Immobility

1. IMMOBILITY By, SAGAR SHARMA

2. 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

3. 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

4. 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)    

5.  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)

6. 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.

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

8.   Venous thrombosis, embolism Pulmonary      Decreased ventilation       Atelectasis      Aspiration pneumonia Gastrointestinal      Anorexia      Constipation      Fecal impaction, incontinence Genitourinary      Urinary infection    

9.   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

10. 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

11. 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      

12. 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

13. 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

14. 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.

15. 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).

16. 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.

17. 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 nonspecificâ €”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 .

18. Any symptoms suggestive of involvement of the temporal arteryâ €”headache, jaw claudication , recent changes in visionâ €”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.

19. 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.

20. 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.

21. 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.

22. 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.

23. 1)__________ is a common pathway by which these disorders result in immobility. a)Pain b)Neurological c)Osteoporosis d) Decubital Ulcer

24. 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