- Five facts everyone should know about mobility, vigour and self-care
- What is mobility, vigour and self-care?
- Why is it important to consider mobility, vigour and self-care when working with older people in hospital?
- Maintaining mobility, vigour and self-care in relation to falls
- What are the benefits to an older person in maintaining their mobility, vigour and self-care in hospital?
- What care or management principles should I follow to ensure maximum mobility, vigour and self-care for older people in hospital?
- How do I screen and assess for mobility, vigour and self-care?
- How do I screen and assess for falls risk?
- How can I prevent falls in older people identified as at risk?
- What can I do to promote mobility/self-care during an older person's hospital stay?
- How can I encourage optimal mobility, vigour and self-care in hospital?
- What can patients, families or carers do to maintain mobility, independence and reduce the risk of falls?
- What should I consider when planning discharge to help older people maintain mobility, vigour and self-care?
- Case study
- The ability to mobilise and participate in self-care is fundamental for interaction and control within a person's environment.
- Screen or assess older people for falls risk and take action to minimise the likelihood of falls.
- Provide supervision for walking or transfers for older people at risk of falls.
- Maintain or retrain an older person in skills of activities of daily living and self-care.
- Encourage physical activity via incidental exercise and participation in functional maintenance or enhancement programs, as appropriate.
Functional mobility is the capacity to move from one position (sitting, lying down, standing, and so on) to another, to enable participation in normal daily routines and activities. Functional mobility includes bed mobility, transfers, walking, wheelchair mobility, driving and taking public transport. Having independence in functional mobility tasks significantly reduces the level of long-term care required by an individual with a disability and allows an individual to participate in a range of self-care, productive and leisure activities, thereby promoting a sense of self-worth and actualisation .
Vigour is the active strength or force of body or mind . For example, in addition to the need for mobility, a person's ability to function is also determined by their energy levels, endurance, motivation and cognitive capacity.
Self-care is the personal care carried out by a person in hospital, for example, eating, bathing, personal grooming and toilet hygiene. The older person might require assistance or instruction from a health care worker for these tasks.
Why is it important to consider mobility, vigour and self-care when working with older people in hospital?
The ability to mobilise and participate in self-care is fundamental for interaction and control within a person's environment.
By maintaining mobility and adequate self-care it is possible for older people to maximise their:
- opportunities for personal independence
- social connectedness
Age-related functional decline means that older people are more susceptible to de-conditioning . For people living in the community, loss of the ability to mobilise and participate in self-care safely can determine the range of support services required. For people living alone, this loss of ability can result in placement into residential care.
For those entering hospital, mobility and self-care are often key measures used by health care workers to predict length of stay, discharge destination and the requirement for support services. For this reason, it is essential to ensure that a patient's mobility and capacity for self-care is maintained or improved during a hospital stay. This will provide them with the opportunity to return to their previous level of function and social situation wherever possible. During a hospital stay, a person-centred partnership with the older person is necessary to ensure mobility and self-care are maintained or improved.
Falls, related injuries and loss of confidence due to the fear of falling are common causes of morbidity in Australia. In hospital and residential care settings, the risk of falling is even greater than in the community setting because of acute illness, increased levels of chronic diseases and different environments and routines .
In the acute hospital setting, falls rates of between two to seven falls per 1000 bed days, have been reported . This translates to up to four falls per day in a 500-bed hospital, or over 1400 falls per year.
Between 30 - 40 per cent of falls in hospitals cause injuries , most commonly resulting in soft tissue injuries, fractures and cranial trauma. Even when no injury has occurred, the patient often loses confidence in their mobility, which can cause them to reduce their walking and other activities. Over time, this results in de-conditioning and increases their risk of further falls and functional decline .
Research evidence indicates that interventions to minimise falls risk can reduce the risk of falling and fall-related injuries, even in older people at high risk of falling. Staff involved in direct care in hospital and residential care settings have a key role in the successful implementation of falls risk minimisation activities .
Maintaining mobility, vigour and participation in self-care during an older person's hospital stay can maintain their independence, reduce the likelihood of falls and fall-related injuries and loss of confidence due to fear of falling.
What are the benefits to an older person in maintaining their mobility, vigour and self-care in hospital?
The ability to walk, climb stairs, transfer in and out of bed, shower, dress and toilet, are related to an older person's level of strength, balance and endurance.
Maintaining strength, balance and endurance during a hospital stay is essential to:
- Maintain or improve independence.
- Prevent de-conditioning that can result in functional decline due to the physiological changes following a period of inactivity or low activity.
- Maintain or increase muscle strength that occurs through an appropriate amount of physical activity and mobilisation.
- Decrease the risk of muscle shortening, joint distortions and reduced muscle capacity that occurs with immobilisation.
- Decrease cardiovascular de-conditioning that can occur with prolonged periods of bed rest.
- Decrease reduced aerobic capacity that can occur through changes in muscle metabolism.
- Reduce admission to long-term residential care services.
- Reduce the likelihood of falls .
What care or management principles should I follow to ensure maximum mobility, vigour and self-care for older people in hospital?
The following eight recommendations  can ensure maximum mobility, vigour and self-care during an older person's hospital stay and after discharge:
- Perform a comprehensive assessment for falls and fracture risk, mobility and functional status.
- With input from the patient and family or carer, develop an individualised care plan and encourage appropriate incidental activity and minimise bed rest through the day.
- Assess and modify the environment to encourage independence and mobility.
- Consider individual or group exercise training for muscle strength, endurance and balance.
- Assist in the retraining of activities of daily living.
- Consider nutritional supplementation where food intake is inadequate, in combination with strengthening exercises to maintain or improve muscle mass and strength. Be aware of the evidence that some older people displace food intake when supplements are introduced, so this needs to be done carefully under the supervision of a dietitian.
- Supervise walking and transfers in those identified to be at risk of falling.
- Consider transitional care needs and community-based strategies for minimising post-discharge falls and maintaining ongoing strength, mobility and vigour.
The following sections provide examples of resources to support the implementation of these guidelines.
Screening tools for this domain can highlight people who are at greatest risk of:
- de-conditioning - a decline in strength, balance and endurance during their hospital stay
- loss of independence with self-care.
Screening tools can also be scored to determine the level of a person's risk. This can assist to confirm a person's improvement or decline on follow-up.
Assessment tools are used to identify underlying risk factors that contribute to a person's overall risk and prompt a more detailed assessment to develop a care plan with appropriate strategies that address areas of identified risk related to de-conditioning.Person-centred screening and assessment should always be conducted in partnership with the older person and their family or carer.
There are a number of mobility and functional assessment tools that can be used by health care professionals:Berg Balance Scale de Morton Mobility Index (DEMMI) Modified Elderly Mobility Scale (MEMS) Timed Up and Go Test Tinnetti Assessment Tool: Balance Barthel Index Functional Independence Measure (FIM) and Functional Assessment Measure (FAM) Performance Orientated Mobility Assessment. These tools can also be useful as outcome measures for program evaluation.
Further informationFor further information on these tools, refer to Mobility and functional assessment tools. 37]. Person-centred screening and assessment are always conducted in partnership with the older person and their family or carer. A range of falls risk screening and assessment tools have been evaluated and published in the Victorian Quality Council Minimising the Risk of Falls and Fall-related Injuries Guideline Pack.
Further informationFor guidelines, refer to Minimising the risk of falls and falls injuries - Guidelines for acute, sub-acute and residential care settings For tools, refer to Minimising the risk of falls and falls injuries - Guidelines for acute, sub-acute and residential care settings (Tools supplement).
Some tools have the potential to be used as either a screening or an assessment tool. Refer to Summary of falls risk screening tools and falls risk assessment tools for further information.
Once a falls risk assessment has been completed, an individualised action list aimed at reducing the risk of falls and fall-related injuries should be developed and implemented, in partnership with the older person and their family or carer.
For more comprehensive guidelines to develop individualised action plans, the following supplements can be used to incorporate this practice into organisational departments:For guidelines, refer to the Victorian Quality Council Minimising the risk of falls and falls injuries - Guidelines for acute, sub-acute and residential care settings For a suite of resources for Australian hospitals and residential aged care facilities, refer to the New South Wales Falls Prevention Network Prevention of Falls Network Europe Falls Prevention for Older People: A program of national workshops on risk factors and prevention strategies
Sitting out of bed
Encourage patients to sit out of bed if possible. Staying in bed unnecessarily can have a detrimental impact on a person's overall function.Sit out of bed initiatives are simple strategies to minimise functional decline that organisations can embed into everyday practice, for example, assisting patients to eat meals out of bed.
Promote independence in self-care
- Encourage patients to dress each day if possible.
- Find out about patients' usual routines at home and try to maintain these in hospital (for example, what time of the day they usually shower). This helps with orientation to the ward and regular sleeping patterns. It is important to base ward routine on patient preferences and usual routines, rather than staff preferences.
- Include patients in self-care programs, such as cooking groups or self-care education sessions.
- Practice activities of daily living with a patient prior to discharge.
- Work with older people and their family or carers to assess and source any equipment that may be required at home.
The hospital environment is important in promoting mobility and self-care in older people.
There are a number of tools that can be used to assess the hospital environment to promote mobility and self-care in older people:Improving the Environment for Older People in Health Services: An Audit Tool Older Person Friendly Ward Round Individual Environmental Checklist Actions for Minimising Individual Environmental Risk Factors For further information on these tools refer to Environmental assessment tools.
There is good evidence to support the use of interdisciplinary interventions that include a component of exercise to reduce in-hospital length of stay. This can increase the proportion of patients discharged directly home and reduce the cost of stay for older acute hospital in-patients . Exercise alone has not been shown to influence acute hospital length of stay. For this reason, it is important that exercise is used as part of a multidisciplinary intervention to be effective in preventing de-conditioning of older people in hospital.
The following sections outline a range of interventions for consideration as part of an interdisciplinary strategy. Interventions should be discussed and implemented in partnership with the older person and/or carer.
Encourage incidental activity
Incidental activities are those where physical activity occurs as part of routine activities, for example, walking to the toilet (rather than using the commode), transferring and dressing. This form of exercise, through encouraging independence with functional tasks, is the easiest to promote and perform in the acute setting.
Minimising bed rest by increasing the number of incidental activities during the day can help to maintain muscle mass, strength and mobility, and reduce agitation in older people.
A benefit of performing incidental activity is that it involves activities people are familiar with, so is less anxiety provoking than starting a new physical activity. It also has a purpose, so if a person is not interested in a formal physical activity program, these personal care and domestic tasks are a beneficial form of exercise .
The summary below outlines some practical strategies that have been implemented in hospital settings throughout Australia to enhance the culture of the wards for both staff and patients, in:
- promoting incidental activity
- minimising bed rest
- preventing functional decline.
Encourage patients to:
Dress (consider the possibility of wearing their normal day clothes and footwear).
Get out of bed and move around the ward, with supervision as required.
Sit out of bed as soon as it is considered safe to do so.Walk to the toilet, with supervision as required. Eat meals out of bed, preferably in a communal dining room where available and appropriate.
Sitting out of bed for meals enables patients to:
See their food, food supplements and medications properly.
See orientation clues like clocks, calendars, signs and photos.
Feed themselves if they are able or better facilitate feeding.
Swallow more safely.
Digest food and medications.
Communicate with other patients.
Be less dependent.
Feel better about themselves.
Maintain their level of function.
Assist patients to:
Mobilise for personal care activities as much as possible.
Practice mobilisation, under prescription, direction or instruction of a physiotherapist.
Undertake theraband strengthening exercises (under prescription, direction or instruction of a physiotherapist).
Educate staff to:Create a continence and mobility plan that fits with patients sitting out of bed for meals.
Adjust bed height to allow for safe, independent, transfers.
Provide an environment that encourages incidental exercise.
Provide aids to assist with optimal transfers for patients getting out of bed.
Avoid using bed rails, which may limit mobility and be a hazard.
Improve staff knowledge of the risks of restricting mobility and provide strategies to prevent de-conditioning.
Individual and group exercise
Exercise programs can be administered in both individual and group settings and may include strength, balance, functional retraining and aerobic (or endurance) exercises.
Although there is limited evidence to draw conclusions of the benefits of individual or group exercises alone for people in hospital, as a component of an interdisciplinary intervention, evidence has indicated that individual or group exercise may:
- Increase the number of patients who are able to return home after discharge.
- Reduce length of stay for older people.
- Reduce cost of hospital stay .
Refer older patients to physiotherapy for prescription of individual or group exercise.
Retrain activities of daily living
Activities of daily living include mobility and self-maintenance activities (feeding, grooming, dressing, bathing, personal hygiene, toileting and skin management) . Bathing and dressing can be divided into upper-body and lower-body management .
To maintain or retrain these skills is important to maintain a person's ability to live independently.
To retrain, staff may need to:
- Retrain older patients in their personal care skills.
- Provide training in alternative strategies for self-care where necessary.
- Provide aids to assist with optimal independence (such as, appropriately designed seating).
- Ensure bed and chair heights are optimal for independence.
- Include patients in self-care programs, such as cooking groups and self-care education sessions.
- Provide verbal encouragement and guidance to promote independence.
Supervision for those 'at risk'
If a person is using a gait aid or is acutely unwell, it is recommended that supervision for walking and transfers is always provided. Supervision can be reduced as medical stabilisation occurs and familiarisation with the environment and equipment is achieved. Physiotherapists should be consulted if staff are in doubt about the supervision needs of patients .
Adequate nursing staff levels are important to ensure that the maximum possible amount of mobility can occur. This will enable staff to provide appropriate levels of supervision.
Other strategies to ensure effective communication between staff with the up-to-date mobility status of each patient commonly include:
- mobility sections in care plans
- entries in medical record
- utilisation of a whiteboard
- daily handovers
- Gait Aid Colour Coding System.
Management for falls riskRisk indicators, actions for injury prevention and hints and tips to assist in the elimination of personal risk factors (such as leg muscle weakness and de-conditioning, poor balance and unsteadiness in walking, and loss of confidence or fear of falling) have been clearly outlined in Minimising the risk of falls and falls injuries - Guidelines for acute, sub-acute and residential care settings (Quick reference guide).
A number of Functional Maintenance Programs (FMPs), otherwise known as Functional Enhancement Programs, have been developed by various health organisations. These programs offer a multidisciplinary approach to the prevention of de-conditioning in hospital. FMPs should be undertaken in partnership with the older person and their family or carer.To review main components of FMPs operating in health services in 2008, refer to Elements of Functional Maintenance Programs. For brief descriptions of FMPs operating within some Victorian health services in 2008, refer to Functional Maintenance Programs.
What can patients, families or carers do to maintain mobility, independence and reduce the risk of falls?
Ensuring both patients and their families or carers are aware of the benefits of keeping active in hospital and participating in self-care, where possible, promotes independence within the hospital setting. Educating people about strategies to prevent falls during a hospital stay is important to reduce the likelihood fall-related injuries.
A booklet has been designed to encourage people to be aware of what they can do for themselves while in hospital.
Further informationInformation about falls for patients, families and carers.
What should I consider when planning discharge to help older people maintain mobility, vigour and self-care?Person-centred discharge planning must be undertaken in partnership with the older person and their family or carers. Ensure the effective transfer of information regarding a person's mobility needs and falls risk, refer to Effective transfer of falls risk information.
Mr Brown is an 86-year-old gentleman. He lives independently at home alone and usually uses a walking stick in the community. He has no community services in place and manages his own personal and domestic care. Mr Brown's only family, a daughter, lives interstate.
After Mr Brown slipped and fell in his bathroom at home, his daughter, who was visiting from interstate at the time, phoned the ambulance. Mr Brown was then admitted to the emergency department (ED) with a possible fractured wrist.
Due to high demand in ED at the time of his arrival, Mr Brown was triaged and instructed to return to the waiting area where he waited with his daughter for approximately two hours. During his waiting period, Mr Brown was instructed not to eat or drink and became increasingly agitated and confused. Once in the ED, the admitting doctor completed a full medical examination, requesting an x-ray and a full blood screen. Mr Brown was put on a drip and informed to remain in bed until test results became available.
Soon after, Mr Brown's daughter informed one of the nurses that her father had appeared more confused than usual in recent days, and was quite unsteady on his feet. The nurse lifted the cot sides and told Mr Brown not to walk on his own, but this information was not noted in the medical history, nor reported to the medical officer. A falls risk assessment was not performed. Given it was now late in the evening and there was an expected delay in blood results and x-rays, it was suggested to Mr Brown's daughter that she go home and call the ED first thing in the morning. Overnight, Mr Brown became increasingly confused, pulled out the drip, and climbed the cot side. He fell, and sustained lacerations to his face.
Mr Brown's daughter returned the next day. She was distressed that inadequate measures had been taken in her absence to manage her father's risk of falls, particularly as she had specifically informed the nurse of his confusion and unsteadiness. Mr Brown had now been in ED for 14 hours and remained in bed during the entire period.
Mr Brown was transferred to the ward but waited several hours before being seen by the doctor and no information would be available regarding test results until the doctor arrived. On assessment, the medical officer asked all the 'same questions' of Mr Brown and his daughter. X-ray results confirmed a fractured wrist and Mr Brown was sent to have his arm cast later that afternoon.
As Mr Brown remained on a drip, due to severe dehydration and resultant kidney problems, his mobility remained severely restricted over the three-day period. On day three, Mr Brown was assessed by the physiotherapist, who confirmed significant de-conditioning and the need for a period of rehabilitation before returning home. A mobility routine was not commenced as Mr Brown was expected to be transferred for rehabilitation as soon as a bed became available.
Although Mr Brown's wrist was plastered on day two, his eating difficulties were not assessed until day four when he was seen by the occupational therapist. In the meantime, Mr Brown needed support from his daughter to set up his meal so he could eat it. There were several food items not eaten because Mr Brown could not manage with the cast when his daughter was absent.
Mr Brown's confusion began to subside with re-hydration, but his food intake remained restricted due to difficulties with using utensils. The occupational therapist provided advice and education but, by this time, Mr Brown had noticeably lost weight since first arriving to hospital.
The overall experience of the hospital stay was very stressful for Mr Brown and his daughter with long periods of waiting and being kept uninformed. Due to the de-conditioning (in mobility, weight, mental state and functional independence) experienced in the early days of hospitalisation, it was necessary to extend Mr Brown's hospital stay to include a period of rehabilitation. This could have been prevented with more proactive care and understanding of Mr Brown's needs.
The following strategies from The toolkit were utilised:
Use of a global screening tool on admission.
Domain and discipline-specific assessment and management where indicated by screening or clinical observation.
Use of a Falls Risk Screening and Assessment tool, given history of fall.
Provision of adequate supervision to facilitate maintenance of mobility.
Use of a Fall alert system to ensure effective communication regarding mobility status.
Consideration of appropriate environment to facilitate incidental activity.
Involvement in a Functional Maintenance Program.
Provision of targeted strength and balance exercises by a physiotherapist.
Management of risk factors contributing to falls risk (hydration, nutritional status, cognitive status).
Assessment of home environment prior to discharge.
Comprehensive discharge planning for ongoing management of mobility and falls risk.Provision of comprehensive discharge summary to facilitate ongoing care.
Encouraging and facilitating physical activity beyond discharge.
Mr Brown's fractured wrist was cast and, as a result of a full assessment, ED staff recommended care strategies, which were then transferred onto Mr Brown's care plan. Some of the recommendations included: Gait Aid Colour Coded System, supervision or assistance for all mobility with his walking stick and a trial of hip protectors. He underwent a medication review by the pharmacist in the ED and was referred to a dietitian. During his stay in ED, Mr Brown was supervised to and from the toilet (rather than using a bed pan), and was encouraged to sit in a suitable, height-adjusted chair to increase his level of incidental activity.
The ED staff identified Mr Brown as frail and at risk of functional decline, prompting an accelerated transfer to the specialist acute geriatric unit. Building upon the ED's care recommendations on the interdisciplinary care plan, Mr Brown was targeted for the Functional Maintenance Program (FMP).