Beyond bedrest: maintaining mobility during hospital stays

Imagine how it would feel to be recovering from a two-week bout of pneumonia that knocked you flat on your back. Even if you’re generally strong and healthy, you can probably sense how tired and weak you would feel. Now, add a couple decades or more to your age and throw in some chronic conditions, like diabetes and heart disease, and imagine how hard it would be to get yourself moving after a prolonged period of bedrest. It might feel—or even literally be—impossible.

“Older people who are very frail are already so low on muscle mass that a long period of almost-complete inactivity can easily tip them over the edge into a really bad situation,” says Dr. Olga Theou, a frailty researcher at Dalhousie University in Halifax, Nova Scotia. “So after a prolonged stay in hospital, the person might be over the pneumonia, but now they can’t walk.”

Dr. Theou is exploring how hospital staff can best help individuals who are frail get out of bed and moving their bodies during inpatient stays, to promote recovery and prevent backsliding into deeper disability. She and co-principal investigator, geriatrician and researcher Dr. Kenneth Rockwood, have received funding from the Canadian Frailty Network to test a “mobility intervention” in a geriatric acute care unit at the QEII Health Sciences Centre in Halifax.

“We knew from our previous research that mobility is the key predictor of how well people recover in hospital and whether they are discharged home or to long-term care,” notes Dr. Rockwood. “In one observational study, we found that older people in hospital are out of bed only 54 minutes every 24 hours. They are losing muscle mass, strength and mobility every day… we want to turn that around.”

In their new CFN-funded study, called the Breaking “Bad Rest” Study: Interrupting sedentary time to reverse frailty levels in acute care, Drs. Theou and Rockwood are laying the groundwork for a massive shift in hospital culture to promote mobility over bedrest.

“Patients have changed but hospitals haven’t,” remarks Dr. Theou.

“Our hospitals were built largely to care for people with acute diseases like diphtheria, heart attacks and tuberculosis, where bedrest was seen as essential. Now our wards are filled with much older people with chronic diseases, whose conditions are made worse rather than better by long periods in bed. But the hospital environment—by design and tradition—encourages staying in bed. That’s not fine even for a few days, much less a few weeks… not for an older person who may be frail.”

As Dr. Theou explains, even hospital staff can be influenced by such misconceptions as the idea that keeping older, frailer patients in bed in the hospital is a good way to keep them safe from falls. The reality, she says, is that the more they stay in bed, the more likely they are to fall when they get out.

“We need to empower hospital staff in getting frail older patients up and out of bed,” says Dr. Theou, noting that even sitting or standing is better than lying down, and that a couple of short walks down the hall each day would go a long way to preserving muscle mass. “It needs to be everybody’s job, not just the physiotherapist, or not just the nurse.”

The Breaking “Bad Rest” Study puts mobility front and centre for the patients in the intervention group. “We are assessing frailty and setting daily mobility targets for these patients,” explains Dr. Theou, adding that the patients in the intervention arm are also being fitted with accelerometers to track their time lying down, sitting, standing and moving around. “Our goal is to see patients increase their activity by 10 to 20 per cent day over day on a trajectory of overall improvement.”

Hospital staff will keep a close eye on patients’ accelerometer readings, to see if they are reaching their daily mobility targets and to help get them up and about if they are falling short. In fact, activity levels that drop day over day could indicate that something is seriously wrong and needs to be checked.

“Mobility is such an important indicator of general health in the older population living with frailty, it should be considered a vital sign,” says Dr. Rockwood. “It should be monitored as closely as blood pressure, temperature and electrolytes in the hospital setting.

The researchers are building evidence to inform guidelines for optimal in-hospital mobility for older people living with frailty.

“Mobility should be part of the formal goal-setting and care-planning process with each patient and family,” says Dr. Theou. “For this to happen, hospital staff need a clear understanding and guidelines to help them successfully incorporate mobility into patient care.”

This includes educating patients and families, Theou says: “We should say to family members, ‘Instead of sitting by the bed, take your mom for a walk!’ Everybody has a role to play.”