Strategies for Improving Resident Mobility

A common challenge for residents in nursing homes is immobility, which can result in a variety of physical complications and cause feelings of isolation, anxiety, and depression. While many people assume that immobility is a natural consequence of old age, research studies have shown that the elderly have a much greater potential for mobility than previously believed.

Mobility and Aging

Several of the physical changes associated with the aging process can impair a resident's ability to move independently. Decreased efficiency of the cardiovascular and respiratory systems can lead to movement difficulty and weakness. Many elderly individuals have diminished muscle tone, often reflecting the result of a sedentary lifestyle. Vision and hearing impairments can make navigation around one's environment challenging. There is also a higher prevalence of chronic illnesses, painful conditions, and medication usage during the later years which can dramatically affect mobility and independence. Some of the common age-related causes of impaired movement include arthritis, osteoporosis, stroke, and Parkinson's disease.

Many elderly enter today's nursing homes in dire physical condition. As reported in the April 7, 1995 issue of Council Close-Up, the National Institute on Aging has released some revealing statistics about elderly beyond the age of 75: 40 percent cannot walk two blocks, 32 percent cannot climb ten steps; 7 percent cannot walk across a small room; and 50 percent of older people who fracture hips never walk independently again and many die from complications. As these statistics reveal, residents in nursing homes face many serious challenges with mobility that affect their autonomy, control, and well-being.

Maintaining mobility has a profound effect on the physical and psychological well-being of the elderly. Disuse or immobility may result in complications in almost every body organ system, which may lead to further disability and illness. Some of the common effects of immobility include:

• Increased stress on the heart
• Orthostatic hypotension
• Pooling of secretions in the lungs
• Demineralization and loss of bone
• Muscle atrophy and weakness
• Pressure ulcers
• Sensory deprivation
• Urinary complications
• Feelings of helplessness, depression, anxiety

In addition, immobility begins a process in which independence is progressively reduced and dependency on staff for basic activities results. Prevention of immobility and its complications are essential actions that should be considered in every resident's care plan.

The Assessment Process

Helping a resident with mobility should begin with a thorough functional assessment. According to the in-service on "Improving Movement and Mobility" in Long Term Care Educator, staff should inspect a resident's body for missing or abnormal structures, uneven lengths of extremities, abnormal posture, edema, or conditions that affect movement. Observe the resident's ability to sit, stand, transfer, walk, dress, hold utensils, and perform other basic activities.

Evaluate the range of motion (ROM) of every joint. Determine the residents' ability to move joints independently (active ROM) and the motion of joints with your assistance to move them (passive ROM). Note any significant differences between active and passive ROM; restricted joint motion, swelling, warmth, tenderness, or wasting of joint; and pain on movement.

Determine muscle tone and strength. Ask the resident to squeeze your hands. Likewise, with gentle force push your hand against the sole of each foot and ask the resident to resist your efforts to move the leg. Note weakness, rigidity, or other abnormalities.

Review the resident's medical record for conditions that could threaten movement, such as arthritis, fatigue, or mental illness. Also examine the resident's medications for their effects on mobility, especially sedatives, psychotropics, and antihypertensives. Note the presence of casts, splints, restraints, and other devices that could affect movement. Be sure to ask the resident about pain, dizziness, and weakness.

The Importance of Exercise

One of the biggest challenges to improving resident mobility is overcoming misconceptions about exercise and the elderly. With advancing age comes an expectation of increasing frailty and a dependence on others for the tasks of daily living. While it is true that physical debilitation is a natural part of the aging process, this debilitation can be minimized through the effective use of exercise and restorative programs.

Many research studies have proven that even frail elderly can derive many physical and psychological benefits from well-developed fitness programs. In the future, exercise will play an increasingly prominent role in nursing facilities, helping to curtail the debilitation that is now seen as a common reality for the elderly.

Developing a Successful Walking Program

To maintain and improve mobility in older persons, many nursing facilities have implemented walking programs, resulting in many positive outcomes. Research studies have shown that these programs build up muscle tone and strength, improve circulation, increase balance, and may help to reduce spasms and contractures. Residents also experience increased self-esteem, dignity, and socialization as a result of their participation.

According to the booklet Group Physical Activities for the Frail Elderly, by Olga Hurley, walking programs work best in a group program format. Walking alone, picking up one's feet again and again, perhaps with discomfort, is often uneventful and boring. But walking in a group, socializing, talking, renewing friendships with peers and looking around at new surroundings relieves boredom and creates pleasurable experiences.

Frail elderly often have physical problems that make walking difficult. Yet, many still can walk with benefit. A person with chronic lung disease, for instance, can be taught breathing techniques to extend his capabilities. With the aid of canes and walkers, some people with strokes, arthritis, and other handicaps can learn to walk safely.

During a group walking program, allow for frequent rest periods and watch for signs of fatigue. Each person's endurance level is different. Some will have to rest more frequently. Some may be ready to stop and rest for a minute after ten or fifteen feet, while others rest at thirty or forty feet. Try to organize walks by matching individuals according to their abilities.

The number of participants in a group can accommodate depends on the group's abilities or disabilities. Staff can recruit volunteers or family members to walk with slow walkers, residents in wheelchairs, or others needing light assistance.

As a rule, shuffling can be eliminated by gradually increasing the length of the stride. As the length and strength increases, balance and posture will also improve. To maintain the best walking cycle, remind the walkers to hold their heads up straight as if wearing a crown, make their backs straight as possible, and pull their abdomens in. Have them point toes and feet forward and swing arms loosely. Advise them to land on the heel first and push off with the ball of their foot.

Give all necessary assistance to participants with poor balance or inadequate muscle strength. Support such persons with your arm under theirs. Don't let them hold you, because if they slip you will not be able to prevent them from falling or ease them down to the ground. A participant in the walking group who is a good walker but has poor vision should be given only minimal help. Let this individual hold your elbow for guidance, not support. Don't hold on to the visually handicapped person but allow as much freedom as possible.

The Roles of Physical Therapy and Nursing

In the September/October 1994 issue of Geriatric Nursing, the authors of the article "Maintenance Ambulation: Its Significance and the Role of Nursing" distinguish between the roles of the physical therapy and nursing departments in developing a successful walking program. The identified role of the physical therapist is defining ambulation goals, communicating appropriate walking techniques, and overseeing the use of assistive devices. Nursing's role is coordinating ambulation activities, enabling staff to recognize residents' ambulation potential, teaching staff methods of improving participants' self-esteem, and encouraging staff to ambulate residents as part of daily activities, such as using the bathroom and walking to the dining room.

To improve the success of a walking program, be sure to educate staff on the benefits of walking and include the nurse aides in interdisciplinary conferences to develop effective individualized approaches. It may be helpful to have start and stop points for the ambulation route of residents, changing the distance walked according to individual need. Facilities have also found success in providing rewards for the residents' accomplishments, such as offering a favorite food or presenting a certificate or recognition.