to and posthospitalization of older adults with medical illness. 

    Over 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 age 85 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 upon 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 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 large percentage of older adults. 

    Consequently, Covinsky et al. (2003) suggest that an older adult's functional trajectory is a critical “vital sign,” an important prognostic marker, and an 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 post-acute rehabilitation plans could be mobilized with the goal of preventing disability.

Patient Risk Factors for Functional Decline

    Intrinsic vulnerabilities to functional decline include prehospitalization functional status, the presence of two or more comorbidities, taking five or more prescription medications, and having had a hospitalization or emergency room visit in the previous 12 months (McCusker, Kakuma, & Abrahamowicz, 2002). 

    Depression scores are associated with ADL decline before admission (Covinsky, Fortinsky, Palmer, Kresevic, & Landefeld, 1997). Symptoms of depression during hospitalization have also been associated with dependence in basic ADI. at discharge and 30 and 90 days after discharge (Covinsky et al., 1997). 

    The association between functional status and cognitive status must also be considered (Inouye, Schlesinger, & Lydon, 1999). Cognitive impairment, including delirium, increases the risk of functional decline in the older adults during and after hospitalization (McCusker et al., 2002). 

    A study of 2,557 patients from two teaching hospitals examined the association between performance on a cognitive status screen and maintenance and recovery of functioning from admission to discharge (Narain et al., 1988). 

    Among patients who needed help performing one or more ADLs at the time of admission, 23% had moderate-to-severe cognitive impairment, 49% had mild impairment, and 67% had little or no impairment in cognitive performance recovered the ability to independently execute an additional ADL by discharge (p<0.001; Narain et al., 1988).

    Pain (Reid, Williams, & Gill, 2005), nutritional problems, and adverse medication effects also contribute to functional decline (Graf. 2006). Fear of falling (Boltz Capezuti, & Shabbat, 2010; Boltz. 

    Capezuti, Shabbat, & Hall, 2010), self-efficacy, and outcome expectations (McAuley et al., 2006; Resnick, 2002), attitudes towards functional independence, and views on hospitalization (Boltz, Capezuti, & Shabbat, 2010; Boltz, Capezuti, Shabbat, & Hall, 2010; Brown, Williams, Woodby, Davis, & Allman. 2007) influence the level of engagement in physical activity and mobility in older adults in general and thus may influence acute care functional outcomes.

Identifyig Of The Problem

    A social ecological perspective assumes that the physical, social, and organizational environment contribute to patient outcomes (Moos, 1979; Stokols, 1992), 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 systems and processes, social climate, policy and procedure, and physical design.

Hospital Care Manners and Processes

    Hospitalization is associated with significantly greater loss of total, lean, and fat mass and strength in older persons. 

    These effects appear particularly important in persons hospitalized for 8 or more days per year (Alley et al., 2010), Hospitalization itself may also pose risks for functional decline due to the deleterious effects of bed rest and restricted activity (Gill, Allore, & Guo, 2004). 

    Bed rest results in loss of muscle strength and lean muscle mass (Kortebein, Ferrando, Lombeida, Wolfe, & Evans, 2007; Kortebein et al., 2008), decreased aerobic capacity (Kortebein et al., 2008), decreased pulmonary ventilation, altered sensory awareness, reduced appetite and thirst, and decreased plasma volume (Creditor, 1993; Harper & Lyles, 1988; Hoenig & Rubenstein, 1991). 

    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 most were able to walk independently (78%). 83% of the measured hospital stay was spent lying in bed (Brown et al., 2009).

    Another study (Brown, Friedkin, & Inouye, 2004) that evaluated the outcomes associated with mobility level found that 66 (83%) were on complete bed rest for at least 24 hours during hospitalization. 

    Almost 60% of the observations had 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 with 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 and colleagues (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.

    Also indicative of the low priority placed upon mobility promotion is the common process of restricting the patients' ability to walk to tests and procedures within the hospital. 

    Other care processes associated with immobility include physical restraints and “tethering devices” such as catheters, intravenous (IV) lines, and medications that contribute to delirium and/or cause sedation (Boltz, Capezuti, & Shabbat, 2010; Graf, 2006; King , 2006). 

    Additionally, there is a tendency for staff to perform ADLs for patients that could participate or do it for themselves, placing older adults at risk for loss of self-care ability (Boltz, Capezuti, & Shabbat, 2010). 

    This “doing for,” as opposed to promoting functional independence, is often associated with a lack of understanding of the patient's underlying capability. 

    Interdisciplinary rounds support a functional approach, with the goal of preventing functional decline and discharging the older adult to the least restrictive setting (McVey, Becker, Saltz, Feussner, & Cohen, 1989). 

    Key elements to be addressed include functional assessment (baseline, admission, and current ADL status, as well as physical capability), alternatives to the use of potentially restrictive devices and agents, and a plan for progressive mobility and engagement in ADL (McVey et al ., 1989).

Social Climate

    Leadership commitment to rehabilitative values is essential to support a social climate conducive to the promotion of function (Boltz. Capezuti, & Shabbat, 2010; Resnick, 2004). 

    Older adults have identified that respectful, discourage communication and engagement in decision making as important to facilitating independence (Boltz, Capezuti, Shabbat, & Hall, 2010: Jaceion, 2004), Staff education that addresses the physiology, manifestations, and prevention of hospital acquired deconditioning; assessment of physical capability.

    Rehabilitative techniques and use of adaptive equipment; interdisciplinary collaboration: and communication that motivates are associated with a function-promoting philosophy (Boltz, Capezuti, & Shabbar, 2010: Jaceion, 2004; Gillis, MacDonald, & Machsaac, 2008: Weitzel & Robinson, 2004).

    Nursing staff have also described the need for well-defined roles, including areas of accountability for follow-through for function-promoting activities (Jaceion, 2004; Resnick, et al., 2011). 

    Clear communication of patient needs among staff and dissemination of data (eg, compliance with treatment plans and functional outcomes) also support these activities (Boltz, Capezuti, & Shabbar, 2010).

Hospital Policy and Procedure

    Policies that clearly define staff roles in assessing physical function and cognition and implementing interventions are foundational to implement function-promoting care (Boltz, Capezuti, & Shabbat, 2010). 

    Additionally, protocols that minimize adverse effects of selected procedures (eg, urinary catheterization) and medications (eg, sedative-hypnotic agents) contribute to positive functional outcomes (Kleinpell, 2007). 

    Other supporting policies address identification and storage of sensory devices (e.g. glasses, hearing aids/amplifiers) and mobility and other assistive devices (St. Pierre, 1998).

Physical Design

    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 does not always fall within the range in which transfers and functions 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 hand rails (including in the patient room) are basic requirements to promote safe mobility (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 (Gabor et al., 2003).

    In addition to the environment in general, it is important to consider person-environment (PE) fit. 

    PE Fit can be measured using the Housing Enabler instrument (Iwarsson, 1999), which includes an assessment of the patient's functional limitations, depending on mobility devices, and a detailed assessment of environmental barriers to engage in functional activities. 

    Assessments include a focus on the outdoor environment, entrances, indoor environment, and communication features (eg, signage) of a community. 

    For each environmental barrier item, the instrument comprises predefined severity ratings and is scored from 1 (potential accessibility problem) to 4 (very severe accessibility problem). 

    The assessment of the individuals' limitations is matched with the environment and a score calculated using Housing Enabler software. Higher scores are indicative of a less desirable PE fit. 

    Areas of concern can then be altered to improve the fit between the individual and the environment to optimize function (Iwarsson, 1999).

Support For Cognition and Interventions

    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 visuospatial ability. 

    Therefore, an appraisal of the older adult's cognition (baseline, admission, and ongoing) is an essential activity associated with promoting physical 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, 2001). 

    Liberal visiting hours and familiar items brought in from home (cg, photos, blanket) provide meaningful sensory input and along with control of excessive noise and attention to sleep hygiene enhance function promoting interventions (Galik et al., 2008; 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, Capezuti, Shabbat, & Hall, 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 sole and an opportunity for emotional expression and relief of boredom (Kresevic & Holder, 1998). 

    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, cloth to fold, tools, and key and lock boards are included for the person with more advanced dementia (Conedera & Mitchell, 2010; Glantz & Richman, 2007).

     Older adults with cognitive impairment can benefit from function-promoting interventions with demonstrated improvements in mood and behavior (Galik et al., 2008). 

    Galik, Resnick, and Pretzer-Aboff (2009), in their work with nursing assistants, identified critical factors associated with successfully engaging persons with cognitive impairment in restorative care activities. 

    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. 

    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 (Galik et al., 2009).

    In addition, adapted communication techniques are necessary to accommodate receptive difficulties associated with cognitive impairment, including dementia. 

    The ability to participate in ADLs is often more preserved than clinicians believe because activities like washing face, brushing teeth, and walking rely on psychomotor memory that is preserved even in those with moderate to severe cognitive impairment. 

    Communicating with short simple verbal requests and visual cues and modeling the activity can be helpful in promoting independence in ADLs. (For example, assist the person to the sink, set them up to brush teeth, hand them tooth brush, and model the behavior, Galik et al., 2008; Galik et al., 2009.)

Physical Therapy and Exercise

    Interventions such as implementation of physical therapy and individualized, targeted exercise programs as soon as possible postadmission have all been tested as ways in which to increase physical activity and prevent deconditioning and functional decline in hospitalized older adults. 

    A single-blind randomized controlled trial was conducted in a tertiary metropolitan hospital involving 180 acute general medical patients aged 65 years and older (Jones, Lowe, MacGregor, & Brand, 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 lower than 48), there was improvement in function among individuals exposed to the exercise interventions versus those who were not (Jones et al., 2006). 

    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 included competing care demands (eg, 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, Keating, Berlowitz, Jackson, & Lim, 2007; de Morton et al., 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. Tucker, Molsberger, and Clark (2004) demonstrated the feasibility of a “Walking for Wellness” program comprised of a patient education program, a screening process to identify patients who would benefit from daily physical therapy walking assistance from cross-trained transportation staff. 

    Walking opportunities included “walking trails” marked inside the hospital, with markers placed every 10 ft at the baseboard of the hallways provided 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 older adults. 

    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-implementation and post-implementation. 

    There was a significant reduction in length of stay (2.4 days) and increase in the percentage of patients discharged to the home setting (Weitzel & Robinson, 2004).

    The positive association between mobility and shorter length of stay was also supported on the 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 length of stay. 

    There were no significant differences in mean daily steps according to illness severity or reason for admission.

    To address motivational issues, Mudge and colleagues (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 sessions of encouragement of functional independence by nursing staff and other members of the multidisciplinary team, and cognitive stimulation in older adults age 70 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 to reduced falls (4.8% vs. 11.3%, p=.19).

    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. Olsson, Karlsson, and Ekman (2007) demonstrated that interventions focused on skin care, pain control, and progressive ambulation yielded improved functional discharge outcomes.