|Strategies for Improving Resident Mobility
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
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
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
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
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