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CHAMP Early to Bed, Early to Rise: The Adverse Consequences of Bed Rest Deón Cox Hayley, DO University of Chicago.

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Presentation on theme: "CHAMP Early to Bed, Early to Rise: The Adverse Consequences of Bed Rest Deón Cox Hayley, DO University of Chicago."— Presentation transcript:

1 CHAMP Early to Bed, Early to Rise: The Adverse Consequences of Bed Rest Deón Cox Hayley, DO University of Chicago

2 Objectives 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 physicians 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.

3 Outline--Adverse Effects of Bed Rest 1. Case 2. History of use 3. Elderly as important sub-group a. special concerns 4. How Bed Rest affects: a. Function b. Individual organ systems 5. Summary Get people out of bed!

4 Patient G.J. 78 y/o female Admitted to sub-acute rehabilitation (in NH) HPI: s/p surgical repair of traumatic right knee fracture then dislocation PMH: OA, DM, HTN, bipolar disease Soc Hx: Husband does most IADLs, independent in ADLs and ambulatory

5 Exam: Gen: flattened affectGen: flattened affect ObeseObese Long leg cast on right (thigh ankle)Long leg cast on right (thigh ankle)

6 Function: On admissionOn admission –NWB on right leg, transfer on left leg –Needed assistance of 2 GoalGoal –Get back to previous status at home

7 Bed rest pressure sores worsened DM pain poor motivation incontinence weakness weight gain Knee fracture delirium narcotics urinary retention IMMOBILITY constipation

8 Follow up Discharged home, walking with a walkerDischarged home, walking with a walker

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10 Sick role model Doctor authorityDoctor authority Hospital disorienting, threatening to older patientsHospital disorienting, threatening to older patients Study of elderly hospitalized patients showed that 72% didnt ambulate in the halls at all.Study of elderly hospitalized patients showed that 72% didnt ambulate in the halls at all. Mahoney J. Wisc Med J

11 Practice of using bed rest Still too much in general medicine Dramatically decreased : 1. OB 2. Surgery a. General b. Orthopedics 3. Cardiology a. Post-MI b. CHF

12 For if the whole body is rested much more than is usual, there is no immediate increase in strength. In fact, should a long period of inactivity be followed by a sudden return to exercise there will be an obvious deterioration. -Hippocrates Chadwick J, Mann Wm. The Medical Works of Hippocrates. Oxford, UK: Blackwell, 1950 p. 140.

13 Review of literature on the utility of bed rest 39 trials of bed rest for 15 different conditions (n= 5777)39 trials of bed rest for 15 different conditions (n= 5777) 24 trials investigating bed rest following a medical procedure24 trials investigating bed rest following a medical procedure –no outcomes improved significantly –8 worsened significantly 15 trials investigating bed rest as a primary treatment15 trials investigating bed rest as a primary treatment – no outcomes improved significantly –9 worsened significantly Allen C et al. Bed rest: A potentially harmful treatment needing more careful evaluation. Lancet 354: , 1999.

14 Why are the elderly more at risk? 1.Co-morbidities 2.Decreased reserve

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17 What do we know about the adverse effects of bed rest? 1. Effects on total functioning 2. Effects on individual organs/systems

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

19 Continued decline in function after hospitalizationContinued decline in function after hospitalization –2 days post-hospitalization, 65% lost ability to walk –At discharge, 2/3 did not improve in function 10% deteriorated further –At discharge, 2/3 did not improve in function 10% deteriorated further Hirsch et al. The natural history of functional morbidity in hospitalized older patients. JAGS 38: , 1990.

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21 One month post-hospitalizationOne month post-hospitalization –59% were not back to baseline Risk Factors for functional decline:Risk Factors for functional decline: –age –cognitive impairment, –low social activity, –pre-hospitalization functional impairment. Innouye S et al. A predictive index for functional decline in hospitalized elderly medical patients. JGIM 8: 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, Hansen K et al. Risk factors for lack of recovery of ADL independence after hospital discharge. JAGS 47(3):

22 Pathophysiology--organ systems Man was designed … to function more or less in the upright posture in earths gravitational environment. Thus, the deconditioning that occurs during bed rest would be viewed as a departure from the optimal posture. Man was designed … to function more or less in the upright posture in earths gravitational environment. Thus, the deconditioning that occurs during bed rest would be viewed as a departure from the optimal posture. - Greenleaf J.

23 CV 1. Change in hemodynamics 2. Orthostatic incompetence 3. Changes in peripheral circulation Browse NL: The Physiology and Pathology of Bed Rest. Springfield, Illinois, Charles C. Thomas Publisher, 1963.

24 1.Eleven percent of circulating blood shunted to the central circulation initial in cardiac output and stroke volume 2.With increased time in bed, HR increases daily 3. Cardiomegaly, mild though progressive Chobanian AV et al, The metabolic and hemodynamic effects of prolonged bed rest in normal subjects. Circulation 49:551, CV

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26 Prolonged bed rest twice the usual fall in SV and CO with standing. Prolonged bed rest twice the usual fall in SV and CO with standing. Pooled blood in lower extremities increased HR and alpha- adrenergic response Pooled blood in lower extremities increased HR and alpha- adrenergic response Symptoms occur early and are profound Symptoms occur early and are profound Orthostasis Hung J, et al. Mechanisms for decreased exercise capacity after bed rest in normal middle-aged med. Am Jour Card. 51;

27 CV response to activity after bed 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

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29 Respiratory 1. Restrictive impairment 2. Alteration in blood flow

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31 Pulmonary Blood Flow 1. Highly perfused areas become posterior V:Q ratio changes 2. Blood flow changes ( central circulation and tissue hydrostatic pressure) pulmonary edema

32 Muscle Rapid loss of strength Rapid loss of strength – 5% per day – 50% of strength lost in first 3 weeks Leg strength loss more quickly than arms Leg strength loss more quickly than arms Atrophy twice as fast if muscle shortened Atrophy twice as fast if muscle shortened Muller LA: Influence of training and of activity on muscle strength.Aron Physics Med Rehab 51:449, 1970.

33 Skeletal Bone loss 0.9 % per week Bone loss 0.9 % per week Both increased absorption as well as cessation of new bone formationBoth increased absorption as well as cessation of new bone formation Wheldon GD: Disuse osteoporosis: Physiological aspects. Calcif tissue Int 36:5146, 1984.

34 Joint changes Joint loading important to keep healthy cartilage Joint loading important to keep healthy cartilage Fibrosis and ankylosis Fibrosis and ankylosis Decreased lubrication Decreased lubrication Diminished cartilage smoothness within one week Diminished cartilage smoothness within one week Osteophyte formation within two weeks Osteophyte formation within two weeks

35 Gastrointestinal Increased risk of aspiration Increased transit time –Anorexia –Constipation

36 Genitourinary 1.Diuresis cc in first week then stable 2. Hypovolemia 3. Bladder evacuation impaired

37 CNS EEG slowing on young immobilized patients who did not have any other sensory deprivations

38 Skin- break down 1. With age, skin is less resistant barrier 2. Mechanics of pressure, friction, traction and maceration

39 Effects on other systems: Effects on other systems: – endocrine – immune – sensory changes


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