© Springer International Publishing AG 2018 57
S. Masiero, U. Carraro (eds.), Rehabilitation Medicine for Elderly Patients, Practical Issues in Geriatrics, DOI 10.1007/978-3-319-57406-6_8
F. Scarponi
Neurorehabilitation Unit, USL Umbria 2, Foligno Hospital, Via. M. Arcamone, Foligno, Perugia 06034, Italy
M. Zampolini (*)
Department of Rehabilitation, USL UMBRIA 2, Foligno Hospital, Via M. Arcamone, Foligno, Perugia 006034, Italy
e-mail: [email protected]; [email protected]
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In older people frailty is a syndrome of lower strength, endurance, and physio- logical functions that increase an individual’s vulnerability and risk of mortality.
Due to frailty, people can lose their independence leading to the condition of being bedridden with assistance required even for “minor” acute events and consequent increased risk of sarcopenia, cachexia, and atrophy. This overlap of geriatric syn- dromes may be relevant in the development of damage caused by being in a bedrid- den condition. In fact, frailty sarcopenia and cachexia can combine to form a vicious circle: strength, endurance, and physical activity are lower, the total energy expen- diture diminished, with a subsequent chronic undernutrition that maintains sarcope- nia [8].
8.1.1 Effects of Bed Rest
Prolonged bedrest is associated with several time-dependent effects. The effects of being bedridden have an impact on the whole organism, and a good knowledge of every physiological mechanism involved is recommended for the physician.
Table 8.1 summarizes the fundamental aspects for the principal body systems.
Table 8.1 Effects of prolonged bed rest Cardiovascular
system
Increased resting heart rate Venous thrombosis
Early increased cardiac stroke Respiratory system Reduced tidal volume
Potential permanent restrictive pulmonary disease due to fixed contractures of the costovertebral joints
Reduced FVC and FEV1
Loss of elastic recoil as a result of structural changes within the lungs Tendency for mucus to pool in the lower part of the airway
Collapse of airways and small areas of lung tissue (atelectasis), which reduces the area available for gaseous exchange
Musculoskeletal system
Atrophy of postural muscles, leading to an increased risk of falls and disability [15]
Reduction of bone mass in the spine and lower limbs Gastrointestinal
system
Decreased gastric bicarbonate secretion and increased acidity within the stomach
Symptoms associated with gastroesophageal reflux disease (GERD) Increased transit time and constipation
Urinary system Release of ANP and increased diuresis
Transient increase in plasma and urinary urea, a decrease in plasma creatinine, and no change in urinary creatinine
Rise of urinary calcium excretion
Incomplete emptying and urinary stasis, due to weakened abdominal and pelvic floor musculature
Renal and bladder stones and infections Skin Higher risk of pressure sores
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8.2 Prevention of Bed Rest Syndrome
Patients in the intensive care unit (ICU) could be the paradigm of the management of bed rest via mobilization. They are often sedated, critical/frail patients, with obvious difficulty in changing position, sitting or walking. Immobilization in complex patients in the ICU, together with systemic inflammation, is a strong independent risk factor for the development of intensive care unit-acquired weakness (ICUAW) [9].
Evidence indicates that functionally significant joint limitations are shown by more than a third of patients admitted to ICU for over 2 weeks.
It is noteworthy that enough damage to create the basis for a decubitus ulcer is done after as little as 2 h of immobility. Susceptibility to pressure ulcers comes from a combination of external factors (pressure, friction, shear force, and mois- ture) and internal factors (e.g., fever, malnutrition, anemia, and endothelial dysfunction).
Although a few years ago, early physical rehabilitation of critically ill patients was considered unsafe, in the last decade growing literature has shown the safety and feasibility of mobilizing ICU patients to prevent impairments, adverse events, in-hospital infections, and functional limitations [10].
In order to address these aspects, components of the ABCDE bundle include:
Awaken from sedation, Breathe independently without a ventilator, Choice of seda- tion, Delirium management, and Early mobilization [11].
While preliminary data regarding early mobilization of ICU patients has been shown to be safe, feasible, and beneficial, in one multicenter, observational Italian study, postural changes and early mobilization were prescribed in about two thirds of the cases, suggesting that these treatments are not yet widely practiced [12].
In this study, despite mobilization being included within the nurses’ activities in some cases, in almost all cases the physiotherapist was indicated for an average of 38 min/day.
Since mobilization is not always possible, another tool to prevent bed rest syn- drome is limiting development of sarcopenia by implementing nutrition with essential amino acids (EAA). The benefit of EAA in these conditions is not completely under- stood but could stimulate anabolic processes in skeletal muscles, thus helping to pre- serve them. In some papers, EAA supplementation leads to stimulation of the
Endocrine system Depressed levels of aldosterone and antidiuretic hormone
Sodium loss during diuresis and hyponatremia with subsequent increased plasma renin activity and increased plasma aldosterone levels
Progressive loss of potassium in the urine due to aldosterone secretion Increased cortisol secretion, onset of insulin resistance, impaired glucose tolerance, and the subsequent development of type 2 diabetes
Central and peripheral nervous system
Dysfunctions in mental status (confusion, sleep disorders, drowsiness) Difficulties in posture and balance in sitting and standing position Development of polyneuropathies
Table 8.1 (continued) 8 Bed Rest Syndrome
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production of lean body mass in older women and is associated in maintaining strength of plantar flexion and going upstairs, muscle mass, and motor coordination [8].
Probably, the most effective strategy to mitigate the impact of bed rest on the development of sarcopenia is adequate nutrition and/or the utilization of resistance exercise [13].
Another strategy is the utilization of “low magnitude mechanical signals (LMMS)” that seem to improve the strength and endurance of hip and knee muscles [8]. Furthermore, in experimental studies LMMS are anabolic to bone if applied at a high frequency (15–90 Hz) and could be useful in preventing osteoporosis caused by bed rest [14]. Further future studies are clearly necessary to understand the effi- cacy of these strategies in preventing the consequences of bed rest syndrome.
Conclusions
Evidence indicates that physiopathological mechanisms of bedridden conditions start very early after immobilization and can lead to prolonged and severe conse- quences that are often difficult to heal, painful, and impact negatively on the individual’s quality of life. Preventing such damage must be considered part of clinical routine. Care should be provided by a multiprofessional team with skills and expertise in medicine, nursing, and physiotherapy.
As specifically recommended also in the acute phase of very critical patients, the minimum provision of interventions is repeated postural changes during the day (every 2–3 h) as well as joint mobilization.
Key Points
• Physiopathological mechanisms of bed rest syndrome are time dependent;
few hours of immobilization are enough to begin a cascade of modifica- tions that can lead to impairments for several weeks or months.
• Immobilization could overlap with geriatric syndromes, with heavier impact on functional recovery.
• Bed rest syndrome involves various physiological systems.
• Bedridden condition should be discouraged when there’re no rational motivations to reduce mobility of patients, even in critical conditions.
• Care must be provided by a multiprofessional team with skills in medicine, nursing, and physiotherapy.
• Essential interventions are early mobilization, change positioning every 2–3 h, facilitating awakeness, and promote weaning from mechanical ventilation.
• If mobilization isn’t possible, a dietary intake of EAA or other solutions could be considerate.
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S. Masiero, U. Carraro (eds.), Rehabilitation Medicine for Elderly Patients, Practical Issues in Geriatrics, DOI 10.1007/978-3-319-57406-6_9
A. Musumeci (*) • A. Pignataro • E. Ferlito • V. Lazzari • H. Zatti • S. Masiero Rehabilitation Unit, Department of Neurosciences, University of Padua, Padua, Italy e-mail: [email protected]; [email protected];
[email protected]; [email protected]; [email protected];