CHAMPCHAMPEarly to Bed, Early to Rise:Early to Bed, Early to Rise:The Adverse Consequences of Bed The Adverse Consequences of Bed RestRest

Deón Cox Hayley, DODeón Cox Hayley, DO

University of ChicagoUniversity of Chicago

ObjectivesObjectives

What you want to teach, ie goals and their explicit content

What you want students to begin doing as a result of the learning in this module

How you expect to teach students to know/do, ie specific teaching methods

Poor functional outcomes associated with hospitalization in the elderly

Recognize the serious consequences of bedrest

Power point lecture with pictures/graphics

Specific organ pathophysiology associated with prolonged bed rest

Identify certain consequences as potentially preventable and be able to explain these to trainees.

Case based lecture

Most hospitalized patients should not be on complete bedrest.

Change physician’s perception of writing an order for physical therapy as fulfilling their obligation to help patients get out of bed

Discuss exceptions to indications for getting out of bed•Brainstorm ways to broaden the approach to getting people out of bed.

Outline--Adverse Effects of Bed Outline--Adverse Effects of Bed RestRest

1. Case1. Case2. History of use2. History of use3. Elderly as important sub-group3. Elderly as important sub-group

a. special concernsa. special concerns4. How Bed Rest affects:4. How Bed Rest affects:

a. Functiona. Functionb. Individual organ systemsb. Individual organ systems

5. Summary5. SummaryGet people out of bed!Get people out of bed!

Patient G.J.Patient G.J.

78 y/o female78 y/o female

Admitted to sub-acute rehabilitation Admitted to sub-acute rehabilitation (in NH)(in NH)

HPI: s/p surgical repair of traumatic HPI: s/p surgical repair of traumatic right knee fracture then right knee fracture then dislocationdislocation

PMH: OA, DM, HTN, bipolar diseasePMH: OA, DM, HTN, bipolar disease

Soc Hx: Husband does most IADLs, Soc Hx: Husband does most IADLs, independent in ADLs and independent in ADLs and ambulatoryambulatory

Exam:Exam:

• Gen: flattened affectGen: flattened affect• ObeseObese• Long leg cast on right Long leg cast on right

(thigh(thighankle)ankle)

Function:Function:

• On admissionOn admission– NWB on right leg, transfer on NWB on right leg, transfer on

left legleft leg– Needed assistance of 2Needed assistance of 2

• GoalGoal– Get back to previous status at Get back to previous status at

homehome

Bed rest

pressure soresworsened DM

pain

poor motivation

incontinence

weakness

weight gain

Knee fracturedelirium

narcotics

urinary retention

IMMOBILITY

constipation

Follow upFollow up

• Discharged home, walking with a Discharged home, walking with a walkerwalker

Sick role modelSick role model

• Doctor authorityDoctor authority• Hospital disorienting, threatening to Hospital disorienting, threatening to

older patientsolder patients• Study of elderly hospitalized patients Study of elderly hospitalized patients

showed that 72% didn’t ambulate in showed that 72% didn’t ambulate in the halls at all. the halls at all.

Mahoney J. Wisc Med J. 1999.

Practice of using bed restPractice of using bed rest

Still too much in general medicine

Dramatically decreasedDramatically decreased::

1. OB1. OB

2. Surgery2. Surgery

a. Generala. General

b. Orthopedicsb. Orthopedics

3. Cardiology3. Cardiology

a. Post-MIa. Post-MI

b. CHFb. CHF

For if the whole body is rested much For if the whole body is rested much more than is usual, there is no more than is usual, there is no immediate increase in strength. In immediate increase in strength. In fact, should a long period of inactivity fact, should a long period of inactivity be followed by a sudden return to be followed by a sudden return to exercise there will be an obvious exercise there will be an obvious deterioration. deterioration.

-Hippocrates-Hippocrates

Chadwick J, Mann Wm. The Medical Works of Hippocrates. Oxford, UK: Blackwell, 1950 p. 140.

Review of literature on the Review of literature on the utility of bed restutility of bed rest

• 39 trials of bed rest for 15 different 39 trials of bed rest for 15 different conditions conditions (n= 5777)(n= 5777)

• 24 trials investigating bed rest following a 24 trials investigating bed rest following a medical procedure medical procedure – no outcomes improved significantly no outcomes improved significantly – 8 worsened significantly 8 worsened significantly

• 15 trials investigating bed rest as a primary 15 trials investigating bed rest as a primary treatmenttreatment– no outcomes improved significantly no outcomes improved significantly – 9 worsened significantly9 worsened significantly

Allen C et al. Bed rest: A potentially harmful treatment needing more careful evaluation. Lancet 354:1229-33, 1999.

Why are the elderly more Why are the elderly more at risk?at risk?

1.1. Co-morbiditiesCo-morbidities

2.2. Decreased reserveDecreased reserve

What do we know about the What do we know about the adverse effects of bed rest?adverse effects of bed rest?

1. Effects on total functioning1. Effects on total functioning

2. Effects on individual 2. Effects on individual organs/systemsorgans/systems

• Elderly admitted to the hospitalElderly admitted to the hospital::– At discharge, 31% deteriorated in ADLs At discharge, 31% deteriorated in ADLs – At 3 months, 51% had either died or At 3 months, 51% had either died or

worsened in functional statusworsened in functional status

Sager MA, et al. Functional outcomes of acute medical illness and hospitalization in older persons. Arch Intern Med 156:645-52, 1996.

• Continued decline in function Continued decline in function after hospitalizationafter hospitalization– 2 days post-hospitalization, 65% lost 2 days post-hospitalization, 65% lost

ability to walk ability to walk – At discharge, 2/3 did not improve in At discharge, 2/3 did not improve in

functionfunction10% deteriorated further10% deteriorated further

Hirsch et al. The natural history of functional morbidity in hospitalized older patients. JAGS 38:1296-1303, 1990.

• One month post-hospitalizationOne month post-hospitalization– 59% were not back to baseline59% were not back to baseline

• Risk Factors for functional Risk Factors for functional decline:decline:– ageage– cognitive impairment,cognitive impairment,– low social activity,low social activity,– pre-hospitalization functional impairment.pre-hospitalization functional impairment.

Innouye S et al. A predictive index for functional decline in hospitalized elderly medical patients. JGIM 8:645-52. 1993.

Sager MA. Hospital Admission Risk Profile (HARP): Identifying older patients at risk for functional decline following acute medical illness and hospitalization. JAGS 44:251-7, 1996.

Hansen K et al. Risk factors for lack of recovery of ADL independence after hospital discharge. JAGS 47(3):360-5. 1999.

Pathophysiology--organ Pathophysiology--organ systemssystems

Man was designed … to function more Man was designed … to function more or less in the upright posture in or less in the upright posture in earth’s gravitational environment. earth’s gravitational environment. Thus, the deconditioning that occurs Thus, the deconditioning that occurs during bed rest would be viewed as a during bed rest would be viewed as a departure from the optimal posture.departure from the optimal posture.

- Greenleaf J.- Greenleaf J.

CVCV

1. Change in hemodynamics2. Orthostatic incompetence3. Changes in peripheral circulation

Browse NL: The Physiology and Pathology of Bed Rest. Springfield, Illinois, Charles C. Thomas Publisher, 1963.

1.1. Eleven percent of circulating blood Eleven percent of circulating blood

shunted shunted to the central circulationto the central circulation

initial initial in in cardiac output and stroke cardiac output and stroke

volume volume

2.2. With increased time in bed, HR With increased time in bed, HR increases increases dailydaily

3. 3. Cardiomegaly, mild though Cardiomegaly, mild though progressiveprogressive

Chobanian AV et al, The metabolic and hemodynamic effects of prolonged bed rest in normal subjects. Circulation 49:551, 1974.

CV

• Prolonged bed rest Prolonged bed rest twice the twice the usual fall in SV and CO with usual fall in SV and CO with standing.standing.

• Pooled blood in lower Pooled blood in lower extremitiesextremities increased HR and increased HR and alpha- adrenergic responsealpha- adrenergic response

• Symptoms occur early and are Symptoms occur early and are profoundprofound

Orthostasis

Hung J, et al. Mechanisms for decreased exercise capacity after bed rest in normal middle-aged med. Am Jour Card. 51;344-8. 1983.

CV response to activity after CV response to activity after bed restbed rest

1. Aging cardiac dilatation maximum heart rate

2. Immobility adrenergic system up-regulation and reserve to increase

CV signals in response to initial exercise

RespiratoryRespiratory

1. Restrictive impairment

2. Alteration in blood flow

Pulmonary Blood FlowPulmonary Blood Flow

1. 1. Highly perfused areas become Highly perfused areas become

posteriorposterior V:Q ratio changesV:Q ratio changes

2. 2. Blood flow changes (Blood flow changes (central central

circulation and circulation and tissue hydrostatic tissue hydrostatic

pressure) pressure) pulmonary edemapulmonary edema

MuscleMuscle

• Rapid loss of strength Rapid loss of strength – 5% per day5% per day– 50% of strength lost in 50% of strength lost in

first 3 weeksfirst 3 weeks• Leg strength loss more Leg strength loss more

quickly than armsquickly than arms• Atrophy twice as fast if Atrophy twice as fast if

muscle shortened muscle shortened

Muller LA: Influence of training and of activity on muscle strength.Aron Physics Med Rehab 51:449, 1970.

SkeletalSkeletal

• Bone loss 0.9 % Bone loss 0.9 % per weekper week

• Both increased Both increased absorption as well absorption as well as cessationas cessation of new of new bone formation bone formation

Wheldon GD: Disuse osteoporosis: Physiological aspects. Calcif tissue Int 36:5146, 1984.

Joint changesJoint changes

• Joint loading Joint loading important to keep important to keep healthy cartilage healthy cartilage

• Fibrosis and ankylosisFibrosis and ankylosis• Decreased lubrication Decreased lubrication • Diminished cartilage Diminished cartilage

smoothness within smoothness within one week one week

• Osteophyte formation Osteophyte formation within two weekswithin two weeks

GastrointestinalGastrointestinal

• Increased risk of Increased risk of aspirationaspiration

• Increased transit Increased transit timetime– AnorexiaAnorexia– ConstipationConstipation

                                                 

GenitourinaryGenitourinary

1.1. Diuresis 300-Diuresis 300-

600 cc in first 600 cc in first

week then stableweek then stable

2. Hypovolemia2. Hypovolemia

3. Bladder 3. Bladder evacuation evacuation impairedimpaired

CNSCNS

• EEG slowing on EEG slowing on young young immobilized immobilized patients who patients who did not have did not have any other any other sensory sensory deprivationsdeprivations

Skin- break downSkin- break down

1. With age, skin 1. With age, skin is less resistant is less resistant barrierbarrier

2. Mechanics of 2. Mechanics of pressure, pressure, friction, traction friction, traction and macerationand maceration

• Effects on other systems:Effects on other systems:– endocrineendocrine– immuneimmune– sensory changessensory changes