Functional Decline in Older Patients during Acute Medical Care

Introduction and Methodology

This chapter presents a review of literature from identified studies in the quest to determine why some older patients lose function in acute medical wards. The studies were sourced from electronic databases using key words. The keywords used included older patients, acute medical care, functional decline and deconditioning. The databases used included Google Scholars, EBSCO, PubMed, and MEDLINE. Seven studies were identified from the literature search.

Mobility

Kirk et al. conducted an ethnographic study to investigate how social contextual situations affect the mobility of older patients and the resultant effect on the functional decline of older patients (2019). The study was conducted in Copenhagen, Denmark, in six medical departments in different public hospitals. The researchers noted that a considerable number of older patients are victims of functional limitations following hospitalizations; the link to the factors that affect the mobility of the patients within an acute medical ward. Reduced activity within a hospital setting besides decreased mobilization is one factor that heightens the functional decline of older patients in acute medical wards, notes Kirk et al. (2019). Boltz et al. (2010) also examined the influence of mobility on the functional decline. The study was carried in New York, USA. They recognized the prevalence of functional decline in hospitalized older adults. In the scope of the study, the researchers identified five themes that included materialities, professional roles, encouraging moments, patients and relatives, and organization and management within the hospitals. The authors made a note of the high risk of functional decline in acute admissions. Besides, such patients are also reported to have decreased recovery ability relative to those that do not experience a functional decline. This emphasized the essentiality of the issue, thus the justification of their study. The researchers also identified some of the barriers to mobilization within acute medical wards. These were categorized into individual, organization, and professional barriers. At the individual level, Kirk et al. noted that they are inclusive of healthcare providers' doubts about patients' motivation for mobilization besides the fear of older patients of falling and injuries. On the other hand, barriers such as the failure of nurses to view mobilization as an essential element of the patient's recovery were noted at a professional level. At an organizational level lack of staff and time besides poor communication and lack of teamwork within healthcare settings.

Kirk et al. derailed a close connection between the mobilization of older patients and materialities (2019). For instance, they realized that the size and the design of the wards failed to support patient mobility. The rooms, such as the bathrooms, lacked ease of access and enough space to support patient mobility. Also, dining or living rooms were noted to lack in the patient rooms. This was identified as one of the reasons why the patients chose to stay in bed and was thus less mobile, consequently leading to heightened functional decline. Apart from space, design, and access to the rooms, lack of mobilization was also tied to the presence, access to, and the design of distinct forms of walking aids. Kirk et al. also noted that professionals have a huge part in bettering the mobilization of patients in acute medical wards (2019). They could verbally encourage the patients to get out of bed. Encouraging moments were one of the themes that the researchers identified in the scope of their investigation. Besides, they reported that not only the patients but also their families significantly impacted mobility. This was tied to the aspect of motivating the patients. Lastly, the researchers investigated the impact that the organization and the hospital management had on patient mobility. In so doing, the researchers reported that the management and organization, in general, had procedures in place that inhibited patient mobilization (Kirk et al., 2019). These also included missing equipment and other acute problems. The study by Kirk et al. exhaustively investigated mobilization's impact on functional decline in acute medical wards. The study thus answered the research question as its findings were extremely relevant and applicable to this study.

Social Interaction

The findings by Kirk et al. (2019) were in line with those from a study by Clarke et al. (2017). In their study, the researchers examined the lack of meaningful activity in acute physical wards by investigating older patients' experiences in acute medical wards. Unlike the study by Kirk et al. that was undertaken in Denmark, this study took place in England. The researchers identified varied themes in the scope of their study. Among the themes they identified included: the impossibility of meaningful activity, the desire for meaningful activity, and waiting to see what happens.

The patients reported that all they do in the hospital is sit. This resulted in longer periods of physical inactivity and passivity. They spent most of the time waiting for the hospital staff to carry out their usual routines (Clarke et al., 2017). The study realized a common experience of passivity among the study participants. They linked this to the increased decline in functionality of the patients as they remained physically inactive for a substantial period. Other patients termed most of the days in the hospital to be boring due to lack of social interaction, while others termed hospital stay as being like a prisoner who is confined and does not move around. Some mentioned being willing to engage but faced various barriers such as lack of space and lack of support to take part in physical activity. This study's lack of mobility was the prevalent theme, just like in Kirk et al.'s (2019) research. The findings explained the effect of immobilization and lack of social interaction on the declining functionality of older patients in acute medical wards.

Environment

The reviewed studies explored the influence of mobility on functional decline. Undoubtedly, mobility is significantly impacted on by the hospital environment. In the scope of the researchers conducting their studies, factors such as space, equipment and the design are some of the environmental factors that are noted to impact on functional decline.

Fear of falling, floor designs and lack of sleep

Boltz et al. (2010) reported that the ability of patients to take part in functional activities and mobilize are affected by the hospital environment. Chan et al. (2020) and Kirk et al. (2019) made similar observations. The researchers in their respective studies noted that this was caused by factors such as fear of falling, floor designs, and lack of sleep. They noted that the lack of sleep was being contributed to by the beeping hospital devices that constantly caused discomfort and disturbance of the older patients. Interruptions from other patients are also noted to contribute to the lack of sleep. These conditions lowered the ability of the patients to function independently as they lacked enough rest for recovery. A noisy hospital also delays the recovery of patients. Besides, it causes them to lose their ability as they lack enough rest.

Consequently, the physical, cognitive, and social aspects of the patients are negatively affected (Guilcher et al., 2021). Older patients are often afraid of falling. Besides, the nurses also tend to be worried about the older patients falling. This has contributed to the lack of encouragement of the older patients to move around the hospital (Kirk et al., 2019). Nurses, for the same reason, restrict the mobility of patients besides obstructing self-care. The hospital’s high safety mind-set of low if not zero tolerance to falls is also reported as the major contributor to the nurses self-care perceptions. Nurses typically feel enormous incentive to prevent falls, leading them to reduce patients' movement that can also reduce functional ability in older patients (Kneafsey et al., 2013).

Lack of Environment Amenities

The studies reviewed noted that patients could not perform self-care activities. Besides, independent patients also need to be assisted with basic care due to their unfamiliarity with the hospital environment and amenities. Lack of amenities has made the hospital quite unfriendly for older patients. Notably, Chan et al. (2020) noted that some hospitals had restrooms further away from the acute medical wards. Also, the hospital clothing was difficult for the patients to put on and move around the hospital setting.

Healthcare Provision

Staff and Knowledge

Lim et al. (2020), Kirk et al. (2019), and Lafrenière et al. (2016) discussed the healthcare providers as a major contributor to functional decline in older patients in acute medical wards. The researchers noted that most patients stated their emotions of powerlessness at not caring for them when the nurses support them with ADLs. As a result of the hospital limitations and everyday ward routines imposed on them while attempting to perform their ADL, patients felt bound and had "no autonomy" (Kirk et al., 2019). Time constraints have seen many nurses failing to complete care of older patients in acute medical wards. This contributes to deconditioning among those patients. There is a sense of failure in giving care because most of the time is spent focusing on wound care, medication administration, and basic hygiene care; by emphasizing physical and noticeable nursing interventions, time pressure has been proven to reduce a high grade of basic care. As a result, there is a feeling of failing to provide high-quality treatment (Lim et al., 2020). Nurses are concerned about patients' willingness to mobilise because of pain and the severity of their mobilization. Nurses are often concerned about injuring patients during mobilisation by causing them to fall. While some nurses may not consider mobilization to be a primary obligation or an important part of their work, while others do. One of the most pressing issues found also is shortage of staff (Kirk et al., 2019). However, there required to wear incontinent pads and were not also fully assisted with personal care because of a shortage of staff and nurse stating they were too busy. Furthermore, due to the nurse's nature of the clinical setting, patients found it difficult to engage in self-care. For instance, if patients see that nurses are busy frequently, they avoid doing personal activities that require a nurses’' assistance, even, some patients who need assistance in going to the toilet or use commode would prefer to wear incontinence pads rather than risk incontinence (Lim et al., 2020).

References

Boltz, M., Capezuti, E., Shabbat, N., & Hall, K. (2010). Going home better not worse: Older adults' views on physical function during hospitalization. International journal of nursing practice, 16(4), 381-388.

Chan, E. Y., Samsudin, S. A., & Lim, Y. J. (2020). Older patients’ perception of engagement in functional self-care during hospitalization: a qualitative study. Geriatric Nursing, 41(3), 297-304.

Clarke, C., Stack, C., & Martin, M. (2018). Lack of meaningful activity on acute physical hospital wards: Older people’s experiences. British journal of occupational therapy, 81(1), 15-23.

Guilcher, S. J., Everall, A. C., Cadel, L., Li, J., & Kuluski, K. (2021). A qualitative study exploring the lived experiences of deconditioning in hospital in Ontario, Canada. BMC geriatrics, 21(1), 1-9.

Kirk, J. W., Bodilsen, A. C., Sivertsen, D. M., Husted, R. S., Nilsen, P., & Tjørnhøj-Thomsen, T. (2019). Disentangling the complexity of mobility of older medical patients in routine practice: An ethnographic study in Denmark. Plos one, 14(4), e0214271.

Lafrenière, S., Folch, N., Dubois, S., Bédard, L., & Ducharme, F. (2017). Strategies used by older patients to prevent functional decline during hospitalization. Clinical nursing research, 26(1), 6-26.

Lim, S. H., Ang, S. Y., Ong, H. K., Lee, T. Z. Y., Lee, T. X. L., Luo, E. Z., & Thilarajah, S. (2020). Promotion of mobility among hospitalised older adults: an exploratory study on perceptions of patients, carers and nurses. Geriatric Nursing, 41(5), 608-614.