Treatment of immobility syndrome in older people

Are complications can be organic, psychological and social, and the adaptation of the environment of the elderly to minimize the consequences of immobility.

The general care program will be basically the same, but the rehabilitation treatment of mobility must be individualized, taking into account the time of evolution of the deconditioning, the functional reserve of the individual and the support of the environment. Three major sections can be distinguished in the treatment of immobility syndrome: general care, rehabilitation or progressive approach to movement and technical aids, and adaptation of the environment.

Caring for the immobile elderly

• Prevention of skin problems. The appearance of pressure ulcers is one of the most serious complications in immobilized patients. The preventive activities to be carried out are:
  • Postural changes: must follow a certain rotation, always respecting the same posture and body alignment. Carry out the changes carefully, without dragging the patient, avoiding shear and friction forces. Distribute body weight evenly in order to avoid muscle aches due to compensatory contractures. Padded supports can be used. In lying patients should be done every 1-2 hours, to minimize the effects of continued pressure on bony prominences. In seated patients it is ideal to perform them every 10 minutes, lifting it up for 10 minutes, to avoid the appearance of pressure ulcers at the sacral level. To maintain this rhythm of postural changes at home, the use of anti-decubitus mattresses and cushions is very useful, which help to lengthen the period between changes, which should never be longer than 4 hours when bedridden or 1 hour when seated.
  • Hygiene: with awater, neutral soap and soft sponge, followed by a good rinse and perfect drying (especially the folds), without rubbing. The bed and / or chair will be clean, dry and free of any foreign objects. The sheets should be soft and not wrinkle. The room should be well ventilated and at a suitable temperature.
  • Massage: activates circulation, promotes muscle relaxation, stimulates sensitivity and facilitates intercourse. It also helps to maintain the body outline. It should be done gently, gently moving the skin and subcutaneous cellular tissue using wide circular movements (kneading) or pinching and releasing the muscle plane again with the fingers. It is ideal to use a moisturizer and in areas of special pressure risk (sacrum, hips, elbows, scapulae and any other that supports pressure). The application of oils rich in hyperoxygenated fatty acids improves the prevention of ulcers in these areas.
  • Padding: in areas of higher pressure such as elbow, knee, sacrum, trochanters, scapulae, etc.
  • General hydration and nutrition: protein deficiencies should be avoided, a contribution of vitamin C (1 g per day in already established ulcers) and zinc (15 mg / day) in the diet is advisable. Also, the intake of 1-1.5 liters of water per day.
• Prevention of musculoskeletal complications. Attention should be paid to posture and body alignment, as well as early movements through active or passive exercises, depending on the patient's situation.
• Prevention of cardiovascular complications. The blood pressure and heart rate looking for rhythm disturbances, as well as avoiding pulmonary embolisms and phlebitis.
• Prevention of respiratory complications. Mucus stagnation is a problem to prevent. For this it is recommended:
  • In bedridden patients it is advisable to maintain head of bed raised, perform respiratory physiotherapy, inform and encourage the patient to take deep breaths, cough and expectorate; Sometimes it will be convenient to use aerosols and it is advisable to drink plenty of fluids to fluidize secretions and promote their expulsion.
  • In the case of uncooperative or seriously disabled patients, early postural drainage can be established, the purpose of which is the passive elimination of secretions from the specific bronchial area by placing the patient in positions in which the gravity. To be effective, these positions should be held for 20-30 minutes and repeated a minimum of three times a day. You can also use the percussion or clapping (It is struck on the back, from bottom to top with the patient positioned in a position that favors the expulsion of mucus by gravity), which only has an effect on the mucus organized in mass and located in the large airways. Percussion should be gentle considering osteoporosis and pain.
• Prevention of gastrointestinal complications. Constipation is a very common problem. As a general rule, the diet must be sufficient, balanced, rich in fiber, varied, easily ingested, digested and absorbed. In addition, it must:
  • Check the status of mouth (teething, poorly fitted prostheses, etc.).
  • Promote food out of bed and in company to prevent anorexia.
  • Incorporate the bedridden patient to avoid problems of aspiration.
  • Favor a pattern defecation schedule and preserve your privacy. In severely impaired patients, flat hand abdominal massage is effective, starting from the bottom right, going up and ending at the bottom left, to stimulate bowel movements.
• Prevention of genitourinary complications. The most pressing problem is incontinence, as well as incomplete bladder emptying, as they will promote urinary tract infections and stone formation. It is important:
  • Maintain a suitable position in the urination and privacy conditions.
  • If there is incomplete emptying, recommend voluntarily contracting the abdominal wall or exerting manual pressure on it, in the area above the pubis.
  • In case of incontinence With a short evolution time and in collaborating patients, it is useful to perform detrusor training exercises such as Kegel exercises (start urinating and stop urinating several times during a normal evacuation).
• Prevention of psychological problems. We must promote the expression of feelings and encourage the sharing of emotions, as well as maintain motivation by setting accessible objectives in the short and medium term. Encourage visits and conversation with the elderly person about his life, his past and his interests. Empathy is an essential instrument for the caregivers of these patients.

Rehabilitation or progressive approach to movement

• Bedridden patient.
  • If immobility is total, passive postural changes should be made, at least every two hours, ensuring that the posture is correct to avoid spasticity, contractures or vicious postures (especially important after a cerebrovascular accident or stroke). Exercises, initially passive, will be started to increase the range of joint mobility. The maneuvers must be carried out carefully, with continuous and sustained movements, without causing pain. The application of gentle moist heat to the joints makes it possible to stretch more and reduce pain. As soon as possible, the patient should perform active mobilization exercises in bed: turn sideways and flex the trunk forward. The patient must be helped to sit on the edge of the bed periodically, with his feet flat on the floor, increasing the sitting time little by little, until he can balance without help and can sit for half an hour three times a day.
• Sitting in an armchair
  • The transfer from the bed to the chair will be done while the patient is sitting on the bed, with his feet resting on the floor, he will grasp the arms of the chair and push the body. The time the patient is sitting out of bed should be progressively increased throughout the day, starting at one hour twice a day. It is important that you maintain a correct posture (upright trunk and aligned head), if necessary with the help of pillows, and that you continue to exercise limb mobilization. Elevating your feet on a stool will help prevent edema. Sitting is the minimum objective to be achieved in every patient, since by maintaining the vertical posture of the trunk, feeding is facilitated and aspiration is avoided. The sitting also has a positive psychological effect.
• Standing
  • The patient should try get up and stand helped by two people or leaning on a walker located in front. You must maintain an upright position without flexing your hips or knees. In the first days it is normal for the patient to report great instability, so it should be done very gradually. Balance will be practiced with the support on one foot and alternately, with the feet in tandem.
• Wandering
  • Daily ambulation should be practiced, at a slow pace but with increasing distances, counteracting the fear of falling and watching for the appearance of automatisms (for example, swinging the arms). Initially you can use a walker and then move to a cane or without support. Cardiorespiratory tolerance must be monitored. The objective is to ensure that the elderly are able to walk around their home and carry out activities of daily life with the least amount of help possible.
• Maintenance.
  • It must be adapted to the degree of physical tolerance of the patient. The program should include breathing exercises, flexing and extending the limbs, practicing standing up and sitting down again, taking short walks several times a day, and if possible, doing some type of gymnastics, better if it is scheduled. The fundamental objective is strengthen muscle groups directly involved in ensuring autonomy in activities of daily living, especially when walking. Coordination can be enhanced with the serial performance of a certain exercise. Crafts are a good alternative.

Technical aids and adaptation of the environment

• Auxiliary elements for mobilization: They increase the stability of the gait, increase the base of support, unload part of the weight that the lower extremities bear, thereby reducing pain and providing confidence and security. These elements include:
  • The walking stick, which is justified in cases of muscle weakness of a lower limb, to relieve joint pain secondary to walking, to expand the base of support if there is instability, to compensate for deformities or as a point of reference if there is sensory deficiency. It should be used on the arm opposite the affected leg, as this produces a normal gait pattern and further increases the base of support. The length of the cane should correspond to the height between the floor and the patient's wrist, when the patient is standing with his arms down.
  • The crutches, which provide more support, discharge and stability. They are used in cases of muscle weakness in both lower limbs, inability to support one of them, hand and wrist disabilities or significant balance impairment. There are two main types: those that fit in the elbow and the axillary ones. The former are preferable because they are lighter, give greater autonomy (for example, when opening doors) and do not cause complications such as nerve compression in the armpit.
  • The walker, whose use is recommended after prolonged periods of immobility with generalized weakness or if the gait is not stable. There are different types: four-legged, with wheels, with legs and wheels, etc. The choice will depend on the characteristics of the patient; thus, those with wheels are preferable if there is pain in the shoulder and generally produce a faster and smoother but more unsafe gait.
• Home adaptations
  • Ladders: the height can be reduced by inserting intermediate steps, there must be handrails on both sides and if possible ramps will be used although avoiding excessive inclination.
  • Doors: we will try to make them as high as possible and the opening mechanism will be facilitated. Delayed closing mechanisms are helpful for slow-moving individuals.
  • Furniture: there should be ample space for mobilization; It is useful to place furniture in strategic and well anchored places that allow support, as well as handrails in the corridors. The chairs must be firm, with an adequate height to make it easier to get up, a high back that exceeds the height of the head and with arms, preferably covered, since a lot of force is exerted with the hands when getting up.
  • Bed: its height will be adjusted to facilitate transfers. In bedridden patients, articulated beds, similar to hospital beds, are very useful.
• Other aids
  • Wheelchair: they can be high or low back, wide or narrow, with large or small wheels, with or without a urinal included, indoor or suitable for walking outside, in patients who do not wander they are very useful for transfers in and out home and thus avoid social isolation.
  • Hoisting cranes: very useful for transfers from bed to sitting and vice versa in severely disabled patients. There are manual and motorized ones.