Colleen M. Casey, PhD, ANP-BC, CNS

14 Pages·2013·2.93 MB·English

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ABSTRACT
HHOOWW TTOO OOBBTTAAIINN CCOONNTTAACCTT HHOOUURRSS BBYY RREEAADDIINNGG TTHHIISS AARRTTIICCLLEE
The purpose of this study was to review relevant literature on ac-
IInnssttrruuccttiioonnss tivity of older critically ill patients, including activity interventions
X1.X3 c coonnttaacctt h hoouurrss w wilill lb bee a awwaarrddeedd b byy V Vilillalannoovvaa U Unniviveerrssitityy C Coollleleggee o off N Nuurrss-- conducted in this population, with a focus on activity measure-
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mmeeaassuurreemmeenntt tthhaatt ddeennootteess 6600 mmiinnuutteess ooff aann oorrggaanniizzeedd lleeaarrnniinngg aaccttiivviittyy.. TThhiiss ment and technology. Literature published between 1996 and
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2012 was reviewed using keywords older adults, inactivity, mobil-
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tthhee eevvaalluuaattiioonn ffoorrmm oonnlliinnee aatt hhttttppss::////vviillllaannoovvaa..ggoossiiggnnmmeeuupp..ccoomm.. TToo oobbttaaiinn
ccoonnttaacctt hhoouurrss yyoouu mmuusstt:: tion, ICU (intensive care unit), and accelerometry using CINAHL,
11.. RReeaadd tthhee aarrttiiccllee,, ““SXtXuXdXy XoXf XAXc tXivXitXyX iXnX O XldXeXrX AXdXuXl tX IXCXUX P XaXtiXeXn tXsX: AXn X IXnXte gra-
MEDLINE, and the Cochrane Database of Systematic Reviews. Pre-
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iilllluussttrraattiivvee mmaatteerriiaallss tthhaatt aarree iinncclluuddeedd ttoo eennhhaannccee yyoouurr kknnoowwlleeddggee aanndd vious relevant research is discussed and includes intervention and
uunnddeerrssttaannddiinngg ooff tthhee ccoonntteenntt.. BBee ssuurree ttoo kkeeeepp ttrraacckk ooff tthhee aammoouunntt ooff ttiimmee
((nnuummbbeerr ooff mmiinnuutteess)) yyoouu ssppeenndd rreeaaddiinngg tthhee aarrttiiccllee aanndd ccoommpplleettiinngg tthhee nonintervention studies. Although studies have demonstrated
qquuiizz..
the benefits of early mobilization in the ICU setting, this research
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yyoouu hhaavvee iinnccoorrrreecctt aannsswweerrss,, rreettuurrnn ttoo tthhee aarrttiiccllee ffoorr ffuurrtthheerr ssttuuddyy..
has it addressed how best to quantify these clinical activities. Cur-
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yyoouu ccoommpplleettee tthhee oonnlliinnee eevvaalluuaattiioonn,, aa cceerrttiifificcaattee wwiillll bbee aauuttoommaattiiccaallllyy patient activity and in mobilizing high-risk patients during acute,
ggeenneerraatteedd..
critical illness. [Journal of Gerontological Nursing, 39(8), 12-25.]
TThhiiss aaccttiivviittyy iiss vvaalliidd ffoorr ccoonnttiinnuuiinngg eedduuccaattiioonn ccrreeddiitt uunnttiill MJuOlyN 3T1H, 2 X0X1,5 2.0XX.
CCoonnttaacctt HHoouurrss
TThhiiss aaccttiivviittyy iiss ccoo--pprroovviiddeedd bbyy VViillllaannoovvaa UUnniivveerrssiittyy CCoolllleeggee ooff NNuurrssiinngg aanndd T
SSLLAACCKK IInnccoorrppoorraatteedd.. he aging of Americans presents many challenges
to the U.S. health care system. Older adults are
VViillllaannoovvaa UUnniivveerrssiittyy CCoolllleeggee ooff NNuurrssiinngg iiss aaccccrreeddiitteedd aass aa pprroovviiddeerr ooff ccoonnttiinnuu--
iinngg nnuurrssiinngg eedduuccaattiioonn bbyy tthhee AAmmeerriiccaann NNuurrsseess CCrreeddeennttiiaalliinngg CCeenntteerr’’ss CCoomm-- hospitalized more frequently and have longer
mmiissssiioonn oonn AAccccrreeddiittaattiioonn.. hospital lengths of stay than any other age group, ac-
AAccttiivviittyy OObbjjeeccttiivveess counting for more than half of the nation’s hospital bill
11.. IXdXeXntify the factors that contribute to muscle breakdown and loss of func- (Buie, Owings, DeFrances, & Golosinskiy, 2010; Carson
2. tXioXnX in older intensive care unit (ICU) patients. & Bach, 2002). Estimates of the older population (>65) in
2. Discuss the types of activity that have been used in the study of early the intensive care unit (ICU) setting range from 48% to
Dismcloobsiulizraeti oSnt aint eICmU epnattients.
58%, their mortality rates vary between 20% and 50%,
Neither the planners nor the author have any conflicts of interest to disclose.
Disclosure Statement and they make up more than half of chronically critically
Neither the planners nor the author have any conflicts of interest to disclose. ill patients (Carson & Bach, 2002; Cuthbertson, Rough-
ton, Jenkinson, Maclennan, & Vale, 2010).
Many older adults recover from critical illness
(Garrouste-Orgeas et al., 2006; Montuclard et al., 2000).
However, studies show that as many as three quarters of
Colleen M. Casey, PhD, ANP-BC, CNS
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older hospitalized patients experience
some loss in function during hospital-
ization that persists beyond the hos-
pital stay (Boyd et al., 2008; Covinsky
et al., 2003; Wu et al., 2000). Patients
who have an ICU stay, particularly
those who are chronically critically
ill, are especially vulnerable to physi-
cal deconditioning during lengthy
hospitalizations because they are of-
ten older, frequently postoperative,
and at a higher risk for morbidity,
hospital readmissions, and mortality
(Carson & Bach, 2002). The resul-
tant functional limitations and related
disability translate into significant
personal and societal costs that may
include nursing home placement, in-
creased demands on family caregiv-
ers, and the potential for a decreased
quality of life (Carson, 2003; Carson
& Bach, 2002; Cuthbertson et al.,
2010; Zanni et al., 2010).
INACTIVITY IN HOSPITALIZED
PATIENTS
Hospitalized patients are likely to
spend much of their time in bed and
alone (Bernhardt, Dewey, Thrift, &
Donnan, 2004; Brown, Friedkin, &
Inouye, 2004; Goldhill, Badacsonyi,
Goldhill, & Waldmann, 2008). Spon-
taneous physical activity decreases by Nerthuz
ahilnyso g msl ephsuiostc ashtplh iaaatdsan ml 5iaz0igas%etsi-ioo iannnn, , dpar anegtmdiee nainsdit nesssi rfg -olmnolilwafiotc wcdahiunnertdg-- © 2013 Shutterstock.com/
community-dwelling older adults
(Browning, Denehy, & Scholes,
2007). The reasons for such immobil-
ity, in addition to physiological insta-
bility of the patient, are complex. Bed
Journal of GerontoloGical nursinG • Vol. 39, no. 8, 2013 13
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•Altered muscle morphology
•Cellular-level damage
•Decreases in muscle mass,
muscle fiber diameter, and
number of fibers per muscle
(Kasper, Talbot, & Gaines, 2002)
Disuse/ Bed Rest
•Oxidative and proteolytic
injury to muscle cells
•Cytokine-mediated changes
•Decreased muscle
in insulin receptors and
Inflammation
cross-sectional area
electrolyte gradients Aging
of Critical
•Decreased muscle
decrease muscle contractility
Illness
regeneration
(Wagenmakers, 2001)
•Malnutrition (Kasper, 2001)
Accelerated Muscle Breakdown
Figure 1. Factors leading to muscle breakdown in older hospitalized patients.
rest orders are often the default ac- characteristic of critical illness. Dur- muscles, further exacerbating skeletal
tivity order on admission, are some- ing this time, an increased release and muscle atrophy (Kasper, 2003). Wa-
times not revised during hospitaliza- action of proinflammatory cytokines genmakers (2001) found that ICU
tion, and may not have documented promote further muscular atrophy patients can lose more than 1.5 kg of
medical indications for such bed rest through several complex, interre- skeletal muscle mass per day, with up
(Brown et al., 2004; Needham, 2008). lated pathways (Winkelman, 2004). to a 50% loss in total muscle mass in
Despite commonly accepted stan- Increased proteosomal proteolytic 2 weeks. Clinically, these losses often
dards of care, minor activities, such activity, such as occurs in sepsis, also result in global muscle wasting, foot
as turning every 2 hours, may hap- causes protein degradation and mus- drop, joint immobility, dyspnea, and
pen as infrequently as every 5 hours cle loss in critically ill patients (Klaude weakness (Clavet, Hébert, Fergusson,
(Goldhill et al., 2008; Krishnagopalan, et al., 2007). Neuromuscular patholo- Doucette, & Trudel, 2008; Needham,
Johnson, Low, & Kaufman, 2002), gies caused by and acquired during 2008).
putting the ICU patient at increased critical illness are increasingly recog- The rate of muscle atrophy result-
risk for musculoskeletal, cardiovas- nized as phenomena specific to ICU ing from inactivity or critical illness is
cular, respiratory, and integumentary patients. These pathological changes even more rapid than that of normal
sequelae. occur along a clinical spectrum, aging. For the older ICU patient, the
Inactivity, age, and the inflam- with the most severe manifestations muscle wasting induced by critical ill-
matory process that occurs during termed critical illness polyneuropathy ness compounds the 40% reduction
critical illness conspire to promote (CIP) and critical illness myopathy in muscle cross-sectional area that
muscle breakdown and loss in physi- (CIM). Even less severe neuromuscu- occurs as part of the natural aging
cal function in older hospitalized pa- lar deficits than CIP and CIM are of- process between the ages of 20 and
tients (Figure 1). Muscle breakdown ten overlooked or misdiagnosed and 80, leaving the older ICU patient less
occurs as early as several hours from delay patient recovery (Stevens et al., protein reserve (Griffiths, 1996; Win-
the onset of immobility or disuse, 2007). kelman, 2004). Moreover, the ability
independent of any injury or illness Pharmacological interventions and of specialized muscle cells to regener-
(Hirsch, Sommers, Olsen, Mullen, & other treatments common in the ICU ate muscle to divide and proliferate
Winograd, 1990; Kasper, 2003; Win- setting, such as the use of exogenous is finite, decreasing with age (Kasper,
kelman, 2009). The process of muscle corticosteroids, muscle relaxants, 2003). These age-related changes,
breakdown related to inactivity fur- neuromuscular blockers, and antibi- along with the high levels of inactivity
ther compounds the inflammation otic agents, can be toxic to nerves and documented and the inflammation of
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critical illness, put inactive and criti- FINDINGS
cally ill older adults at high risk for a A total of 16 studies meeting the
compromised recovery. criteria were retrieved: 5 were ran-
Prior systematic reviews of pro- domized controlled trials, 5 were ex-
gearrelsysi vem omboilbitiyli tyi nitne rvtehnet ioICnsU haanvde m/Creations pweerriem oebnstearl vqautiaonntaitla sttiuved isetsu. dDieast,a a wnder 6e
pi(anCprgiphm rpooarir,ao icllhToyean fssgo oectdutao ,sm e&dew c ohenHaa nnpoiicnaffatgmil e vnapentsnr, otri2teloa0ctce0ioio8vl)ns-, © 2013 Shutterstock.co rcv&eliaod Ksuussincfi earcdflea l,t ebi2voy0an 0n 5dts )ey.rt seSetsrteeummadri yncfih inet tlg(eiWn mgahen nit thttosee v mweporeraerrlee-l
(Clini & Ambrosino, 2005), the in- summarized into a matrix (Table 1 and
fluence of neuromuscular weakness Table 2) for easy comparison across
(Truong, Fan, Brower, & Needham, all primary sources. Studies meeting
2009), and the timing of early versus Mobility interventions the selection criteria were evaluated
delayed intervention (Thomas, 2011). for setting, appropriate description
within these studies
No reviews have specifically focused of methods used in the study, effect
typically included the
on older ICU patients, nor has any of the intervention when applicable,
use of clinical care
review evaluated the way in which and conclusions. This review discuss-
activity has been measured. The pur- activities such as range es only components of interventions
pose of this integrative review was to of motion (ROM), involving activity, although some
review relevant literature regarding multicomponent interventions also
turning, dangling/
inactivity and activity of critically ill included cognitive or respiratory re-
sitting on the edge of
patients, particularly older ICU pa- habilitation.
the bed, transferring,
tients. This review also focuses on
how activity and activity interven- sitting in a chair, and Activity Interventions in ICU
tions have been measured. The fol- walking, often termed Patients
lowing questions were addressed: Research on early mobilization
“progressive mobility”
l What activity interventions in the ICU has developed primarily
or “early mobilization.”
have been conducted in ICU in the past 5 to 10 years. Most of the
patients? activity interventions occurred in spe-
l Has activity been studied in cial respiratory care units or medical
older ICU patients? ICUs, involving only patients who
l How has activity been mea- were mechanically ventilated (MV).
sured in the ICU setting? functional status, rehabilitation, am- Only a single study occurred in a sur-
l What types of technology have bulation, early mobilization, ICU, gical ICU (Burtin et al., 2009), and no
been used to promote activity in and accelerometry. Studies were lim- published studies of progressive mo-
the ICU setting? ited to those in the English language bility have occurred in trauma or car-
and involving human participants 18 diac ICUs. Burtin et al. (2009), Sch-
METHOD and older primarily in an ICU or re- weickert et al. (2009), and Pohlman et
This review followed the inte- spiratory care unit setting. Addition- al. (2010) studied a standardized early
grative literature review process ally, an ancestry approach was used, exercise training intervention in the
outlined by Whittemore and Knafl analyzing reference lists of retrieved early ICU phase when many patients
(2005), which allows for the inclusion reports. Abstracts of conference are still sedated. However, most in-
of diverse methods and the simulta- presentations, personal communi- terventions occurred in patients who
neous inclusion of experimental and cations, case studies, and scholarly had been MV for at least 5 days or
nonexperimental research to more dissertations and theses were not longer.
fully describe varied perspectives included. Other exclusion criteria Mobility interventions within
on a phenomenon. Published stud- included studies that had fewer than these studies typically included the use
ies were retrieved from CINAHL, 10 participants; did not describe par- of clinical care activities such as range
MEDLINE, and the Cochrane Da- ticipants’ age; used solely inspiratory of motion (ROM), turning, dangling/
tabase of Systematic Reviews from (versus whole body) muscle train- sitting on the edge of the bed, trans-
1996 to 2012. The search includ- ing as an intervention; did not study ferring, sitting in a chair, and walking,
ed the following keywords: older activity as a primary variable; and often termed “progressive mobility”
adults, inactivity, mobility, progres- included ICU survivors beyond hos- or “early mobilization” (Needham,
sive mobility, progressive activity, pital discharge. Truong, & Fan, 2009). A few studies
Journal of GerontoloGical nursinG • Vol. 39, no. 8, 2013 15
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Key Findings Improved walk test, decreased dyspnea Improved muscle strength and fewer days to transfer bed to chair in COPD patients Improved strength, decreased weaning time Improved arm, leg, and respiratory strength; improved functional status 69% ambulated >100 feet at ICU discharge; early activity feasible and safe 73% received PT (vs. 6% UC); out of bed earlier, reduced ICU and hospital LOS, decreased mortality; dedicated mobility team aided mobility at no increased cost 88% ambulated median of 200 feet at ICU discharge
Additional Activity-Related Outcomes Measured 6MWT Muscle strength score, time needed to transfer from bed to chair Manual muscle testing, FIM Barthel Index, FIM, hand grip and leg strength, 2-minute walk test (distance) Distance ambulated Receipt of PT, days to activity Distance ambulated
Measurement/Documentation of Activity Not described Not described Not described Borg Rating of Perceived Exertion; patient tolerance; type and frequency of activity Activity events recorded Days to out of bed Activity events recorded
Type of Activity Passive ROM, sitting, early ambulation, treadmill Active limb mobilization, electrical stimulation Passive/active ROM, upper and lower ergometer, standing, ambulating ROM, arm and leg exercises with weights; rolling; sitting; standing; transfers; walking Sitting on bed, sitting in chair, ambulating (turning, sitting, and ROM excluded) Passive ROM, turning, active resistance, sitting, transfers, ambulating Passive ROM, sit on edge of bed, sit in chair, ambulate using walker
Mean Age 65 (SD = 6) 66 (SD = 8) 59 (SD = 7) b75 (range = 63 to 80) 63 (range = 18 to 91) 54 (SD = 17) 58 (range = 20 to 89)
STUDIES n/MV Status 80; some MV 24, all MV 49; MV >14 days 39; MV >14 days 103; MV >4 days 230; MV on admission 104; MV >4 days
N
O U
NTERVENTI Design/Duration RCT, 7 weeks RCT, 4 weeks Prospective cohort, to discharge RCT, 6 weeks Prospective cohort Prospective cohort, to ICdischarge Prospective cohort
U ACTIVITY I Setting/aCountry Respiratory ICU, Italy Respiratory ICU, Italy Respiratory unit Respiratory unit, Taiwan Respiratory ICU MICU Respiratory ICU
C
TABLE 1 SUMMARY OF I Author(s) Nava (1998) Zanotti, Felicetti, Maini, & Fracchia (2003) Martin, Hincapie, Nimchuk, Gaughan, & Criner (2005) Chiang, Wang, Wu, Wu, & Wu (2006) Bailey et al. (2007) Morris et al. (2008) Thomsen, Snow, Rodriguez, & Hopkins (2008)
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used less common inter-
ventions such as cycle
Key Findings Increased walking distance, quadriceps force, and self-perceived functional status Control group was more independent at hospital discharge; had shorter duration of delirium; more ventilator-free days; longer walking distance; median distance = 15 feet Significant increase in number of PT/OT consultations and treatments; decrease in MICU LOS and hospital LOS U = medical intensive care unit; UC = usual care. es2NCFctrh0eirgim0ilmiaoin9c,um ;ece2 lrhtaMe0,t utit0,irka o3y2Mr,)n 0 t.i 0Ga(nEoBi5,nraa ;u cuiH,rhe gt&Zl ihiesnnaact c nFunetarotdr,pi aatcyit&clae’i.-sl,,,
d Ce definition of activity was
TABLE 1(CONTINUED) SUMMARY OF ICU ACTIVITY INTERVENTION STUDIES Additional Measurement/Activity-RelateSetting/Design/n/MV Type of Documentation Outcomes aAuthor(s)CountryDurationStatusMean Age Activityof ActivityMeasured bBurtin et al. (2009)MICU/SICU, RCT, length of 90, MV and 56 Bedside Number of Quadriceps force, Belgiumhospital staynon-MV(SD = 16)ergometer, activity sessions, functional status, passive/active mean resistance 6MWTROM (20 minutes (watts); therapist per day)perception of exercise tolerability; vital signs bSchweickert et al. Multisite (2), RCT, length 104, MV 58 Passive ROM, Duration of PT/OT Manual muscle (2009)/Pohlman et MICUof hospital after (range = 36 active ROM, bed session; number testing, hand grip al. (2010)stay or until intubationto 69)mobility exercises of repetitions of strength; Barthel functionally (transferring to ROM, duration Index, FIM; days to independentupright sitting); of therapy, activitysitting balance percentage of days activities, transfer participating, days training, pre-gait to milestones (e.g., exercises, and first day out of walkingbed, standing) Needham et al. MICUQuality 30, MV 4+ 53 Supine to sit, sit Number of PT/None(2010)improvement days(range = 43 on edge of bed, OT treatments, (pre-/post-to 69)transfer from bed number of comparison)to chair, transfer consultations, from sit to stand, activities walkingcategorized Note. 6MWT = 6-minute walk test; COPD = chronic obstructive pulmonary disease; FIM = functional independence measure; ICU = intensive care unit; LOS = length of stay; MIunit; MV = mechanical ventilation; ROM = range of motion; OT = occupational therapy; PT = physical therapy; RCT = randomized controlled trial; SICU = surgical intensive carab If outside the United States; Intervention group. sssiiiamicwetetapIaeitsiptrtmctW2SZte2teeSHnnnntniiiiiiialtiCoelhrvllslttt0c0nrrevsoovnmitau.l.e n eets gg ceeogaehomo,,ty aa00soiinaa nn Ua oMrddrnaic, ttnna hlie2bp6w6gv2 l esnbewa eoiy.r ,seoue yt.ldg 0, tet;;ree k0ct,b an,acu.gl o i t a- e,rl, fr p,es2i,b d0dhnMtc0 sot iyuata d s r 2enscisNa sonoiwa0ehvr8yc ,7atpmenaWhntn e t0 csld 2oted s0nkeda) aiR .os)c e idoaesa0igRar,.0,r p.tv arbsru9 aete ei cui,uoevd el 7mtvotOidfis0ti drerkhPn2x;orutic2tnphmhvava,fgif a;elfi e9i te enC0c e h ytydbl0a,belica ehnMn m W mSa;stritlcorat0 tnas0esls rltizhu dyh teeteab1ecui y nthic9sbiito8i( ee aotdcsTedlhgnuhr i9 ioeomdtotdM( ;ae“. ida)nttbva a a hnrB,u aeld9et,iw,hntu i erepcn inm latelC .iooldi ess8epcet,o (c d.ala o &t.(osdog er ,ctyItiBs,mznob )cBrsaiar R2hrbt t remui nnlesil,,(fei22o,utdcerym r.nciuatu e0cimuati Bu duol OaitittW00atkmdttiys Aidse0doirsio li insaiiizurvnufal00emiaeaviet oi 3ennieeneMondncoop&ceaecceinueessl59grrtris)dyndngg”.erss---------------tftftt,,,;;,,,
of physical therapy (PT)
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s s g 2
Key Findings Wrist actigraphy correlated with agitation scores Sitting in chair or standing occurred rarely and for short duration Only 27% of patientreceived any PT Only 63% of patientsat out of bed durinICU stay; median number of times sitting out of bed = No significant difference in cytokines after rest and activity Patients received median of 2 treatments during entire ICU stay nical ventilation;
a
Outcomes of Intervention NA NA NA NA NA; primary outcome was interleukin-6 and 10 levels at rest and after activity NA; joint ROM, manual muscle testing, and functional status of those who received consultations care unit; MV = mech
Measurement/Documentation of Activity Accelerometry Accelerometry, observation log with total time in each activity Number of consultations Numbers of times sitting out of bed or edge of bed; number of attempted mobilizations Accelerometry, log of activities, including frequency and duration Number of consultations, total number of treatments, duration of routine treatments; vital signs; duration of unsupported sitting at edge of bed; maximum distance ambulated; Functional Status Score for the ICU unit; MICU = medical intensive
e
NTION STUDIES n/MV StatusMean Age Type of Activity 20, some 51 (SD = 16)All activityMV 2060 (SD = 16)Turning, ROM, dangling, chair sitting, ambulating 15052 (range = Occurrence of PT/43 to 66)OT 3068 (range = Occasions of sitting 59 to 77)out of bed after tracheostomy 17, COPD60 (SD = 9, Turning, ROM, range = 35 dangling, chair to 74)sitting, ambulating 32, MV >4 49 (range = Rolling, sitting days42 to 57)at edge of bed, transferring, ambulation, grooming, bathing hronic obstructive pulmonary disease; ICU = intensive caral therapy; PT = physical therapy.
ERVE /n nal, nal, nal nal nal, nal, OPD = cupation
TABLE 2 SUMMARY OF ICU ACTIVITY NON-INT Sites/Setting/DesignaAuthor(s)CountryDuratio Grap, Borchers, MICU/ObservatioMunro, Elswick, & CMICU2 hoursSessler (2005) Winkelman, ICUsObservatioHiggins, & Chen 2 x 4 hours(2005) Needham et al. Multisite, Observatio(2007)ICUcohort Bahadur, Jones, & ICU, ObservatioNtoumenopoulos England(2008) Winkelman MICU; step Observatio(2010)down unit90 minutes Zanni et al. (2010)Single MICUObservatioto hospital discharge Note. CMICU = coronary medical intensive care unit; CNA = not applicable; ROM = range of motion; OT = occa If outside the United States.
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(Morris et al., 2008; Needham et al., initial ICU admission to activity was <65 ambulated >100 feet, 64% of
2010; Pohlman et al., 2010), days to 6.6 days (SD = 5.5) to sit on the edge older adults did the same. The same
out of bed (Morris et al., 2008; Sch- of the bed, 8.8 days (SD = 7.6) to sit study did find that older patients
weickert et al., 2009), and functional in a chair, and 11.3 days (SD = 10.1) participated in more sedentary (sit-
status (Burtin et al., 2009; Chiang et to walk (Bailey et al., 2007). Morris et ting in chair or bed) activity but did
al., 2006; Schweickert et al., 2009). al. (2008) also found that only 6% of not provide statistical significance
Sedative use was associated with a 135 MV patients received PT in the for these differences. Bahadur et
2-fold decrease in likelihood of am- ICU. Needham et al. (2010) found al. (2008) found that patients who
bulation in patients with acute respi- that 24% of patients received PT/oc- were not mobilized tended to be
ratory distress syndrome in one study cupational therapy (OT), but prior to older (70 versus 66); these results
(Thomsen et al., 2008); Needham et any intervention, averaged only one were not statistically significant.
al. (2010) similarly found decreased treatment per patient per ICU stay.
sedation to positively correlate to Measurement of Activity in ICU
activity levels. In Schweickert et al.’s Study of Activity in Older ICU Studies
(2009) and Pohlman et al.’s (2010) Patients As described above, many inter-
study of early mobility, sedation in- None of the reviewed studies vention studies measured the fre-
fusions were stopped before 83% of specifically examined activity in quency of rehabilitation, for example,
therapy sessions; agitation after seda- older ICU patients. Interestingly, three times daily passive ROM or
tive interruption required stopping although activity interventions twice daily PT. Needham’s (2008)
therapy in less than 10% of sessions. within the acute care setting focus study of patients with acute respira-
Schweickert et al. (2009) found on older adults (Inouye, Bogardus, tory distress syndrome found that
that despite substantial differences Baker, Leo-Summers, & Cooney, patients received activity beyond
between functional measurements, 2000; Prvu Bettger & Stineman, bed rest in only 11% of 2,470 ICU
the intervention did not produce 2007), the ICU-based studies days observed. Furthermore, stud-
any significant differences in manual mostly took place on younger, MV ies showed that patients did not
muscle testing or hand grip strength. patients, with mean ages in the 50s routinely receive PT or OT consulta-
Morris et al. (2008, 2011) found that (Bailey et al., 2007; Burtin et al., tion as part of their usual care (Mor-
in addition to shorter hospital stays, 2009; Martin et al., 2005; Morris ris et al., 2008; Needham et al., 2007;
intervention patients progressed et al., 2008; Needham et al., 2010; Zanni et al., 2010). Although distance
more quickly to active PT, were out Schweickert et al., 2009; Thomsen ambulated was commonly reported,
of bed earlier, experienced no adverse et al., 2008). Only three interven- duration of both non-walking and
events during ICU therapy sessions, tion studies reported mean ages of walking activities was often not re-
and had fewer hospital readmissions the sample >65; mean ages were 75, ported. Recent studies have pointed
or death during the first year. Impor- 65, and 66, respectively (Chiang et to higher-intensity rehabilitation
tantly, some of the studies measured al., 2006; Nava, 1998; Zanotti et al., leading to greater benefit but have not
adverse outcomes, such as a change 2003). Two intervention studies in- objectively measured the activity it-
in clinical status, falls, and accidental cluded patients as old as 89 (Thom- self except to describe the activity (sit-
extubation, all concluding that based sen et al., 2008) and 91 (Bailey et al., ting, walking) and document the dis-
on minimal adverse events, early mo- 2007). Bahadur, Jones, and Ntou- tance walked and duration of activity.
bilization can be performed safely menopoulos’ (2008) work was the Zanni et al.’s (2010) prospective ob-
in the MV population (Bailey et al., only observational study to study servational study measured duration
2007; Morris et al., 2008; Pohlman et older patients (mean age = 68). No of unsupported sitting at the edge of
al., 2010; Stiller, 2007). study described an upper age limit the bed and maximum distance am-
In addition to establishing the pos- as part of any exclusion criteria. bulated. However, other than scoring
itive outcomes of early mobilization, Most of the intervention stud- a patient as “unlimited” if they could
numerous intervention studies docu- ies did not discuss age as a covari- sit for more than 30 minutes or ambu-
mented the magnitude of inactivity ate in the analysis of their findings. late more than 600 feet, the study pro-
across ICUs. Morris et al. (2008), for Burtin et al. (2009) reported that vided no additional detail for patients
example, reported that even for ICU the three patients who dropped out not achieving this benchmark.
patients assigned to a mobility pro- of the ergometer intervention were A number of non-intervention,
tocol, it took 5 days (SD = 0.9) to older. Bailey et al. (2007) examined observational studies have examined
touch their feet to the floor as com- various activities by age (<65 ver- the influence of ICU clinical care
pared to 11.3 days (SD = 2.1) for a sus >65) and found that older age activities on a variety of physiologi-
control group receiving usual care. did not preclude participation in cal parameters, such as SvO2, heart
Similarly, the time to activity from activity. Although 74% of patients rate, blood pressure, and cytokines
Journal of GerontoloGical nursinG • Vol. 39, no. 8, 2013 19
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ARTICLE
Figure 2. Progressive mobility algorithm developed through a multicenter mobility collaborative to promote consistent mobility
practices across intensive care units (ICUs). Reprinted with permission from Rick Bassett, MSN, RN, APRN, ACNS-BC, CCRN.
Note. RR = respiratory rate; HR = heart rate; MAP = mean arterial pressure; SBP = systolic blood pressure; RASS = Richmond Agitation
Sedation Scale; ROM = range of motion; HOB = head of bed; UAP = unlicensed assistive personnel; CLRT = continuous lateral rotation
therapy; PT = physical therapy; OT = occupational therapy; prn = as needed; RT = respiratory therapy; ADLs = activities of daily living;
OOB = out of bed.
(Gawlinski & Dracup, 1998; Verder- ity. Grap, Borchers, Munro, Elswick, riods, only turning and ROM were
ber & Gallagher, 1994; Winkelman, and Sessler (2005) found accelerom- actually observed as activities in one
2010). This attention underscores the etry to correlate well with observed study (Winkelman et al., 2005), while
important role activity plays in the activity levels and subjective reports turning, ROM, dangling, sitting, and
relationship to various physiological of agitation and sedation in 20 ICU walking were observed in the second
indicators, especially during a criti- patients. The study included only study (Winkelman, 2010).
cal illness. However, most of these a 2-hour time period and measured
studies have not measured the activi- associated physiological parameters, Technology to Promote Activity in
ties themselves beyond chart review, such as blood pressure, invasively ICU Patients
observation, or nurse recall, nor have and separately. Winkelman (2010) Both standard, as well as custom-
they studied the effect of activities on and Winkelman, Higgins, and Chen designed, equipment have been
overall physical functioning. (2005) found acceptable agreement adapted to facilitate physical activ-
Additional efforts have been made between accelerometry and observa- ity in ICU patients. Unfortunately,
to quantify activity in the critical care tion. Although accelerometry did not only preliminary study has occurred
setting through the use of accelerom- differentiate the type of activity, it did on most of these technologies with
etry, which measures activity counts distinguish activity from rest or bed hospitalized or critically ill patients
noninvasively during rest and activ- rest. Given limited observation pe- (Needham et al., 2009). Equipment
20 Copyright © SLACK Incorporated
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ARTICLE
developed with the intent of helping Overall, daily uptime duration was requirement to mobilize a patient
intubated and sedated patients move low (30 minutes on Day 4 postopera- from four to two, a significant clini-
includes continuous lateral rotation tive). Despite finding that daily uptime cal and resource concern and current
therapy (CLRT) as well as modified was low and predicted length of stay, barrier to patient mobility (see http://
bedside cycle ergometry (Burtin et the device did not discriminate be- www.mobilization-network.org/
al., 2009; Delaney, Gray, Laupland, tween sitting out of bed and standing Network/Links.html for more infor-
& Zuege, 2006; Goldhill, Imhoff, and walking. mation on the MOVER Aid).
McLean, & Waldmann, 2007). CLRT These efforts were precursors to
was developed in the 1970s specifi- the study of accelerometers. As de- DISCUSSION
cally in an effort to reduce pulmonary scribed previously, although accel- The ICU activity intervention
complications of immobility and has erometers have been used minimally studies in the past 10 years come
been shown to be effective when ini- to study ICU activity (Grap et al., amidst a transition away from a cul-
tiated early and used for at least 18 2005; Winkelman, 2010; Winkelman ture of deep sedation and bed rest
hours per day (Delaney et al., 2006). et al., 2005), they have been used that has persisted despite historical
Bedside ergometry has been intro- clinically to monitor physical activ- evidence of the physical and psycho-
duced more recently in the ICU set- ity patterns of cardiac rehabilitation logical benefits of early mobilization
ting to prevent joint contractures and patients (Ayabe et al., 2004), patients (Needham, 2008). Increasingly, early
maintain lower extremity strength, with spinal cord injury (Warms & mobilization has been established as
with prior clinical studies in patients Belza, 2004), COPD patients (Pitta, safe, feasible, beneficial, and finan-
with chronic obstructive pulmonary Troosters, Spruit, Decramer, & Gos- cially sound (Bailey et al., 2007; Lord
disease (COPD) and patients dur- selink, 2005; Steele et al., 2003), pa- et al., 2013; Stiller, 2007). Theoreti-
ing hemodialysis (Burtin et al., 2009). tients after stroke (Haeuber, Shaugh- cally, because ICU-related weakness
Neuromuscular electrical stimulation nessy, Forrester, Coleman, & Macko, and debility is more “acquired” than
(NMES) creates passive contraction 2004), and postoperative patients “degenerative,” patients who receive
of skeletal muscle using electrodes in the hospital setting (Inoue et al., early mobility during critical illness
that deliver a low-voltage electrical 2003). Accelerometry has only begun have a large potential to benefit from
impulse to target muscle groups (Bax, to be used in older hospitalized adults rehabilitation (Jackson et al., 2012).
Staes, & Verhagen, 2005). Thought to (Culhane, O’Connor, Lyons, & Ly- Findings of this integrative review
mimic the effects of repetitive muscle ons, 2005), but has been shown to ad- demonstrate that ICU-based studies
contractions in mild exercise, NMES equately measure physical activity in have not specifically examined activ-
has yet to be studied in the ICU set- nonhospitalized, community-dwell- ity in older ICU patients, who are
ting, although preliminary study sug- ing older adults (Gerdhem, Dencker, frequent users of critical care and are
gests its use as a potential rehabilita- Ringsberg, & Akesson, 2008). known to be at high risk for com-
tion adjunct (Needham et al., 2009; Lastly, because of the technologi- plications and decreased functional
Zanotti et al., 2003). cally intense environment of the ICU, outcomes related to critical illness.
Technology aimed at quantifying which serves as a barrier to patients Moreover, because many of the stud-
movement has also been only mini- actually moving their bodies, tech- ies tested interventions in special re-
mally studied in the ICU setting. In nology has been specially designed to spiratory care units, the results have
the 1970s, Halstead (1978) studied address the equipment-laden patient. limited generalizability to non-MV,
“time out of bed” of quadriplegic pa- Most simply, newer ICU bed frames critically ill patients, and broader
tients using the Rest Time Monitor, can be positioned to place patients in critically ill patient populations, such
finding that longitudinal activity mon- a feet-down, head up posture to pro- as surgical or trauma patients. Non-
itoring could be a useful clinical tool. vide gravitational loading (Winkel- respiratory care units may have dif-
Unfortunately, little progress has been man, 2009). The ICU Moving Our ferent unit cultures around mobiliz-
made in the past 30 years to promote Patients for Very Early Rehabilitation ing patients and different staffing and
routine incorporation of activity mon- (MOVER) Aid, developed at Johns interdisciplinary structures that influ-
itoring into both research and clinical Hopkins University by biomedical ence the delivery of physical therapy
practice. In a study by Browning et al. engineering students, includes a more to patients. These studies also did not
(2007), researchers used a positional elaborate mobility aid that combines continue the interventions beyond
activity device, worn on the leg, to the support of a walker with the safe- the ICU into the general hospital set-
study “uptime,” the quantity of time ty features of a wheelchair (for rest ting upon the patient’s discharge from
spent in an upright position, in a post- breaks) as well as a separate wheeled the ICU, although a recent study has
surgical population across hospital and tower for life-support equipment found this type of intervention be-
ICU settings (mean age = 61; SD = 12 (Sneiderman, 2008). Importantly, the yond ICU discharge to be beneficial
years; n = 6 [12%] were ICU patients). MOVER Aid eliminates the staffing and feasible (Jackson et al., 2012).
Journal of GerontoloGical nursinG • Vol. 39, no. 8, 2013 21