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CHAMP Early to Bed, Early to Rise: The Adverse Consequences of Bed Rest

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Specific organ pathophysiology associated with prolonged bed rest ... Brainstorm ways to broaden the approach to getting people out of bed. ... – PowerPoint PPT presentation

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Title: CHAMP Early to Bed, Early to Rise: The Adverse Consequences of Bed Rest


1
CHAMPEarly to Bed, Early to RiseThe Adverse
Consequences of Bed Rest
  • Deón Cox Hayley, DO
  • University of Chicago

2
Objectives
3
Outline--Adverse Effects of Bed Rest
  • 1. Case
  • 2. History of use
  • 3. Elderly as important sub-group
  • a. special concerns
  • 4. How Bed Rest affects
  • a. Function
  • b. Individual organ systems
  • 5. Summary
  • Get people out of bed!

4
Patient G.J.
  • 78 y/o female
  • Admitted to sub-acute rehabilitation (in NH)
  • HPI s/p surgical repair of traumatic right knee
    fracture then dislocation
  • PMH OA, DM, HTN, bipolar disease
  • Soc Hx Husband does most IADLs, independent in
    ADLs and ambulatory

5
Exam
  • Gen flattened affect
  • Obese
  • Long leg cast on right (thigh?ankle)

6
Function
  • On admission
  • NWB on right leg, transfer on left leg
  • Needed assistance of 2
  • Goal
  • Get back to previous status at home

7
Knee fracture
delirium
narcotics
pain
urinary retention
constipation
Bed rest
incontinence
weight gain
pressure sores
weakness
worsened DM
IMMOBILITY
poor motivation
8
Follow up
  • Discharged home, walking with a walker

9
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10
Sick role model
  • Doctor authority
  • Hospital disorienting, threatening to older
    patients
  • Study of elderly hospitalized patients showed
    that 72 didnt ambulate in the halls at all.

Mahoney J. Wisc Med J. 1999.
11
Practice of using bed rest
  • Dramatically decreased
  • 1. OB
  • 2. Surgery
  • a. General
  • b. Orthopedics
  • 3. Cardiology
  • a. Post-MI
  • b. CHF

Still too much in general medicine
12
For if the whole body is rested much more than is
usual, there is no immediate increase in
strength. In fact, should a long period of
inactivity be followed by a sudden return to
exercise there will be an obvious deterioration.
-Hippocrates
Chadwick J, Mann Wm. The Medical Works of
Hippocrates. Oxford, UK Blackwell, 1950 p. 140.
13
Review of literature on the utility of bed rest
  • 39 trials of bed rest for 15 different conditions
    (n 5777)
  • 24 trials investigating bed rest following a
    medical procedure
  • no outcomes improved significantly
  • 8 worsened significantly
  • 15 trials investigating bed rest as a primary
    treatment
  • no outcomes improved significantly
  • 9 worsened significantly

Allen C et al. Bed rest A potentially harmful
treatment needing more careful evaluation. Lancet
3541229-33, 1999.
14
Why are the elderly more at risk?
  • Co-morbidities
  • Decreased reserve

15
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16
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17
What do we know about the adverse effects of bed
rest?
  • 1. Effects on total functioning
  • 2. Effects on individual organs/systems

18
  • Elderly admitted to the hospital
  • At discharge, 31 deteriorated in ADLs
  • At 3 months, 51 had either died or worsened in
    functional status

Sager MA, et al. Functional outcomes of acute
medical illness and hospitalization in older
persons. Arch Intern Med 156645-52, 1996.
19
  • Continued decline in function after
    hospitalization
  • 2 days post-hospitalization, 65 lost ability to
    walk
  • At discharge, 2/3 did not improve in function10
    deteriorated further

Hirsch et al. The natural history of functional
morbidity in hospitalized older patients. JAGS
381296-1303, 1990.
20
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21
  • One month post-hospitalization
  • 59 were not back to baseline
  • Risk Factors for functional decline
  • age
  • cognitive impairment,
  • low social activity,
  • pre-hospitalization functional impairment.

Innouye S et al. A predictive index for
functional decline in hospitalized elderly
medical patients. JGIM 8645-52. 1993. Sager MA.
Hospital Admission Risk Profile (HARP)
Identifying older patients at risk for functional
decline following acute medical illness and
hospitalization. JAGS 44251-7, 1996. Hansen K et
al. Risk factors for lack of recovery of ADL
independence after hospital discharge. JAGS
47(3)360-5. 1999.
22
Pathophysiology--organ systems
  • Man was designed to function more or less in
    the upright posture in earths gravitational
    environment. Thus, the deconditioning that occurs
    during bed rest would be viewed as a departure
    from the optimal posture.
  • - Greenleaf J.

23
CV
1. Change in hemodynamics 2. Orthostatic
incompetence 3. Changes in peripheral
circulation
Browse NL The Physiology and Pathology of Bed
Rest. Springfield, Illinois, Charles C. Thomas
Publisher, 1963.
24
CV
1. Eleven percent of circulating blood shunted
to the central circulation? initial ? in
cardiac output and stroke volume 2. With
increased time in bed, HR increases daily 3.
Cardiomegaly, mild though progressive
Chobanian AV et al, The metabolic and
hemodynamic effects of prolonged bed rest in
normal subjects. Circulation 49551, 1974.
25
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26

Orthostasis
  • Prolonged bed rest ?twice the usual fall in SV
    and CO with standing.
  • Pooled blood in lower extremities?? increased HR
    and alpha- adrenergic response
  • Symptoms occur early and are profound

Hung J, et al. Mechanisms for decreased exercise
capacity after bed rest in normal middle-aged
med. Am Jour Card. 51344-8. 1983.
27
CV response to activity after bed rest
1. Aging? cardiac dilatation? ?maximum heart
rate 2. Immobility? adrenergic system
up- regulation and ? reserve to increase CV
signals in response to initial exercise
28
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29
Respiratory
1. Restrictive impairment 2. Alteration in
blood flow
30
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31
Pulmonary Blood Flow
  • 1. Highly perfused areas become posterior? VQ
    ratio changes
  • 2. Blood flow changes (?central circulation
    and ? tissue hydrostatic pressure) ?pulmonary
    edema

32
Muscle
  • Rapid loss of strength
  • 5 per day
  • 50 of strength lost in first 3 weeks
  • Leg strength loss more quickly than arms
  • Atrophy twice as fast if muscle shortened

Muller LA Influence of training and of activity
on muscle strength.Aron Physics Med Rehab 51449,
1970.
33
Skeletal
  • Bone loss 0.9 per week
  • Both increased absorption as well as cessation of
    new bone formation

Wheldon GD Disuse osteoporosis Physiological
aspects. Calcif tissue Int 365146, 1984.
34
Joint changes
  • Joint loading important to keep healthy cartilage
  • Fibrosis and ankylosis
  • Decreased lubrication
  • Diminished cartilage smoothness within one week
  • Osteophyte formation within two weeks

35
Gastrointestinal
  • Increased risk of aspiration
  • Increased transit time
  • Anorexia
  • Constipation

36
Genitourinary
  • Diuresis 300-600 cc in first week then stable
  • 2. Hypovolemia
  • 3. Bladder evacuation impaired

37
CNS
  • EEG slowing on young immobilized patients who did
    not have any other sensory deprivations

38
Skin- break down
  • 1. With age, skin is less resistant barrier
  • 2. Mechanics of pressure, friction, traction and
    maceration

39
  • Effects on other systems
  • endocrine
  • immune
  • sensory changes
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