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• To enhance your awareness of the risk of deconditioning associated with hospitalisation in older people
• To learn about strategies for identifying at-risk patients and reducing or preventing deconditioning
• To contribute towards revalidation as part of your 35 hours of CPD (UK readers)
• To contribute towards your professional development and local registration renewal requirements (non-UK readers)
Deconditioning is caused by complex physiological changes occurring as a result of immobility, for example during or after a period of acute illness or injury and hospitalisation. It leads to functional decline and compounds or contributes to conditions such as frailty and sarcopenia. In the past, prolonged bed rest was considered therapeutic, but the need to reduce or avoid prolonged immobility is now widely recognised. Hospital-associated deconditioning can be reduced or prevented through mobilisation strategies such as those promoted by the #EndPJparalysis campaign. This article explains the importance of reducing or preventing hospital-associated deconditioning and nurses’ role in this.
Nursing Older People. doi: 10.7748/nop.2023.e1396
Peer reviewThis article has been subject to external double-blind peer review and checked for plagiarism using automated software
Correspondence Conflict of interestNone declared
Swinnerton E, Price A (2023) Recognising, reducing and preventing deconditioning in hospitalised older people. Nursing Older People. doi: 10.7748/nop.2023.e1396
Published online: 08 February 2023
The aim of this article is to increase nurses’ awareness of the risk of deconditioning associated with hospitalisation in older people and provide nurses with strategies for identifying at-risk patients and reducing or preventing deconditioning. The article focuses on hospital-associated deconditioning, but deconditioning can also occur as a result of prolonged immobilisation in the community, therefore the information is partly relevant to nurses working in community settings.
After reading the article and completing the time out activities you should be able to:
• Define deconditioning and describe its causes and consequences.
• Discuss the harmful effects of prolonged bed rest and immobility on hospitalised older people.
• Explain the links between deconditioning and sarcopenia and between deconditioning and frailty.
• List potential barriers to early mobilisation of older people in hospital and strategies to overcome them.
Although patient safety is at the forefront of healthcare policy, healthcare-associated harm is an ongoing concern (Tessier et al 2019, Guilcher et al 2021). The risks associated with hospitalisation and acute illness, particularly among older people, are well-documented. One such risk is deconditioning, which can be defined as a decrease in muscle mass caused by complex physiological changes occurring as a result of prolonged immobility and leading to significant functional decline (Briguglio et al 2020, Smith et al 2020).
The coronavirus disease 2019 (COVID-19) pandemic has increased the prevalence of deconditioning among vulnerable groups, notably older people. During the pandemic, social distancing measures forced older people to stay at home, keep away from friends and relatives and refrain from daily activities and exercise outside the home. This had a detrimental effect on their mobility and function and has increased the number of those presenting with health issues linked to deconditioning (Briguglio et al 2020, Santy-Tomlinson 2021). According to Gray (2021), a ‘deconditioning pandemic’ is now occurring as an indirect consequence of COVID-19. Age UK (2020) conducted research asking older people how their health had changed since the start of the pandemic; one in three respondents had less energy, one in four could not walk as far as before and one in five felt less steady on their feet.
In a qualitative study by Gillis et al (2008), nurses recognised that they had substantial gaps in their knowledge and understanding of deconditioning but had a positive attitude towards their role in its reduction and prevention. Rehabilitation used to be considered the domain of therapists (Waters and Luker 1996) but is now seen increasingly as a shared responsibility between nursing and therapy staff (Decoyna et al 2018). Furthermore, nurses are well-placed to act as care coordinators for older people and to produce and implement a person-centred care plan tailored to their health conditions, circumstances and care needs (British Geriatrics Society (BGS) 2019).
• Older people are at particular risk of deconditioning after an episode of acute illness or injury and hospitalisation
• Hospital-associated deconditioning can be reduced or prevented through early mobilisation, optimal nutrition and oral health and regular assessment for sarcopenia, frailty and delirium
• Hospital nurses have an important role in identifying patients at risk of deconditioning and embedding preventive strategies in routine care
Deconditioning is a decrease in muscle mass and overall function associated with prolonged immobility (Briguglio et al 2020, Smith et al 2020). Prolonged immobility, whether in hospital or at home, exposes patients to external stressors that negatively affect their internal homeostatic mechanisms. These stressors include prolonged bed rest and relative inactivity, suboptimal sleep quality and nutritional deficits (Falvey et al 2015, Briguglio et al 2020). Additionally, immobility puts patients at risk of other significant adverse events such as venous thromboembolism, pressure ulcers and delirium (Oliver et al 2014).
For Wald et al (2019), mobility – ‘the ability to move or be moved’ – is a crucial component of overall function. Historically, hospitalised patients were prescribed bed rest due to the misconception that ‘rest is best’ (Surkan and Gibson 2018). There is now a wealth of evidence that prolonged bed rest is harmful and early mobilisation is crucial for recovery. However, many hospitalised patients, particularly older people, remain at risk of hospital-acquired harm associated with prolonged bed rest and immobility.
Surkan and Gibson (2018) reviewed the evidence regarding the harms and risks that older people, particularly those with frailty, are exposed to because of immobility due to acute illness and hospitalisation. They found that older people in hospital are often confined to bed even after their condition has improved, while catheterisation, falls and delirium contribute to making it more challenging for them to mobilise and for staff to support them in this. Bed rest is associated with sarcopenia, infection and increased length of stay. Furthermore, non-ambulatory patients are at risk of developing dysphagia and aspiration pneumonia (Hathaway et al 2014).
Fitzpatrick et al (2019) reviewed the notes of 100 hospital inpatients aged >75 years and found that only one third were wearing day clothes, 75% spent more than half the day in bed, 73% required assistance to mobilise compared with 22% at baseline, and that poorer levels of mobility correlated with incontinence and delirium. Tasheva et al (2020), who explored the association between physical activity levels in the hospital setting and hospital-associated functional decline in older patients, found that reduced strength and muscle mass increased patients’ risk of falling.
In a qualitative study by Guilcher et al (2021), hospitalised patients who experienced deconditioning described barriers to participating in physical activity such as pain, fatigue, sleep disturbances, ongoing health issues and lack of opportunities to do so due to insufficient hospital resources. Koenders et al (2020) showed that supporting hospitalised patients to undertake physical activity beyond the confines of their bed made them feel free and autonomous.
The fictional case study of Mary illustrates how certain factors associated with an inpatient hospital stay can compound and/or cause deconditioning and what the outcomes for an older person may be (Case study 1).
Mary’s circumstances
Mary is 83 years old and lives in sheltered housing. Once a week she receives a phone call from the housing warden but is otherwise independent and able to undertake activities of daily living.
Mary used to walk to the local shopping centre with her shopping trolley every Friday. However, two months ago she began to find the walk too challenging and for a few weeks used a taxi instead. Three weeks ago, she stopped going out altogether, even for her weekly shopping, and has not left her house since. Her daughter has been assisting her with shopping.
Fall leading to hospitalisation
On the first day of the Easter bank holiday weekend Mary is admitted to hospital after a fall. She was coming out of the bathroom and fell in her living room. Unable to get up, she pressed her care-on-call pendant, which alerted the housing warden. The warden found Mary with no obvious injuries but unable to get up by herself so called an ambulance.
On admission, Mary is assessed as requiring to be ‘nursed in bed’. She is admitted on Good Friday and transferred to a medical ward and is not seen by a geriatrician until the following Tuesday.
In the meantime, Mary is confined to bed and no attempts are made to support her to get up and mobilise. Mary is not assisted to go to the toilet and is given bed pans instead. However, she finds it challenging to use the bed pan and consequently develops constipation and urinary retention. On the Monday, a urinary catheter is inserted.
Therapy team involvement
The geriatrician who sees Mary on the Tuesday recommends that while she is in hospital she should be assisted to get out of bed and mobilise. There are no acute medical issues that require her to remain in bed. The geriatrician advises regular measuring of Mary’s lying and standing blood pressure to check for postural hypotension and prescribes a laxative medicine to assist Mary to move her bowels before removal of the catheter.
The geriatrician refers Mary to the therapy team, who visit her on the Thursday. By then, Mary is no longer able to transfer out of bed without standing equipment. The therapy team assesses Mary and finds that she has overall muscle weakness. They advise nursing staff to use a standing hoist for transfers while further assessments are undertaken with the aim of attempting to get Mary back to her baseline. They also recommend leg exercises that nursing staff can prompt Mary to do in bed.
Prolonged immobility
By the Friday, Mary has developed a urinary tract infection – likely due to having a urinary catheter – and starts to present with signs of delirium. This affects her ability to engage with the nursing staff’s attempts to prompt her to mobilise and exercise her legs and with the therapy team’s attempts to undertake further assessments.
Mary remains in hospital for another ten days, during which she is in bed most of the time. There are not enough nursing staff on the ward to ensure that Mary regularly gets up and some staff lack understanding of how important it is to get Mary moving. On discharge, Mary is deemed to require a period of assessment in a 24-hour care facility.
Having read the case study, do you think Mary shows signs of deconditioning? If so, what are the likely causes and consequences? How could it have been prevented or reduced?
Deconditioning is associated with further immobility, reduced ability to walk, falls, confusion, swallowing difficulties, pressure ulcers, constipation, lack of appetite and venous thromboembolism (BGS 2020). Figure 1 summarises the potential consequences of deconditioning.
Prolonged immobility and its associated detrimental effects accelerate the rate at which older people may experience deconditioning and increase the risk of sarcopenia, a progressive loss of skeletal muscle mass linked to ageing. An overall reduction in muscle mass of 1-2% is seen each year after the age of 50 years and muscle mass can be up to 50% smaller in older people compared with younger people (Nishikawa et al 2021). Sarcopenia may be caused by multiple factors and is largely characterised by a loss of fast-twitch muscle fibres, an increase of fatty deposits in muscle tissue and ageing of cellular mitochondria, leading to an overall functional decline of muscle tissue (Nishikawa et al 2021). Sarcopenia is associated with reduced strength and function and has been shown to be closely related to falls and frailty in older people (Nishikawa et al 2021). It is important to remember that people who are overweight or obese can have sarcopenia.
Deconditioning increases the risk of developing frailty (Gray 2021), a clinical syndrome characterised by a marked vulnerability due to a decline in physiological reserve and function (Ofori-Asenso et al 2019). Many people with frailty also have sarcopenia and vice versa (Gingrich et al 2019). Older people with frailty are at greater risk of adverse outcomes such as falls, increased admissions to hospital, increased length of hospital stay and death (Church et al 2020). It is important that frailty is identified early to address causative factors (Boutette et al 2018) but it is equally important to identify people at risk of frailty, since it is difficult to reverse once established. There are several tools that can be used to screen for frailty, including Rockwood et al’s (2005) Clinical Frailty Scale, which is validated for use in a variety of settings in people aged ≥65 years (Church et al 2020). Nurses can incorporate this tool into routine assessment processes.
The population of people at risk of deconditioning is highly variable and there is limited evidence concerning that population (Falvey et al 2015). Deconditioning is not widely assessed or identified in routine clinical practice, partly because of a lack of standardised screening and assessment tools (Gordon et al 2019). However, understanding the risk factors for deconditioning can assist nurses in identifying at-risk patients.
Physical signs and symptoms indicating that a person is at risk of deconditioning include (Joyner 2012):
• Decreased muscle size.
• Decreased strength.
• Balance difficulties.
• Increased breathlessness or tachycardia on physical exertion or mobilisation.
Furthermore, people who are aged >65 years, who have frailty, are obese and/or have an injury or acute illness that affects their ability to mobilise should be considered at risk of deconditioning (Smith et al 2020).
Assessment tools for health issues other than deconditioning can assist nurses in recognising contributing or compounding factors (McGrath et al 2017). These factors include pressure ulcers, malnutrition and falls and their risk can be assessed with tools such as the Waterlow Score (Waterlow 1991), the Malnutrition Universal Screening Tool (‘MUST’) (British Association for Parenteral and Enteral Nutrition 2011) and the Falls Risk Assessment Tool (FRAT) (Nandy et al 2004).
Every contact with an older person can be used to assess the person’s mobility and function, which will provide a baseline against which to measure deconditioning. In the hospital setting, for example, nurses can assess patients’ baseline mobility and function on admission and again a few days into their hospital stay to determine whether they are starting to experience deconditioning. The findings can be communicated to the wider team and measures can be implemented to reduce or prevent deconditioning.
The need to reduce or avoid prolonged immobility and its detrimental effects has been recognised in the UK and globally. In recent years a culture change has occurred in hospitals where staff are more conscious of, and more motivated to reduce or prevent, the detrimental effects of hospital-associated deconditioning. Efforts have focused on encouraging mobility while patients are still in hospital to ensure a higher level of function once they are discharged (Chastin et al 2019).
These efforts have been promoted through campaigns such as #EndPJparalysis, a nurse-led patient and clinician engagement movement to encourage patients to get up, get dressed and get moving every day during their hospital stay (Sweeney et al 2020). Measures prompted by #EndPJparalysis have been shown to lead to a reduction in falls, pressure ulcers and deconditioning, while encouraging patients to mobilise and maintain a ‘normal’ routine has improved patient experience (Sweeney et al 2020).
Individual organisations have launched their own versions of #EndPJparalysis. University Hospitals of North Midlands NHS Trust, for example, ran a deconditioning awareness campaign aimed at prompting staff to assess, support and encourage patients. Figure 2 – one of the materials produced for the campaign – illustrates measures hospital staff can take to reduce or prevent deconditioning in their patients (BGS 2018).
Discuss with your colleagues how you as a team could support patients to mobilise and therefore avoid deconditioning. What two or three essential changes to practice would the team need to implement?
#EndPJparalysis
https://endpjparalysis.org/downloads/
Sit Up, Get Dressed, Keep Moving
An acute multidisciplinary rehabilitation programme involving medical, mobility, functional, diet, cognitive and psychological assessments has been shown to improve function in patients identified as at risk of hospital-associated deconditioning (Suriyaarachchi et al 2020). Participants were still receiving medical treatment, which shows that patients do not need to be medically stable to benefit from tailored rehabilitation and that rehabilitation should therefore start as early as possible during the hospital stay.
In the view of the authors of this article, reducing or preventing deconditioning in older people in hospital can be achieved by:
• Encouraging early mobilisation.
• Ensuring optimal nutrition and mouth care.
• Taking into account cognitive impairment.
Early mobilisation appears to have benefits beyond physical functioning, as it can also contribute to psychological and social well-being (Kalisch et al 2014). Supporting early mobilisation after the acute phase of a hospital stay, whether post-surgery or during medical treatment, has been shown to lead to improvements in functional status (Juma et al 2016, Goldfarb et al 2018). Supporting early mobilisation in older hospital patients, particularly those with frailty, helps decrease length of stay and reduce adverse outcomes (Juma et al 2016). The MOVE ON study (Liu et al 2018), involving more than 12,000 hospitalised people aged >65 years in 14 sites in Canada, demonstrated that early mobilisation led to improved functional status, reduced length of stay, reduced risk of falls and reduced care needs on discharge.
Research suggests that nurses are aware of the benefits of early mobilisation but that it is not routinely implemented (Fontela et al 2018). Barriers to early mobilisation reported by nurses include time constraints, safety concerns and patient non-adherence (Liew et al 2021). In the context of staffing issues during and beyond the COVID-19 pandemic, time constraints are likely to continue to pose a significant challenge (Jeleff et al 2022). It is crucial that measures to reduce or prevent deconditioning, such as those shown in Figure 2, are implemented proactively and become part of the routine care of older hospital patients. Goal setting has been identified as helpful by patients and nurses when considering physical activity in hospital (Koenders et al 2020). Completing activities of daily living such as washing and dressing, for example, can be used as a goal to encourage mobilisation and preserve function.
Malnutrition is one of the factors that negatively affect the rehabilitation of deconditioned older people (Wakabayashi and Sashika 2014). There is a link between non-ambulatory status, sarcopenia and dysphagia (Hathaway et al 2014) and between sarcopenia and deconditioning (Payne and Morley 2017). ten Cate et al (2020) discussed the role of nurses in assessing their patients’ nutritional status and in developing and implementing effective nutritional care plans. Oral intake can be increased in older people through social dining (Wright et al 2006), since people eat more when they eat in groups (Herman 2017). Social dining can be difficult to organise in the acute hospital setting, where communal dining facilities may not be available, but staff can support patients into an upright position in bed, or transfer patients from their bed to a bedside chair, to improve food intake while reducing the risk of dysphagia and aspiration.
Suboptimal oral health is a predictor of the onset of ill health, particularly among older people (Tanaka et al 2018). The Faculty of Dental Surgery of the Royal College of Surgeons of England (2017) has stressed that improving oral health is essential to improving overall health. In recent years increased attention has been paid to mouth care in hospitals, notably through the Mouthcare Matters initiative (Haslam 2017). Older people are at increased risk of dysphagia and sarcopenia due to aspiration pneumonia, so maintaining optimal oral hygiene can prevent deconditioning (Oda et al 2021). Maintaining optimal oral hygiene also reduces the risk of suboptimal dentition and oral infections such as candidiasis, both of which negatively affect oral intake (Paillaud et al 2004). Nurses can incorporate oral hygiene into patients’ rehabilitation care plan and routine, thereby encouraging mobilisation and self-care. Where possible, the National Institute for Health and Care Excellence (NICE) (2018) guide to improving oral health in care homes can be adapted to the hospital setting.
Patients most at risk of deconditioning are those with cognitive impairment, whether chronic, for example dementia, or acute, for example delirium. People with dementia are more likely to be admitted to hospital than the general population while delirium is associated with long-term functional and cognitive decline (Rudolph et al 2014). It is important to be particularly alert to the risk of deconditioning in patients with cognitive impairment and to address any factor that can compound cognitive impairment and/or cause delirium.
Delirium can result from a range of factors. The most common are incorporated in the PINCH ME mnemonic (BGS 2022):
P – Pain.
I – Infection.
N – Nutrition.
C – Constipation.
H – Hydration.
M – Medication.
E – Environment.
Nurses can use PINCH ME to identify obvious causes of delirium and implement strategies to reduce the risk and severity of incidental delirium. Two other useful tools to detect delirium are the 4 ‘A’s rapid clinical test for delirium (4AT) (Tieges et al 2021) and the Confusion Assessment Method, which is recommended by NICE (2019).
Kowalska et al (2019) found that functional improvement after a physiotherapy rehabilitation programme was significantly lower in older people who had dementia than in older people who did not. Hospital patients with cognitive impairment may be less able than others to engage in physiotherapy and their optimal time for exercise might fall outside the hours when physiotherapists are available. Therefore, nurses have a particularly important role in reducing or preventing deconditioning in these patients, notably by working with the rehabilitation team to develop their own confidence in supporting patients to mobilise and exercise.
Deconditioning is associated with a decrease in muscle mass caused by complex physiological changes occurring as a result of prolonged immobility. Older people are particularly at risk of deconditioning after an episode of acute illness or injury and hospitalisation. Deconditioning contributes to or compounds sarcopenia and frailty and leads to functional decline, which in turn increases a person’s risk of adverse health outcomes and reduced quality of life. Hospital-associated deconditioning in older people can, however, be reduced or prevented through strategies for ensuring that patients mobilise as early as possible, have optimal nutrition and oral health, and are regularly assessed for conditions such as sarcopenia, frailty and delirium. Hospital nurses have an important role in identifying patients at risk of deconditioning, addressing deconditioning in patients’ care plans, embedding preventive strategies in routine nursing care and coordinating patient care in that area.
Identify how recognising, reducing and preventing deconditioning in hospitalised older people applies to your practice and the requirements of your regulatory body
Now that you have completed the article, reflect on your practice in this area and consider writing a reflective account: rcni.com/reflective-account
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