4 HOURS
Continuing Education
By Carla Graf, MS, RN, APRN,BC
FUNCTIONAL DECLINE
IN HOSPITALIZED
OLDER ADULTS
It’s often a consequence of hospitalization, but it
doesn’t have to be.
OVERVIEW: In older adults who are hospitalized, functional decline can occur in
a matter of days. This devastating outcome is a common result of the older adult’s
“cascade to dependency,” in which normal aging changes—combined with bed
rest or immobility—result in irreversible physiologic changes, poor outcomes at
discharge, and for many, placement in a nursing home. Routine walking schedules,
activities to prevent sensory deprivation, and timely hospital discharge are among
the interventions that can help prevent functional decline.
I
n April 1967 AJN published a collection of articles called “The Hazards of Immobility,”
which summarized the physiologic changes that occur in healthy, ill, or injured people who
undergo bed rest.1 The articles described the detrimental effects of immobility on cardio-
vascular, respiratory, gastrointestinal, musculoskeletal, urinary, metabolic, and psychoso-
cial health. In the foreword, the editors noted that in 1960, the “U.S. Public Health Service
reported that disability from immobilization was one of 10 preventable health problems
and, with then existing knowledge, such disability could be reduced 50% to 75%.”
Nearly 40 years later, even more is known about the hazards of immobility. Yet the
problem remains, especially in older adults. Hospitalization for an acute illness, even a
short admission, imposes a degree of immobility on any patient, and in an older adult
Carla Graf is a geriatric clinical nurse specialist at the University of California, San Francisco Medical Center. Contact
author: . This article is 10th in a series that’s supported in part by a grant from the Atlantic
Philanthropies to the Gerontological Society of America. Nancy A. Stotts, EdD, RN, FAAN (),
a John A. Hartford scholar, and Carole E. Deitrich, MS, GNP, RN (), are the series editors.
The author of this article has no significant ties, financial or otherwise, to any company that might have an interest in the
publication of this educational activity.
58 AJN January 2006 Vol. 106, No. 1 http://www.nursingcenter.com
,The hospital is not the only place where functional decline occurs. Across all settings, movement and
function must be evaluated consistently and strength and balance encouraged. Here, during a home care
visit, nurse Joan Trelease helps veteran Bob Ray to rise from a chair—a crucial ability in remaining inde-
pendent. Photograph taken from Aging in America: The Years Ahead, by photographer Ed Kashi and
writer Julie Winokur.
AJN January 2006 Vol. 106, No. 1 59
, HOW SERIOUS IS THE PROBLEM?
INSTRUMENTAL ACTIVITIES In the United States in 2002, “more than 12.5 mil-
lion people aged 65 and older were discharged
OF DAILY LIVING from hospitals”; the average length of stay was 5.8
days.7 Hirsch and colleagues found that functional
• Use of telephone decline could occur as early as the second day of
• Shopping hospitalization.2
• Food preparation This highlights the threat evidenced in other stud-
• Housekeeping ies. In one, a study of 1,279 community-dwelling
• Laundry adults ages 70 and older who were hospitalized for
• Transportation acute medical illnesses, 31% experienced a decline
• Medication administration in ability to perform ADLs between preadmission
• Handling finances (baseline) and time of hospital discharge.8 After
three months, 51% had either died or had a new
impairment in an instrumental activity of daily liv-
such immobility can be devastating. Decline can ing (IADL). The authors found that 16% of patients
happen quickly. One early study of hospitalized who experienced functional decline during hospital-
patients over the age of 74 noted that by the second ization died within three months of discharge,
day of admission statistically significant deteriora- compared with 13% of those who improved in
tion had occurred in “individual scores for mobility, functional ability and 7% of those who stayed the
transfer, toileting, feeding and grooming.”2 same. Three months after discharge, 40% of the
Deconditioning is the term used to describe the original cohort for whom data were still available
decrease in muscle mass and other physiologic reported additional disabilities in daily activities.
changes that result from either aging or immobility In another study, Landefeld and colleagues found
or both and contribute to overall weakness. that 35% of older adults hospitalized in an acute
Functional decline is the consequence of those phys- care medical unit experienced a decline in ability to
iologic changes—the resulting inability to perform perform one or more basic ADL by the time of dis-
activities that ensure a person’s independence, such charge.3 Other investigators have found that
as rising unaided from a chair. patients with the greatest loss in ADLs during hos-
Hospital care is often focused on treating acute pitalization are most likely to be admitted to a nurs-
illness; physical and cognitive functioning—the fac- ing home.9
tors that most affect the patient’s independence and
overall prognosis—are often overlooked.3 For AGING AND OTHER CONTRIBUTORS
example, mobility regimens (such as scheduled There are many complex contributors to functional
walks) while hospitalized are often initiated only as decline, although much is still not understood.
a patient is close to discharge, when it may already Aging and the hospital. Creditor describes a
be too late. After two bedridden weeks in the hospi- “cascade to dependency,” a process leading to dis-
tal, a patient who is taught a few exercises at the ability that occurs when a person who has under-
time of discharge will gain little immediate benefit. gone normal aging changes is hospitalized with bed
Indeed, one recent study found that nearly one-third rest.5 Changes to be expected with aging include
of hospitalized patients 70 years of age and older • decline in muscle strength and aerobic capacity.
showed a decline in activities of daily living (ADLs) • vasomotor instability.
upon discharge.4 • baroreceptor insensitivity.
The costs are both human and financial. • reduced total body water.
Functional decline leads to increased risk of illness • reduced bone density.
and death, often irreversibly diminishes quality of • reduced ventilation.
life, results in less autonomy and greater depend- • reduced sensation.
ence, and sometimes leads to institutionalization. • altered thirst, taste, smell, and dentition.
Functional decline also leads to increased lengths of • fragile skin.
hospitalization and readmission.5 Palmer and colleagues developed a conceptual
To prevent functional decline in hospitalized model for older adults, depicting the “syndrome of
older adults, nurses must look for risk factors and dysfunction” that occurs when a functional older
intervene. As the physician Richard Asher once person is hospitalized.10 Both acute illness and the
wrote, “Teach us to live that we may dread unnec- hospital environment can contribute to a decline in
essary time in bed. / Get people up and we may save function. The authors suggest that the hospital envi-
our patients from an early grave.”6 ronment is designed for the caregiver rather than the
60 AJN January 2006 Vol. 106, No. 1 http://www.nursingcenter.com
, patient; high beds, shiny floors, equipment clutter,
and a lack of orienting cues, for example, may cause
the patient not to walk because of fear of falling. In FUNCTIONAL DECLINE:
addition, both acute illness and uncomfortable envi-
ronments can lead to or exacerbate depression,
HOW IS YOUR FACILITY DOING?
compounding functional decline.10, 11 Questions to evaluate your preventive efforts.
While in the hospital, older adults may be left
immobilized in a bed or chair, quickly becoming Is the environment elder friendly?
deconditioned.5 They may become dehydrated or Attributes include nonglare floors; handrails and distance markers in
malnourished from inadequate intake of food and hallways; shower chairs, raised toilet seats, and grab bars in bathrooms;
drink or from nothing-by-mouth orders. They are at low beds (if necessary), large clocks, and calenders in the room.
higher risk for delirium caused by acute illness, the
adverse effects of medication, sensory deprivation Are you taking appropriate steps to prevent sensory deprivation?
because of isolation, and lost eyeglasses or hearing Use of hearing aids, eyeglasses, and dentures is essential, and,
aids. These risk factors may lead to falls, depend- when appropriate, provide alternatives such as amplifiers and mag-
ency, use of restraints, infections, and rejection from nifiers. Encourage family involvement and use of items from home
family. such as robes, blankets, or pictures. Provide newspapers, music,
Aging and immobility. Aging causes an ongoing television, puzzles, and word and math games. Consider an animal-
loss of muscle fiber; consequently, skeletal muscles assisted therapy program.
lose mass and strength. The imposition of immobility
on aging muscle may cause significant atrophy that Are you promoting self-care activities?
occurs more rapidly than in younger patients, leads to Activity routines should be specific, for example, 50 feet of hallway
falls and functional decline, and necessitates long peri- walking twice a day. Include rest periods in the schedule. If feasible,
ods of rehabilitation.12 To maintain strength, muscles start the routine at admission. Post instructions in the room as a
must contract; without contraction, muscle strength reminder. Patients should be out of bed for meals, walking to bath-
decreases by as much as 5% per day.5 The antigravity room, and in the hall as tolerated. If necessary, provide assistive
muscles of the leg and back (the muscles primarily devices such as walkers, and refer the patient to physical and occu-
responsible for maintaining erect posture) are prima- pational therapy.
rily affected by periods of immobility. In fact, Kasper
theorizes that given repeated cycles of atrophy and Are you providing sufficient patient support and education?
recovery, an older adult may lose the ability to restore The benefits of exercise and ambulation, the hazards of functional
skeletal muscle mass and become permanently decline, the use of assistive devices, fall prevention, the patient’s
disabled.12 routine—it’s crucial that both the patient and family understand these
The cardiovascular system. The most common topics. Provide ample information and make time to answer ques-
cardiovascular changes that accompany aging tions. Coaching and providing positive feedback can motivate
include blood vessel stiffening, which can raise patients to continue walking. If staff value these activities, patients
blood pressure. In addition, valve calcification and families are more likely to value them as well.
affects blood flow. Reductions in blood and plasma
volume and in total body water, as well as dehydra- Is your patient safe?
tion, may precipitate syncope.5 Within 24 to 48 Avoid using physical restraints or sedatives. Alternatives include low
hours of bed rest in the supine position, plasma vol- beds, and camouflage devices to hide IVs, tubes, and drains.
ume decreases by almost 7% or 500mL.1, 5, 12 Blood Fidgeting devices and diversional activities are also helpful. Remove
pools in the thorax. The body perceives an increase Foley catheter and IVs as soon as medically feasible. Review medica-
in venous volume; this triggers central blood volume tions for geriatric dosing and possible side effects.
receptors that generate a reduction in antidiuretic
hormone secretion and a loss of water and sodium.
During periods of inactivity and bed rest, hemoglo-
bin and hematocrit values may initially rise with the rest.13 Olson also describes the Valsalva maneuver
corresponding fall in plasma volume, but they fall occurring as a result of using the muscles of the
dramatically during recovery and resumption of arms and upper body to change position in bed.1
activity, leading to the potentially unnecessary treat- She estimates that bedridden patients may perform
ment of anemia.12 this maneuver 10 to 20 times per hour, with the pos-
Cardiac output and stroke volume are affected sible risk of cardiovascular compromise in predis-
by changes in body position. Both decrease when posed patients. (Note that this is not a problem of
the body is supine, due to redistribution of venous deconditioning; it’s an immediate risk created by a
blood returning to the heart during periods of bed sudden increased demand on the heart.)
AJN January 2006 Vol. 106, No. 1 61
Continuing Education
By Carla Graf, MS, RN, APRN,BC
FUNCTIONAL DECLINE
IN HOSPITALIZED
OLDER ADULTS
It’s often a consequence of hospitalization, but it
doesn’t have to be.
OVERVIEW: In older adults who are hospitalized, functional decline can occur in
a matter of days. This devastating outcome is a common result of the older adult’s
“cascade to dependency,” in which normal aging changes—combined with bed
rest or immobility—result in irreversible physiologic changes, poor outcomes at
discharge, and for many, placement in a nursing home. Routine walking schedules,
activities to prevent sensory deprivation, and timely hospital discharge are among
the interventions that can help prevent functional decline.
I
n April 1967 AJN published a collection of articles called “The Hazards of Immobility,”
which summarized the physiologic changes that occur in healthy, ill, or injured people who
undergo bed rest.1 The articles described the detrimental effects of immobility on cardio-
vascular, respiratory, gastrointestinal, musculoskeletal, urinary, metabolic, and psychoso-
cial health. In the foreword, the editors noted that in 1960, the “U.S. Public Health Service
reported that disability from immobilization was one of 10 preventable health problems
and, with then existing knowledge, such disability could be reduced 50% to 75%.”
Nearly 40 years later, even more is known about the hazards of immobility. Yet the
problem remains, especially in older adults. Hospitalization for an acute illness, even a
short admission, imposes a degree of immobility on any patient, and in an older adult
Carla Graf is a geriatric clinical nurse specialist at the University of California, San Francisco Medical Center. Contact
author: . This article is 10th in a series that’s supported in part by a grant from the Atlantic
Philanthropies to the Gerontological Society of America. Nancy A. Stotts, EdD, RN, FAAN (),
a John A. Hartford scholar, and Carole E. Deitrich, MS, GNP, RN (), are the series editors.
The author of this article has no significant ties, financial or otherwise, to any company that might have an interest in the
publication of this educational activity.
58 AJN January 2006 Vol. 106, No. 1 http://www.nursingcenter.com
,The hospital is not the only place where functional decline occurs. Across all settings, movement and
function must be evaluated consistently and strength and balance encouraged. Here, during a home care
visit, nurse Joan Trelease helps veteran Bob Ray to rise from a chair—a crucial ability in remaining inde-
pendent. Photograph taken from Aging in America: The Years Ahead, by photographer Ed Kashi and
writer Julie Winokur.
AJN January 2006 Vol. 106, No. 1 59
, HOW SERIOUS IS THE PROBLEM?
INSTRUMENTAL ACTIVITIES In the United States in 2002, “more than 12.5 mil-
lion people aged 65 and older were discharged
OF DAILY LIVING from hospitals”; the average length of stay was 5.8
days.7 Hirsch and colleagues found that functional
• Use of telephone decline could occur as early as the second day of
• Shopping hospitalization.2
• Food preparation This highlights the threat evidenced in other stud-
• Housekeeping ies. In one, a study of 1,279 community-dwelling
• Laundry adults ages 70 and older who were hospitalized for
• Transportation acute medical illnesses, 31% experienced a decline
• Medication administration in ability to perform ADLs between preadmission
• Handling finances (baseline) and time of hospital discharge.8 After
three months, 51% had either died or had a new
impairment in an instrumental activity of daily liv-
such immobility can be devastating. Decline can ing (IADL). The authors found that 16% of patients
happen quickly. One early study of hospitalized who experienced functional decline during hospital-
patients over the age of 74 noted that by the second ization died within three months of discharge,
day of admission statistically significant deteriora- compared with 13% of those who improved in
tion had occurred in “individual scores for mobility, functional ability and 7% of those who stayed the
transfer, toileting, feeding and grooming.”2 same. Three months after discharge, 40% of the
Deconditioning is the term used to describe the original cohort for whom data were still available
decrease in muscle mass and other physiologic reported additional disabilities in daily activities.
changes that result from either aging or immobility In another study, Landefeld and colleagues found
or both and contribute to overall weakness. that 35% of older adults hospitalized in an acute
Functional decline is the consequence of those phys- care medical unit experienced a decline in ability to
iologic changes—the resulting inability to perform perform one or more basic ADL by the time of dis-
activities that ensure a person’s independence, such charge.3 Other investigators have found that
as rising unaided from a chair. patients with the greatest loss in ADLs during hos-
Hospital care is often focused on treating acute pitalization are most likely to be admitted to a nurs-
illness; physical and cognitive functioning—the fac- ing home.9
tors that most affect the patient’s independence and
overall prognosis—are often overlooked.3 For AGING AND OTHER CONTRIBUTORS
example, mobility regimens (such as scheduled There are many complex contributors to functional
walks) while hospitalized are often initiated only as decline, although much is still not understood.
a patient is close to discharge, when it may already Aging and the hospital. Creditor describes a
be too late. After two bedridden weeks in the hospi- “cascade to dependency,” a process leading to dis-
tal, a patient who is taught a few exercises at the ability that occurs when a person who has under-
time of discharge will gain little immediate benefit. gone normal aging changes is hospitalized with bed
Indeed, one recent study found that nearly one-third rest.5 Changes to be expected with aging include
of hospitalized patients 70 years of age and older • decline in muscle strength and aerobic capacity.
showed a decline in activities of daily living (ADLs) • vasomotor instability.
upon discharge.4 • baroreceptor insensitivity.
The costs are both human and financial. • reduced total body water.
Functional decline leads to increased risk of illness • reduced bone density.
and death, often irreversibly diminishes quality of • reduced ventilation.
life, results in less autonomy and greater depend- • reduced sensation.
ence, and sometimes leads to institutionalization. • altered thirst, taste, smell, and dentition.
Functional decline also leads to increased lengths of • fragile skin.
hospitalization and readmission.5 Palmer and colleagues developed a conceptual
To prevent functional decline in hospitalized model for older adults, depicting the “syndrome of
older adults, nurses must look for risk factors and dysfunction” that occurs when a functional older
intervene. As the physician Richard Asher once person is hospitalized.10 Both acute illness and the
wrote, “Teach us to live that we may dread unnec- hospital environment can contribute to a decline in
essary time in bed. / Get people up and we may save function. The authors suggest that the hospital envi-
our patients from an early grave.”6 ronment is designed for the caregiver rather than the
60 AJN January 2006 Vol. 106, No. 1 http://www.nursingcenter.com
, patient; high beds, shiny floors, equipment clutter,
and a lack of orienting cues, for example, may cause
the patient not to walk because of fear of falling. In FUNCTIONAL DECLINE:
addition, both acute illness and uncomfortable envi-
ronments can lead to or exacerbate depression,
HOW IS YOUR FACILITY DOING?
compounding functional decline.10, 11 Questions to evaluate your preventive efforts.
While in the hospital, older adults may be left
immobilized in a bed or chair, quickly becoming Is the environment elder friendly?
deconditioned.5 They may become dehydrated or Attributes include nonglare floors; handrails and distance markers in
malnourished from inadequate intake of food and hallways; shower chairs, raised toilet seats, and grab bars in bathrooms;
drink or from nothing-by-mouth orders. They are at low beds (if necessary), large clocks, and calenders in the room.
higher risk for delirium caused by acute illness, the
adverse effects of medication, sensory deprivation Are you taking appropriate steps to prevent sensory deprivation?
because of isolation, and lost eyeglasses or hearing Use of hearing aids, eyeglasses, and dentures is essential, and,
aids. These risk factors may lead to falls, depend- when appropriate, provide alternatives such as amplifiers and mag-
ency, use of restraints, infections, and rejection from nifiers. Encourage family involvement and use of items from home
family. such as robes, blankets, or pictures. Provide newspapers, music,
Aging and immobility. Aging causes an ongoing television, puzzles, and word and math games. Consider an animal-
loss of muscle fiber; consequently, skeletal muscles assisted therapy program.
lose mass and strength. The imposition of immobility
on aging muscle may cause significant atrophy that Are you promoting self-care activities?
occurs more rapidly than in younger patients, leads to Activity routines should be specific, for example, 50 feet of hallway
falls and functional decline, and necessitates long peri- walking twice a day. Include rest periods in the schedule. If feasible,
ods of rehabilitation.12 To maintain strength, muscles start the routine at admission. Post instructions in the room as a
must contract; without contraction, muscle strength reminder. Patients should be out of bed for meals, walking to bath-
decreases by as much as 5% per day.5 The antigravity room, and in the hall as tolerated. If necessary, provide assistive
muscles of the leg and back (the muscles primarily devices such as walkers, and refer the patient to physical and occu-
responsible for maintaining erect posture) are prima- pational therapy.
rily affected by periods of immobility. In fact, Kasper
theorizes that given repeated cycles of atrophy and Are you providing sufficient patient support and education?
recovery, an older adult may lose the ability to restore The benefits of exercise and ambulation, the hazards of functional
skeletal muscle mass and become permanently decline, the use of assistive devices, fall prevention, the patient’s
disabled.12 routine—it’s crucial that both the patient and family understand these
The cardiovascular system. The most common topics. Provide ample information and make time to answer ques-
cardiovascular changes that accompany aging tions. Coaching and providing positive feedback can motivate
include blood vessel stiffening, which can raise patients to continue walking. If staff value these activities, patients
blood pressure. In addition, valve calcification and families are more likely to value them as well.
affects blood flow. Reductions in blood and plasma
volume and in total body water, as well as dehydra- Is your patient safe?
tion, may precipitate syncope.5 Within 24 to 48 Avoid using physical restraints or sedatives. Alternatives include low
hours of bed rest in the supine position, plasma vol- beds, and camouflage devices to hide IVs, tubes, and drains.
ume decreases by almost 7% or 500mL.1, 5, 12 Blood Fidgeting devices and diversional activities are also helpful. Remove
pools in the thorax. The body perceives an increase Foley catheter and IVs as soon as medically feasible. Review medica-
in venous volume; this triggers central blood volume tions for geriatric dosing and possible side effects.
receptors that generate a reduction in antidiuretic
hormone secretion and a loss of water and sodium.
During periods of inactivity and bed rest, hemoglo-
bin and hematocrit values may initially rise with the rest.13 Olson also describes the Valsalva maneuver
corresponding fall in plasma volume, but they fall occurring as a result of using the muscles of the
dramatically during recovery and resumption of arms and upper body to change position in bed.1
activity, leading to the potentially unnecessary treat- She estimates that bedridden patients may perform
ment of anemia.12 this maneuver 10 to 20 times per hour, with the pos-
Cardiac output and stroke volume are affected sible risk of cardiovascular compromise in predis-
by changes in body position. Both decrease when posed patients. (Note that this is not a problem of
the body is supine, due to redistribution of venous deconditioning; it’s an immediate risk created by a
blood returning to the heart during periods of bed sudden increased demand on the heart.)
AJN January 2006 Vol. 106, No. 1 61
