TORONTO - A hospital stay can be a heart-rending pivot point in the life of an older person.
Frail seniors who go into hospital still able to manage at home can within a short period of time lose the strength and mobility they need to get out of bed, go to the bathroom alone, walk around their home or neighbourhood.
When it comes time for them to be discharged, they may be cured of the condition that led to their hospitalization, but the illness may have been replaced by more profound problems. For some, time in hospital marks the end of independent living.
The cause of the sharp decline? Lying in bed for days on end.
"Some people believe rest is a good form of medicine, but actually it's not helpful to most patients," says Dr. Barbara Liu, a geriatrician at Toronto's Sunnybrook Health Sciences Centre and executive director of the Regional Geriatric Program of Toronto.
That's especially true for seniors. "They were on the borderline of being independently mobile before and now after a few days of immobility, it's not possible for them to mobilize independently anymore. They're now requiring assistance," Liu explains.
"It's a big difference in terms of the ability of somebody to return home if they can't walk."
Liu and colleague Dr. Sharon Straus of St. Michael's Hospital in downtown Toronto are spearheading a project aimed at stemming the decline seen when older adults spend time in hospital.
The goal of the initiative, which goes by the acronym Move On (short for Mobilization of Vulnerable Elders in Ontario), is to ensure that staff of busy hospital wards don't lose sight of the fact that seniors are in a critical use-it-or-lose-it phase of life. They need to be coaxed or aided or given permission — whichever the case may be — to get out of bed and move, as often as is feasible given their physical state.
Straus, who is director of the knowledge translation program at St. Michael's Li Ka Shing Knowledge Institute, says the idea is to prevent the type of mobility erosion that renders seniors unable to perform the tasks of daily life.
"If they lose their ability to do any of these activities of daily living while they're in hospital or lose any of their mobility or walking ability, then that's going to increase their length of stay, increase the chance that they're going to have to go to a rehab facility, in some cases increasing the chance that they might have to go to a long-term care facility if they really become impaired from a functional point of view," she says.
Liu and Straus are the lead investigators on a study that is assessing the program, which they devised and first implemented at their hospitals. With funding from the Council of Academic Hospitals of Ontario, the initiative is being rolled out to academic hospitals elsewhere in the province.
Christine Conrad, of Maple, Ont., has seen how the project works with her father, Michael Fijal, 90. Fijal and his wife, Edzia, are originally from Poland; they moved to Canada in 1948. The two, who both look younger than their years, met in a Siberian prisoner-of-war camp when he was 18 and she was 15.
Fijal broke his back and left shoulder last Halloween when he took a nasty tumble in his garden. He was pulling out weeds when he lost his balance and fell out of a raised flower bed, crashing to the ground a metre below. It was his second bad fall in two years. In May of 2010, he fell and broke his neck, also while gardening.
His daughter says it's time to give up the pastime he loves, but Fijal has another idea. "I think I should quit falling," he says with a sly grin.
His latest injury led to a nearly three-month stay in Sunnybrook but on a recent Friday he and his family are all smiles. Fijal is going home. And he is able to do it walking under his own steam.
While Conrad says her father's legs are thinner than they were before the accident, Fijal has been walking up and down the corridors of his hospital unit as part of the program. "He's a tough guy," says Edzia, who has been with him in the hospital daily throughout his stay. Conrad says her father has been very motivated to get better and go home.
"Psychologically I'm ready," he says.
Straus says studies have shown that while in hospital, older people end up standing on average only 40 minutes a day. "That's probably going to the bathroom, right?" she says.
The protracted immobility is really unwise at that time of life. It puts people at risk of developing blood clots or skin ulcers — pressure sores. They are also at risk of developing delirium, becoming confused about where they are.
"We know that older people, for each day that they're in hospital, you can lose one to five per cent of your muscle strength," Straus says, adding that about a third of older adults lose their ability to do at least one activity of daily living during a hospital stay and about half of them aren't able to recover the function by the time they are discharged.
The Move On program seems so simple it's hard to believe it wasn't already part of standard hospital care. Members of the treatment team — nurses, doctors, physiotherapists, orderlies — plus family and volunteers are urged to make sure that patients get out of bed. If they can't walk at first, the move might be to spend more time sitting in a chair. But the goal is eventually to get people moving at least three times a day.
It's built into the daily patient assessments that staff do. Liu says a patient's capacity should be reconsidered each day, so that if they can handle more movement the bar gets raised.
Jocelyn Denomme, a physiotherapist at Sunnybrook who is attached to the program, says evidence shows that if staff on wards take the time to assess patients' mobility daily, the patients tend to be up and moving more. It's a way of making sure the issue doesn't tumble down the long list of priorities facing busy health-care workers.
"For seniors especially, mobility really hits delirium, functional decline and falls. So it's a very simple way almost to have the attitude that we want our patients to live in the hospital as they would at home," she says.
It takes some adjustment. Straus notes some hospital rooms don't have chairs — or at least not the type of chair a senior can get in and out of easily. Hallways can be a bit of an obstacle course, cluttered with equipment and quick-moving staff.
"Yes, it's not an ideal environment," Denomme admits. "But it is what it is and it doesn't excuse not moving patients."