Assume that Cynthia Brown’s audience, as she addressed the American Geriatrics Society’s annual scientific meeting in Texas this month, already knew that hospitalized older adults spend too much time in bed. Her listeners — geriatricians, nurses, administrators — had probably observed for themselves how quickly elderly patients become deconditioned, how even a few days of “bed rest” causes loss of strength and muscle mass, while the risks of blood clots, bed sores and pneumonia increase.
Dr. Brown, the director of geriatric medicine at the University of Alabama at Birmingham, has been sounding this alarm for a decade. But one number sent a murmur through the auditorium anyway: 43 minutes. That’s the median time a hospitalized elderly patient spends standing or walking daily, Dr. Brown and her colleagues reported in 2009.
Healthy older adults at home are on their feet more than six hours a day. But in this small study, hospitalized patients in their 70s spent 83 percent of their time in bed, according to the accelerometers attached to their thighs and ankles to measure movement. Forty-three minutes. “And this was a population that wasn’t delirious, that didn’t have dementia,” Dr. Brown said when we spoke later. “They were able to walk in the two weeks before they were admitted.” Once they have donned their immodest gowns (another problem), however, “the patient thinks he’s supposed to lie there and no one says, ‘We want you to get up.’”
So even when doctors fix whatever problem brought older people to the hospital, prolonged immobility often sends them to rehabilitation (i.e., a nursing home) for weeks or sometimes for good. The less their mobility, Dr. Brown has determined, the greater the decline in patients’ ability to perform “activities of daily living,” like bathing or dressing. Less active patients were also much more likely to be discharged to institutions.
Anyone gets weaker after days spent horizontally, but older people have less of what doctors call physiologic reserve. “If we put you in bed for the typical three- to five-day stay, we might tip you over the edge,” Dr. Brown cautioned. “So you’re not able to recover your previous level of functioning.”
Her Texas talk — she was receiving an award for “outstanding scientific achievement” — encompassed both depressing and heartening findings. One consequence of hospitalization, she reported, is a reduction in something called “life-space mobility,” a scale measuring how often a person leaves the room where he sleeps, leaves his home, moves around his neighborhood or goes “into town.” Patients in their 70s who had surgical hospitalizations — joint replacement, even heart surgery — show sharp declines in such mobility, but they recover fairly quickly.
But patients hospitalized for medical reasons thereafter inhabit a narrower world; they don’t regain their “community mobility” even two years later. “They stay a lot closer to home,” Dr. Brown said. Unless — and here’s the better news — they get up and walk in the hospital. When I last wrote about hospitals and mobility, I mentioned research by Dr. Steven Fisher, of the University of Texas Medical Branch, showing that elderly patients went home two days earlier if they did modest amounts of early walking.
Dr. Brown’s latest experiment involved 100 patients at the VA Medical Center in Birmingham. Those in the mobility group received twice-daily visits from staff members who helped them out of bed and brought them a wheeled walker if they needed one. “They were encouraged to get up and do as much as they could,” to take meals in a chair or walk 15 feet or make a loop around the ward, Dr. Brown said. Their progress was tracked in a folder.
The control group received visits, too. “We’d talk about football or the kids,” Dr. Brown said. “But not encourage them to move.” A month after discharge, the mobility group showed virtually no change in their life-space score, but those who had not walked suffered a significant decline. Their lives had contracted.
To climb out of a hospital bed, after a nurse has warned you not even to take the few steps to the bathroom without ringing for help, can be frightening to an older person who is sick, in pain, afraid of falling. Fear of injuries makes staff members and administrators nervous too, especially because Medicare will not reimburse for additional costs from falls, like surgery.
Even when physicians recognize the hazards of immobility and write orders that include ambulation, overworked staff can’t always find the time. Old people in hospitals walk slowly. But entering a nursing home is an alarming prospect too.
In my own experience, hospital nurses seemed grateful when I asked if I could walk with my father. I brought his walker (it is startling that hospitals don’t typically provide them) and a robe and supportive slippers, wheeled his IV along on a pole and accompanied him up and down the halls several times a day. I’m convinced that helped him recover.
Visiting family members cannot give their elders injections or change their IVs, but walking is something that — with staff permission — we can take on. “If families can be there to be cheerleaders and to help, it can make a huge difference in the health of an older person,” Dr. Brown said. “We want people to say, ‘We need Mama to get up.’ ”
By Paula Span
Paula Span is the author of When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions.