DECONDITIONING

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DECONDITIONING

• Christopher Patterson
• McMaster University
• Hamilton Health Sciences
• 23 September 2008

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DECONDITIONING

• Definitions
• Epidemiology
• Causes
• Consequences
• Treatment
• Prevention

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DECONDITIONING a simple definition

• The adverse physiological
• consequences of
• too much rest

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Setting the Scene

• Mrs. D an 84 year old lady who lived
  independently
• Became short of breath, taken to hospital,
  diagnosed with pneumonia, admission arranged
• Lay on a stretcher in ER for 3 days
• Became weak, fell on the way to the BR
• Told not to get up alone, restrained when she
  tried
• Now incontinent, disorientated, requiring
  assistance with daily activities
• After admission, too weak to go home nursing
  home recommended

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Why did this happen?

• Rest in an acutely ill older person
• Loss of muscle strength
• Alteration of cardiovascular responses
• Etc.

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Bed rest and muscle strength

• Muscle strength (MVC) lost at 2-5 per day
  
• Harper Lyles. JAGS 1998 36 1047

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Lower limb strength after 6 weeks of bed
restBerg H et al. J Appl Physiol 1997 82 182
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Immobilization of forearm (21 d)Kitahara A et
al. Med Sci Sports Exerc 2003 351697
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Immobilization of forearmKitahara A et al. Med
Sci Sports Exerc 2003 351697
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Lower limb muscle strength and unloading for 10
daysActa Physiol Scand 1996 15763
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Man vs. bear
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Muscle and age
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Aging and loss of muscle mass/strength
(sarcopenia)

• Muscle strength declines by 15 per decade in 6th
  and 7th decade
• Declines by 30 per decade thereafter
• Killewich, L. Journal of American College of
  Surgeons,2006, 2035

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Muscle mass and ageKehayias J et al. Am J Clin
Nutr 199766904
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Muscle mass over lifespan
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DECONDITIONINGConsequences
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DECONDITIONINGConsequences

• Conversion of an individual barely able to rise
  from a chair to a bedridden state
• Resulting immobility promotes incontinence
• Increases risk of falls

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Bedrest effects on cardiovascular system

• Reduction in plasma volume
• Reduced stroke volume and cardiac output
• Orthostatic hypotension
• Results in falls, syncope
• Convertino V et al. Am J Med Sci 2007 334 72
• Killewich L. J Am Coll Surg 2006 203 5

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Plasma volume and bed restConvertino V et al. Am
J Med Sci 2007 334 72
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DECONDITIONINGthe essence

• Loss of muscle strength
• Altered cardiovascular responses
• But there is more, much more

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Bed rest and calcium balance
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Bone Mineral Content and restRittweger J et al.
J Physiol 2006 577 331
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DECONDITIONING

• Muscle weakness
• Circulatory changes
• Many other consequences including negative
  calcium balance (effects on bone) catabolic state
  (effects on nutrition) pressure effects on skin
  (risk of ulceration) insulin resistance,
  inflammatory responses etc.
• Changes may occur soon after rest

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DECONDITIONING

• A complex process of physiological change
  following a period of inactivity, bedrest or
  sedentary lifestyle, which results in functional
  losses.
• Brand C et al. 2003 www.mh.org.au/ClinicalEpide
  miology

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DECONDITIONING

• Results in
• Decreased ability to perform activities of daily
  living (including incontinence)
• Increased risk of falls, fear of falling and
  fractures
• Potential skin breakdown
• Eventually contractures

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Mortality rate from falls Canada
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DECONDITIONINGSimilar terms

• Functional decline
• Dysfunction syndrome
• Weightlessness effects

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DECONDITIONINGSimilar terms

• Functional decline
• Dysfunction syndrome
• Weightlessness effects

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What do they have in common?
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Similarities
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Similarities
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DECONDITIONING IN HOSPITALEpidemiology

• 35-50 of older adult patients experience
  functional decline during hospitalization
• Covinsky K et al. JAGS 2003 51 451

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DECONDITIONING IN HOSPITALEpidemiology

• 35-50 of older adult patients experience
  functional decline during hospitalization
• Covinsky K et al. JAGS 2003 51 451
• Second most common reason for delaying hospital
  discharge in Geriatric patients
• Lim S et al. Ann Acad Med Singapore 2006
  35 27

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DECONDITIONING IN HOSPITALEpidemiology

• 35-50 of older adult patients experience
  functional decline during hospitalization
• Covinsky K et al. JAGS 2003 51 451
• Second most common reason for delaying hospital
  discharge in Geriatric patients
• Lim S et al. Ann Acad Med Singapore 2006
  35 27
• Only half of those who declined regained their
  function 3 months after discharge
• Hanson K et al. JAGS 1999 47 360

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DECONDITIONINGConsequences

• Prolongs hospital stay
• Increases risk of hospital acquired complications
  (injuries, infections)
• May result in (inappropriate) discharge to long
  term care

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DECONDITIONING

• Factors contributing
• Aging
• Sedentary lifestyle
• Chronic disease
• Malnutrition

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DECONDITIONING

• Factors precipitating
• Acute illness
• Surgery and postoperative state
• Bedrest or other immobility
• Being in hospital

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Surgery and postoperative state

• Surgery
• Catabolic state
• Decrease in cardiac work
• Decrease in pulmonary function
• Immunosuppression
• Immobilization
• Postoperative state
• Pain, fatigue, rest, nutrition
• Killewich L. J Am Coll Surg 2006 203 5

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DECONDITIONINGcaused by bed rest in hospital

• 16-33 of older adults on complete bedrest at
  some point in hospitalization
• Brown C et al.JAGS 2004 52 1263

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DECONDITIONINGcaused by bed rest in hospital

• 16-33 of older adults on complete bedrest at
  some point in hospitalization
• Brown C et al.JAGS 2004 52 1263
• Begins as early as 3 days post admission
• Inouye S et al. JAGS 1993 41 1353

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Effects of Hospitalization

• 78 patients admitted for investigations (!) not
  restricted to bed
• Measures before and at end of 5 days
• Upper limb strength ?plt.001
• MIP ? plt.001
• Distance in 6 minute walk ? plt.001
• FVC ? plt.001
• Spinal trunk mobility ? plt.001
• Suesada M et al. Am J Phys Med Rehab 2007
  86 455

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Is bed rest ever justified?

• Meta analysis of 39 randomized controlled trials
  of bed rest
• 24 studies of rest following procedures
• 15 studies of rest as primary treatment
• 15 different conditions considered
• Total of 5777 patients
• Allen C et al. Lancet 1999 354 1229

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Is bed rest ever justified?

• 24 studies of bed rest following procedures
• 16 no difference in outcome
• 8 worse outcome (LP, cardiac catheterization)

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Is bed rest ever justified?

• 24 studies of bed rest following procedures
• 16 no difference in outcome
• 8 worse outcome (LP, cardiac catheterization)
• 15 studies of bed rest as primary treatment
• NO studies showed better outcome
• 6 studies showed no difference in outcome
• 9 studies showed worse outcome (acute LBP,
  hepatitis, MI)

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DECONDITIONINGTreatment
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DECONDITIONINGTreatment

• Recognize risks and identify deconditioning
• Muscle strengthening
• Early mobilization
• Correction of cardiovascular changes (fluids,
  salt)

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DECONDITIONINGTreatment

• Resistance training increases muscle strength and
  volume by 1 per day (remember that it is lost at
  2-5 per day)
• More importantly, resistance training increases
  spontaneous activity

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Effect of 8 weeks resistance exercise on
spontaneous activity
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One way to promote mobility
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Another way to promote mobility
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DECONDITIONINGPrevention

• Maintain mobility
• Resistance exercise
• Adequate nutrition including vitamin D
• Adequate fluid and electrolyte intake (especially
  sodium)
• Avoid tethers wherever possible (including i.v.
  lines, catheters, restraints)

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Environmental barriers to mobilizing patients

• Small ward rooms with little space for bedside
  chairs
• Inaccessible bathrooms
• Cluttered hallways

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Attitudinal barriers to mobilizing patients

• Limiting responsibility for patients mobility
  to OT PT. It needs to be owned by the entire
  team
• Common use of tethers (IVs, Catheters) and
  failure to recognize them as such

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Systems barriers to mobilizing patients

• Staffing models
• Equipmentlack of, in certain clinical areas
• Lack of interesting or motivating destinations in
  hospital setting

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DECONDITIONINGPrevention

• Hospital Elder Life Program (HELP)
• Early mobilization
• Maintenance of hydration
• Attention to eyesight hearing
• Orientation protocol
• Sleep (non pharmacological)
• Reduces incidence of delirium and functional
  decline

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Prevention a 3 pronged strategy to combat
deconditioning

• Continuing gerontological education for all
  staff
• Modification of physical environment to create
  an elder friendly hospital
• Exercise programs even just walking
• Gillis A, MacDonald B. Canadian Nurse 2005
  101 6

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DECONDITIONINGPrevention

• When nurses initiated
• interventions, risk of functional
• decline was reduced by 2/3
• Wanich C et al. Image Journal of Nursing
  Scholarship1992 24 201

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DECONDITIONINGSummary

• Deconditioning is common, serious and disabling

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DECONDITIONINGSummary

• Deconditioning is common, serious and disabling
• Muscle weakness and circulatory changes

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DECONDITIONINGSummary

• Deconditioning is common, serious and disabling
• Muscle weakness and circulatory changes
• It results in longer hospital stays and more
  adverse outcomes

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DECONDITIONINGSummary

• Deconditioning is common, serious and disabling
• Muscle weakness and circulatory changes
• It results in longer hospital stays and more
  adverse outcomes
• It is preventable by early mobilization and
  strengthening exercise

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DECONDITIONINGSummary

• Deconditioning is common, serious and disabling
• Muscle weakness and circulatory changes
• It results in longer hospital stays and more
  adverse outcomes
• It is preventable by early mobilization and
  strengthening exercise
• It should be a rarity in our hospitals

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