Preservation of Function in Older Adults Who Are in the Emergency Department During COVID-19

Supplement

Suzanne Ryer, PT, MPT, GCS, CEEAA; Pamela Martin, RN, MSN, FNP-BC, APRN GS-C; Aaron J Malsch RN MSN GCNS-BC
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The Journal of Geriatric Emergency Medicine has a mission to improve emergency health care for older adults by providing open access, peer-reviewed, quality education and dissemination platform giving providers in all disciplines the evidence they need to enhance emergency care of older adults.

Introduction

  1. Functional status is an independent predictor of morbidity and mortality in older ED patients and physical function can be worsened by immobility, especially during extended ED stays.1,2
    1. Immobility can lead to loss of muscle mass, deconditioning, and weakness.
    2. Decreased physical function can contribute to inpatient complications such as falls, delirium, increased length of stay, and higher rates of discharge to skilled nursing facilities.
  2. Many of the risk factors for functional decline3, physical and mental, can be exacerbated by the response to COVID-19, such as low frequency of social contacts, low physical activity, depression, poor self-perceived health, cognitive impairment, and comorbidity.
  3. Baseline functional status is an important part of obtaining a history, which may include home setting, caregiver support, and use of assistive or adaptive equipment.
  4. Patient premorbid functional status has implications for health interventions, outcomes, and recovery beyond the ED.
    1. Use common assessment tools such as the Katz ADLs, ISAR5, and TRST.5
    2. Evaluate IADLs to ensure that patient will be able to perform these items especially if patient is going home independently. Key activities are the management of medications, meals, transportation, finances, housekeeping and communication.
  5. Unless contraindicated, maximize and facilitate mobility at the bedside despite limitations and confinement of social distancing:
    1. ambulate in room
    2. sit on side of bed with feet on floor
    3. use bedside commode
    4. sit in chair for meals
  6. The combination of aerobic and strength exercises is most effective in prevention of functional decline associated with disuse and immobility.4
  7. Any activity is better than none, but patients with extended ED lengths of stay should be encouraged to perform exercises and mobility. Prescribe exercises for those boarding in the ED, as well as for those who will be discharged. See table below to select the appropriate program for your patient.
Table 1

Standing Exercises in the ED for Preservation of Function

  • Sit up in a chair or at the edge of bed to eat meals.
  • Walk in the room (with help as needed) every 1-2 hours at a comfortable pace.
  • Use hand support on a stable surface like bed rail or countertop for safety.
  • Perform the circuit of exercises every 2-3 hours to increase activity and maximize function. Take rests as needed.
  • If you become lightheaded, short of breath or feel pain do not continue.
Standing exercises for preservation of mobility in older adults in the ED during COVID-19

Sitting Exercises in the ED for Preservation of Function

  • Sit up in a chair or at the edge of bed to eat meals.
  • Walk in room with help.
  • Perform the circuit of exercises every 2-3 hours to increase activity and maximize function. Take rests as needed.
  • If you become lightheaded, short of breath or feel pain do not continue.
Sitting exercises for preservation of mobility in older adults in the ED during COVID-19

Bed Exercises in the ED for Preservation of Function

  • Sit up at edge of bed or raise head of bed throughout the day to improve breathing and position.
  • Perform the circuit of exercises every 2-3 hours to increase activity and maximize function. Take rests as needed.
  • If you become lightheaded, short of breath or feel pain do not continue.
Bed exercises for preservation of mobility in older adults in the ED during COVID-19

References

  1. Gill TM, Williams CS, Tinetti ME. The combined effects of baseline vulnerability and acute hospital events on the development of functional dependence among community‐living older persons. J Gerontol A Biol Sci Med Sci 1999;54A:377-383.
  2. Hastings ,S. M., Sloane, R, Morey, M.C., Pavon, J.M., &Hoenig, H. (2014). Assisted Early Mobility for Hospitalized Older Veterans: Preliminary Data from the STRIDE Program. J Am Geriatri Soc, 62 (11), 2180-2184
  3. Stuck, A. E., Walthert, J. M., Nikolaus, T., Büla, C. J., Hohmann, C., & Beck, J. C. (1999). Risk factors for functional status decline in community-living elderly people: a systematic literature review. Social science & medicine48(4), 445-469.
  4. Valenzuela, P. L., Morales, J. S., Pareja-Galeano, H., Izquierdo, M., Emanuele, E., de la Villa, P., & Lucia, A. (2018). Physical strategies to prevent disuse-induced functional decline in the elderly. Ageing research reviews47, 80-88.
  5. Carpenter, C. R., Shelton, E., Fowler, S., Suffoletto, B., Platts‐Mills, T. F., Rothman, R. E., & Hogan, T. M. (2015). Risk factors and screening instruments to predict adverse outcomes for undifferentiated older emergency department patients: a systematic review and meta‐Academic Emergency Medicine22(1), 1-21.

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