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causes, management of immobility, deconditioning

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  1. 1. Immobility Dr. DoHA RASHEEDY ALY Lecturer of Geriatric MedicineDepartment of Geriatric and Gerontology Ain Shams University
  2. 2. Bed rest benefits in acute conditions• Reduces oxygen needs• Decreases pain levels• Helps in regaining of strength• Uninterrupted rest has psychological and emotional benefits
  3. 3. "Bed is Bad"
  4. 4. 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.
  5. 5. • Immobilization – physical restriction of movement to body or a body segment• Deconditioning – decreased functional capacity of multiple organ systems
  6. 6. 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
  7. 7. 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
  8. 8. 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
  9. 9. 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.
  10. 10. CAUSES• Physical.• Psychological.• Environmental.
  11. 11. Physical• Musculoskeletal disorders Arthritis‘ Osteoporosis Fractures (especially hip and femur) Podiatric problems Other (e.g., Pagets disease)• Neurological disorders Stroke Parkinsons 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)
  12. 12. • 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
  13. 13. Psychological• Fear (from instability and fear of falling)• Depression
  14. 14. Environmental causes• Forced immobility (in hospitals and nursing homes)• Inadequate aids for mobility.• Poor lightening.
  15. 15. 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
  16. 16. 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
  17. 17. Skin Genitourinary Pressure ulcers Urinary infectionMusculoskeletal Urinary retention Muscular deconditioning and atrophy Bladder calculi Contractures Bone loss (osteoporosis) IncontinenceCardiovascular Metabolic Deconditioning Altered body composition (e.g.,decreased Orthostatic hypotension plasma volume) Venous thrombosis, embolism Negative nitrogen balancePulmonary Impaired glucose tolerance Decreased ventilation Altered drug pharmacokinetics Atelectasis Psychological Aspiration pneumoniaGastrointestinal Sensory deprivation Anorexia Delirium Constipation Depression Fecal impaction, incontinence
  18. 18. 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 wont blanch• .
  19. 19. Pressure Areas
  20. 20. Musculoskeletal• Muscle: disuse atrophy "if you dont use it, youll 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)
  21. 21. • 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.
  22. 22. Genitourinary Decreased voiding (stasis) ↓• Increased post-void residual volume, retention• Increased risk of urinary tract infections• Increased risk of calculus formation
  23. 23. Venous thrombosis, embolismvenous stasis + increased blood coagulability+decreased plasma volume
  24. 24. Cardiovascular↑ 1) decreased coronary blood flow and heart rate (1 beat/ decreased O2minute every 2 days) available to cardiac2ry to increased sympathetic activity muscles ↓ decrease in diastolic filling time 1)• and a decreased systolic ejection 2)↓ CO, SV time2).
  25. 25. • Orthostatic hypotension (begins after 3 weeks of bed rest ) due to:1. excessive pooling of blood in the lower extremities2. 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.
  26. 26. 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.
  27. 27. 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
  28. 28. • 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
  29. 29. 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.
  30. 30. 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
  31. 31. 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
  32. 32. • Fowler• Semi Fowler• Lateral sim’s position
  33. 33. 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.
  34. 34. ROM
  35. 35. Stretching
  36. 36. • Focus on abilities and not disabilities: the use of assistive devices and making the home accessible.
  37. 37. Assistive devices
  38. 38. Anticoagulation, elastic stocking, intermittent pneumaticcompression.
  39. 39. 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
  40. 40. • 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.
  41. 41. OCCUPATIONAL THERAPY IN THE MANAGEMNET OF IMMORBILE OLDER PATIENTSMedalities 1. Assessment of mobility 2. Bed mobility 3. Transfers 4. Wheelchair propulsionAssessment of other ADL using actual or simulated environments 1. Dressing 2. Toileting 3. Bathing and personal hygiene 4. Cooking and cleaningVisit 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)