WHY: Hospitalization poses a risk for altered functional status for older adults due to acute illness, decreased mobility, the negative effects of bedrest such as pressure injuries, pain, dehydration and/or malnutrition, medication side effects, and associated hospital treatment measures such as invasive lines and catheters that limit mobility. Low levels of mobility and bedrest are common occurrences during hospitalization for older adults (Kresevic, 2017; Fischer et al., 2011). Of great significance is that deconditioning and functional decline from baseline have been found to occur by day two of hospitalization in older patients (Kresevic, 2017; Winkelman, 2009).

As part of the American Board of Internal Medicine’s Choosing Wisely Campaign, the American Academy of Nursing (2014)’s recommendation to “Don’t let older adults lie in bed or only get up to a chair during their hospital stay” highlights the importance of implementing measures to promote activity during hospitalization in order to prevent functional decline in older adults during hospitalization. Walking and activity during hospitalization is critical for maintaining functional ability in older adults. Loss of walking and activity independence increases hospital length of stay, the need for rehabilitation services, new nursing home placement, risk for falls both during and after discharge from the hospital, and places higher demands on caregivers and increases the risk of death for older adults (American Academy of Nursing, 2014).

TARGET POPULATION: Hospitalized older adults at risk for functional decline and immobility.

BEST PRACTICE: Reducing the risk for functional decline in hospitalized older adults can make a significant impact on their function and quality of life. A number of evidence-based strategies have been identified for reducing deterioration in hospitalized older adults.

These include:

• Conduct comprehensive and interprofessional geriatric assessment of physical, psychosocial, and functional status at admission.

• Encourage activity during hospitalization with structured exercise, progressive resistance strength training, and walking programs, in coordination with rehabilitation therapies (physical and occupational).

• Implement early mobilization for acute and critically ill patients based on established protocols (http://www.mobilization-network.org/Network/Welcome.html).

• Ensure assistive devices are in use: hearing aids in place; glasses on; walker or cane.

• Ensure use of appropriate footwear to encourage mobility and prevent falls.

• Utilize environmental enhancements for age-friendly care including handrails, uncluttered hallways, large clocks and calendars, elevated toilet seats, and door levers.

• Integrate established evidence-based protocols aimed at reducing risk for geriatric syndromes and improving self-care, continence, nutrition, mobility, sleep, skin care, cognition, and minimizing adverse effects of selected procedures (e.g. urinary catheterization).

• Evaluate the appropriateness of medications, minimizing the use of sedative-hypnotic medications, and ensuring correct medication dosing and frequency; monitor responses to drug therapy and ensure medication reconciliation during hospitalization, at discharge, and during any transitions in care.

• Promote safety while encouraging independence and maintaining dignity.

• Integrate geriatric interdisciplinary team training with use of geriatric specialists and acute care for elderly (ACE) and geriatric resource nurse (GRN) models of care.

• Consider participation in best practice models for age-friendly care including Geriatric Interdisciplinary Team Training (GITT) and Nurses Improving Care for Healthsystem Elders (NICHE) (https://nicheprogram.org).

The American Academy of Nursing’s Expert Panels on Acute and Critical Care, Aging and Quality Health Care developed a framework based on the theme: Healthy Care Environments for Older Adults – Creating a Culture of Care. Within this framework, eight specific goals identify ways to address prevention of functional decline and the promotion of a culture of caring. These goals include: Promoting Recovery, Optimizing Reserve, Maximizing Safety, Supporting Independence, Upholding Dignity, Maintaining Vigilance, Cultivating Responsiveness, and Improving Access.

MORE ON THE TOPIC:

American Academy of Nursing. (2014). Choosing Wisely Campaign Recommendations - Don’t let older adults lie in bed or only get up to a chair during their hospital stay. Available at: http://www.choosingwisely.org/clinician-lists/american-academy-nursing-walking-for-older-adults-during-hospital-stays

Colon-Emeric, C.S., Whitson, H.E., Pavon, J., & Hoenig, H. (2013). Functional decline in older adults. American Family Physician, 88(6), 388-394.

Fischer, S.R., Keu, Y.F., Graham, J.E., Ottenbacher, J.K., & Ostir, G.V. (2011). Early ambulation and length of stay in older adults hospitalized for acute illness.  Archives of Internal Medicine, 170, 1942-1943.

Gentleman, B. (2014). Focused assessment in the care of the older adult. Critical Care Nursing Clinics of North America, 26(1), 15-20.

Gunn, S., & Fowler, R.J. (2014). Back to basics: Importance of nursing interventions in the elderly critical care patient. Critical Care Nursing Clinics of North America, 26(4), 433-446.

Kleinpell, R.M., Fletcher, K., & Jennings, B. (2008). Reducing functional decline in hospitalized elderly.In Patient Safety and Quality: An Evidence Based Handbook for Nurses. Agency for Healthcare Research and Quality. Available at: https://www.ncbi.nlm.nih.gov/books/NBK2629

Kresevic, D.M. (2015). Reducing functional decline in hospitalized older adults. American Nurse Today, 10(5), 8-10. Available at: https://www.americannursetoday.com/reducing-functional-decline-hospitalized-older

Labella, A.M., Merel, S.E., & Phelan, E.A. (2011). Ten ways to improve the care of elderly patients in the hospital. Journal of Hospital Medicine, 6, 351-357.

Lach, H.W., Lorenz, R.A., & L'Ecuyer, K.M. (2014). Aging muscles and joints: Mobilization. Critical Care Nursing Clinics of North America, 26(1), 105-113.

Lafont, C., Gerard, S., Voisin, T., Pahor, M., & Vellas, B. (2011). Reducing “iatrogenic disability” in the hospitalized frail elderly. Journal of Nutrition, Health & Aging, 15(8), 645-660.

Pashikanti, L, & Von Ah, D. (2012). Impact of early mobilization protocol on medical-surgical inpatient population: An integrated review of the literature. Clinical Nurse Specialist, 26(2), 87-94.

Truong, A.D., Fan, E., Brower, R.G., & Needham D.M. (2009). Bench-to-bedside review: Mobilizing patients in the intensive care unit – from pathophysiology to clinical trials. Critical Care, 13(4), 216.

Walker, M., Spivak, M., & Sebastian, M. (2014). The impact of aging physiology in critical care. Critical Care Nursing Clinics of North America, 26(1), 7-14.

Winkelman, C. (2009). Bed rest in health and critical illness. AACN Advanced Critical Care, 20(3), 254-266.

*Developed by a workgroup of the American Academy of Nursing’s Expert Panel on Acute and Critical Care, including Ruth M. Kleinpell, PhD, RN, FAAN, Mary Beth Happ, PhD, RN, FAAN, Carol Reineck, PhD, RN, FAAN, Rich Arbour, MSN, RN, FAAN, Ruth Lindquist, PhD, RN, FAAN, Kathy Fletcher, DNP, RN, FAAN, Mary Lou Sole, PhD, RN, FAAN, Therese Richmond, PhD, RN, FAAN, Hilaire Thompson, PhD, RN, FAAN, Bonnie Jennings, DNSc, RN, FAAN, and Shirley Moore, PhD, RN, FAAN.