2. How do we spot it? What can we do to make a difference?
Deconditioning
How do we spot it?
What can we do to make a difference?
Shana Hall
April Falls Grand Round 2019

3. What can we do to make a difference?
How do we spot it?
Risk Factors
Knowledge
Signs we can see
What can we do to make a difference?
Assessment
Prevention
Treatment
What I will cover in brief in this presentation. Important to acknowledge barriers to implementing deconditioning prevention and treatment in an inpatient setting.

4. Deconditioning may occur to: Teenagers □ Adults (20-65 yrs) □
“Deconditioning is a process of physiological change following a period of inactivity or bedrest that results in a decrease in muscle mass, weakness, functional decline, and the inability to perform daily living activities” Gilles&MacDonald 2005
How long does it take to decondition?
1 day of bed rest □
2 days of bed rest □
7 days of bed rest □
10 days of bed rest □
14 days of bed rest □
I don’t know □
Deconditioning may occur to:
Teenagers □
Adults (20-65 yrs) □
Elderly (65+) □
All of the above □
I don’t know □
It takes 2 days of bed rest and all of the above can and will experience deconditioning.
Study of normal adults and muscle wasting. All measures of lower extremity strength were significantly lower after bed rest including isotonic knee extensor strength ( /- 4.1%, p =.004) and stair-climbing power (-14 +/- 4.1%, p =.01). Maximal aerobic capacity was 12% lower after bed rest. All patients were around 65 years
Kortebein P, Symons TB, Ferrando A et al (2008) Functional impact of 10 days of bed rest in healthy older adults. Journal of Gerontology, 63a(10),
Systematic review: Mid arm circumference/mass and knee extensor strength decrease - Inflammation appeared to be associated with greater loss of muscle strength.
A 50% increase in walking while in hospital was associated with a 6% shorter length of stay (McCullough et al 2006)
47 per cent of delayed transfers of care in one study related to deconditioning (Lim et al 2006)
Lim SC et al (2006) Factors causing delay in discharge of elderly patients in an acute care hospital. Ann Acad Medicine Singapore, 35(1), 27-32
McCullagh R, Dillon C, Dahly D et al. (2016) Walking in hospital is associated with a shorter length of stay in older medical inpatients. Physiological Measurement. 37(10), 1872.

5. Cachexia Sarcopenia Muscle wasting Proximal myopathy
Sarcopenia is now recognized as a multifactorial geriatric syndrome.
Cachexia is defined as a metabolic syndrome in which inflammation is the key feature and so cachexia can be an underlying condition of sarcopenia. Recently, cachexia has been defined as 'a complex metabolic syndrome associated with underlying illness and characterized by loss of muscle mass with or without loss of fat mass. The prominent clinical feature of cachexia is weight loss in adults'.
After middle age, adults lose 3% of their muscle strength every year, on average. This limits their ability to perform many routine activities.
Gowers sign for muscular dystrophy demonstrates how some people with proximal myopathy sit to stand from a chair. Muscle wasting demonstrated even when you break your leg and have been in a cast for 6 weeks!

6. Risk Factors Bedrest Insertion of a catheter Lines and attachments
Using an assistive device
Community acquired deconditioning
It is not always acknowledged how much people can decondition prior to coming into hospital. Have they not walked in a day, 3 days, 3 weeks?

7. Barriers to Deconditioning Care – Nursing research
Lack of Education
Low staffing levels
Lack of valuing prevention efforts
Gilles et al. 2008

8. 30 second Sit to stand test (STS)

9. Deconditioning Prevention

10. Life curve Understand the “cascade to dependency”

11. Deconditioning Treatment
Deconditioning may be best treated by:
Resistance exercises □
Up to the chair three times a day □
An interdisciplinary model of care □
Consulting a physiotherapist □
All of the above □
I don’t know □
Muscles can grow and develop in:
Only adults
Only adolescents
Only elderly
All age groups
I don’t know
Best treated by an interdisciplinary model of care – muscles can grow in all age groups!
Strength training benefits: Increase bone density, muscle size, reduce risk of falls.
Resistance exercises are effective in increasing gait speed, stair power, and balance

12. Interventions that are helpful in treating deconditioning:
Physical stimulation!
Cognitive stimulation
Therapeutic activities to promote mental stimulation
Monitoring effects of anticholinergic drugs
Resistance exercises three times a week for lower limbs
Use of low rather than high hospital beds
Monitoring fluid intake
Rush of blood to the head – why do you think mobilisation is so important in our neuro populations!
6E cat – room for robots in Japanese rest homes to increase cognitive stimulation
Heart failure patients and fluid balance. Affecting their SOB and mobility
Seated Pedals – my favourite exercise aid in hospital – only $29.99 in k mart
Research in Ireland showed the rate of RTI was only 16.6% in the exercise group and 43.3% in the control group (P ¼ 0.024). None of the cases or controls suffered from a DVT or PE. Median postoperative length of stay in the control group was 11 ± 7.5 days whereas in the cases it was 8.5 ± 5.00 days (P ¼ 0.049). The Borg subjective breathlessness score in the cases group showed a decline in the subjective breathlessness on postoperative day 4 (P ¼ 0.002).
Conclusions: Early aerobic activity with a pedal exerciser halves the rate of postoperative RTI and postoperative hospital stay after complex abdominal surgery. Subjective breathlessness was also reduced with the use of pedal exerciser, signifying potential to improve exercise endurance in the postoperative patient
Anticholinergics work by blocking the action of acetylcholine in the brain and at nerves. Neurotransmitters are chemicals made and released by nerves that travel to nearby nerves or, in the case of acetylcholine, nearby muscles and glands where they attach to receptors on the surface of the nerve, muscle or glandular cells.
You only need to see a Parkinsons patient who has missed their medications to see how it impacts their mobility.

13. What if....
Should all our ward based continuing education programs contain a core component on the prevention and treatment of deconditioning?
Is there room for a universal deconditioning prevention program as part of hospital orientation and patient education?
We have integrated surgical post-operative ambulation plans integrated into our standard of care ... Why can’t we have deconditioning ambulation plans for other patient populations?
Should all our ward based continuing education programs contain a core component on the prevention and treatment of deconditioning?
Is there room for a universal deconditioning prevention program as part of hospital orientation and patient education?
We have integrated surgical post-operative ambulation plans integrated into our standard of care ... Why can’t we have deconditioning ambulation plans for other patient populations?

14. Hospital Wide 2018 Falls Incidents
90%
80%
Falls occurred in 44 Area but highest 11 areas account for 80% areas

16. We average 15 falls a week
59% patients falls are in their room and close to their bed
Regular support for toileting
helps keep patients mobile
and safe
- strategies
- challenges

17. References:
Bhatt NR, et al., Postoperative exercise training is associated with reduced respiratory infection rates and early discharge: A case-control study, The Surgeon (2015), - SEATED PEDALS study
Kortebein P, Symons TB, Ferrando A et al (2008) Functional impact of 10 days of bed rest in healthy older adults. Journal of Gerontology, 63a(10),
Gillis, Angela & MacDonald, Brenda & MacIsaac, Allene. (2009). Nurses’ Knowledge, Attitudes, and Confidence Regarding Preventing and Treating Deconditioning in Older Adults. Journal of continuing education in nursing /
Lim SC et al (2006) Factors causing delay in discharge of elderly patients in an acute care hospital. Ann Acad Medicine Singapore, 35(1), 27-32
McCullagh R, Dillon C, Dahly D et al. (2016) Walking in hospital is associated with a shorter length of stay in older medical inpatients. Physiological Measurement. 37(10), 1872.
SQUARE incident data