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Bedrest: Implications for the Aging Population

Jeannette Y. Wick, RPh, MBA, FASCP
Published Online: Thursday, January 13, 2011   [ Request Print ]

Studies indicate the immobilization due to bedrest is a concern for older patients, who lose their ability to perform daily activities as well as quality of life.
For most of us, having a physician tell us that we need to be on bedrest— or confined to bed for 24 hours or more—sounds like a break from our too busy schedules. For patients, however, bedrest’s appropriate objectives are 3- fold: to provide rest for the exhausted, to decrease oxygen consumption, and to reduce pain or discomfort.1

The earliest references to bedrest seem to have occurred around 450 bc, and even then, Hippocrates warned people that protracted bedrest could cause sarcopenia, osteoporosis, and tooth loss.2 Before the 19th century, survival required plenty of activity, so bedrest was perceived as being irresponsible.3 With improvements in automation and industrialization, people began to believe that complete rest would be restorative. Bedrest became a fashionable intervention.

In the late 1800s, alienists (psychiatrists) began to prescribe bedrest frequently. The thought was that making “asylums” look more like regular hospitals would decrease the stigma of mental illness.4 In all areas of health care, bedrest was common until the 1960s—a patient would “enjoy” bedrest after a myocardial infarction (4 weeks), hernia repair (3 weeks), cataract surgery (4 weeks), or childbirth (2 weeks).3

During World War II, clinicians began to question bedrest’s utility, although psychiatry continued to use this intervention. 1,3-5 They saw a relationship between inactivity and functional decline.5,6 The war also created an unprecendented number of wounded soldiers, and clinicians had to free bed space quickly so the more seriously wounded men would have beds. That early activity seemed to improve outcomes. Simultaneously, our national interest in putting a man on the moon spurred research into restricted mobility and weightlessness.3,7 Weightlessness experienced in space has no gravitational pull, but with bedrest, the gravitational pull shifts or is “unloaded.”7 Soon, studies demonstrated that immobilization with or without gravity reduces muscle mass, causes functional decline, and impairs ability to perform activities of daily living.3 Collectively, these symptoms are called “deconditioning” and they present as a “cascade of dependency.”8

This is especially a concern for older Americans. Among elderly patients who experience an acute hospitalization, more than 50% lose half to two thirds of their ability to perform activities of daily living and walking.9-11 Often, this situation results in nursing home placement.12-14

The Cascade of Dependency
Bedrest adversely affects every system in the human body.15 Psychologically, the loss of personal control that accompanies bedrest is horribly debilitating, and it can also affect the patient’s family members because it creates a need for greater caregiving. Both patients and family members may develop anxiety, confusion, depression, and forgetfulness. 3 Bedrest prescribed for healthy people makes them less able to make decisions, sometimes struggling with strategy development and actions associated with executive function and goal-directed behavior. 16,17 Immobilized patients also develop sleep disorders more than those who are ambulatory.18 In psychiatry, bedrest was traditionally used to convince patients that they were really ill and needed treatment4; learned helplessness develops in people with other conditions when they come to the same conclusion. As bedrest continues, it affects other systems, creating a downward spiral that contributes to psychological concerns.

Cardiac Changes and Respiratory Response
A persistent supine position seems to affect the cardiac system first. Upright posture and locomotion govern fluid circulation. Musculature and reinforced venous and lymphatic valves respond to the gravity, pulling fluid through the body and regulating its movement. Just 2 hours of supine immobilization shifts 1 liter of fluid from the legs to the chest. The patient’s fluid load shifts primarily to the abdomen, thorax, and head. Blood volume decreases, and urine output increases. Cardiac stroke volume, dependent on efficient cardiac filling for optimal efficiency, decreases. Cardiac deconditioning and postural hypotension follow.3

The rib cage uses a recoil mechanism to aid respiration. At a 90-degree angle from its best position, respiratory tidal volume and inspiratory/expiratory volumes are reduced, leading to airway narrowing and reduced tissue elasticity. Changing a patient’s orientation with respect to gravity causes mucous pooling in the lungs’ lower areas. Mucous thickens and becomes difficult to clear. This increases risk for pneumonia.18

Table 1

Going Systemic
In the immune system, clinicians should worry about 2 problems associated with bedrest: decreased cytokine production and reactivation of latent viruses, which have been reported in bedridden patients. Cytokine production is necessary for T and B lymphocyte (or natural killer cell) production.19 Decreased cytokine production creates a proinflammatory state, and can lead to cachexia and reduced circulating antibodies.14 As muscles begin to atrophy, protein synthesis decreases and nitrogen synthesis increases.20 Insulin sensitivity decreases,21 and aldosterone and plasma renin activity do as well.22

In just 1 week, bedridden patients can lose up to 10% of their plasma volume. Within a month, it increases to a 15% loss.7,9 This increases blood viscosity, 1 factor in Virchow’s triad (along with venous stasis and blood vessel damage). The risk of venous thromboembolism (VTE) escalates. Shrinking skeletal muscle lowers the body’s oxygen requirements. Consequently, erythropoiesis slows, red blood cell volume drops, and there is less hemoglobin. Decreased oxygen saturation creates morbid consequences for skin.18

Other Systems
In humans, the only skin designed to bear weight is the soles of our feet. All other skin is not as thick or sturdy. Immobilization reduces patients’ ability to alleviate pressure on the skin using unconscious weight shifting. Without this ability, unrelieved weight from internal organs and bones can literally wear a hole through the skin. Ischemia and necrosis start to develop. Perspiration trapped in bed linens and yanking and pulling during repositioning can start pressure ulcers, and create a receptive environment for bacteria. The sacrum, ischial tuberosity, greater trochanters, heels, and ankles are at greatest risk of pressure ulcer.19

Strength and muscle mass loss are serious issues. Weekly, bedrest is associated with a 12% loss of strength and significant muscle mass loss. Lower limbs that are accustomed to resisting gravity (calf, quadriceps, back) are affected first.7,19 Disuse creates muscle weakness and joint or bone stiffness, and elders’ risk for falls and infection increases. Waning endurance creates symptoms of profound fatigue, lack of motivation, and a vicious cycle of immobility and decline. Connective tissue (tendons, ligaments, and cartilage) also begins to deteriorate, and contractures (decreased range of motion) follow. In nursing home residents, foot drop contracture is common, especially in patients who have had strokes.19

Bedbound patients often lose interest in meals, and they may report changes in smell and taste. They may eat less (or not eat). Dysphagia is a risk since swallowing in the supine position is more challenging than when sitting. The gastrointestinal tract slows, and food takes 40% longer to be digested and eliminated when a person is supine.23

Disuse osteoporosis is a serious risk. Calcium clearance in bone is 4 to 6 times greater in the first weeks of bedrest than normal. Both cortical and trabecular bone are affected, particularly the trabecular bone of weight-bearing limbs.7,19

Prevention
Among the elderly, numerous issues should influence a decision or medical order to remain in bed. Often, acute illness prompts bedrest. Many elders use bedrest as a strategy to conserve energy for those days when they have necessary or favorite events planned. Sadly, nursing home patients may remain in bed because of staff shortages, bowel care programs, fear of being up too long because of a lack of help to get back into bed, or the sheer difficulty of rising when fatigue or pain are present. These are cited factors causing residents to remain in bed.18 Simply making patients aware of bedrest’s danger can keep them moving. Pointing out available activities, even if they are simple, can help keep them engaged.1,18

Our space program learned early on that astronauts needed exercise to save their muscles.7 Experts estimate that to regain functional loss here on the ground, patients need approximately 7 days of normal movement for each day of bedrest. In healthy older adults, as little as 10 days of bedrest is associated with considerable loss of strength and aerobic capacity as well as a tendency toward reduced physical activity that can last weeks.24 Avoiding or curtailing unnecessary or prolonged bedrest is critical.

In the Pharmacy
Pharmacists should be vigilant when they see any order for bedrest in a previously ambulatory patient, or hear that a patient is bedbound. Table 1 lists tips for drug regimen review.

Conclusion
Regardless of age, being confined to bed constricts independence. Educating others about the hazards of immobility is essential so they will understand why keeping moving is critical. PT

References
1. DeLaune SC, Ladner PK. Fundamentals of Nursing, Standards & Practice. 2nd ed. Clifton Park, NY: Delmar; 2002.
2. Chadwick, Mann. The Works of Hippocrates. 1950.
3. Knight J, Nigam Y, Jones A. Effects of bedrest 1: cardiovascular, respiratory and haematological systems. Nurs Times. 2009;105:16-20.
4. Boschma G. The Rise of Mental Health Nursing. Amsterdam: Amsterdam University Press; 2003.
5. Dock W. The evil sequelae of complete bed rest. JAMA. 1944;125:1083-1085.
6. Asher R. The dangers of going to bed. Br Med J. 1947;2:967-968.
7. Buckley JC. Space physiology. New York: Oxford University Press; 2006.
8. Gillis A, MacDonald B, MacIsaac A. Nurses' knowledge, attitudes, and confidence regarding preventing and treating deconditioning in older adults. J Contin Educ Nurs. 2008;39:547-554.
9. Hirsch CH, Sommers L, Olsen A, Mullen L, Winograd CH. The natural history of functional morbidity in hospitalized older patients. J Am Geriatr Soc. 1990;38:1296-1303.
10. Sager MA, Franke T, Inouye SK, et al. Functional outcomes of acute medical illness and hospitalization in older persons. Arch Intern Med. 1996;156:645-652.
11. Covinsky KE, Palmer RM, Fortinsky RH, et al. Loss of independence in activities of daily living in older adults hospitalized with medical illnesses: increased vulnerability with age. J Am Geriatr Soc. 2003;51:451-458.
12. Rudberg MA, Sager MA, Zhang J. Risk factors for nursing home use after hospitalization for medical illness. J Gerontol Med Sci. 1996;51A:M189-M194.
13. Fortinsky RH, Covinsky KE, Palmer RM, Landefeld CS. Effects of functional status changes before and during hospitalization on nursing home admission in older adults. J Gerontol Med Sci. 1999;54A:M521-M526.
14. Truong AD, Fan E, Brower RG, Needham DM. Bench-to-bedside review: mobilizing patients in the intensive care unit--from pathophysiology to clinical trials. Crit Care. 2009;13:216.
15. Allen C, Glasziou P, Del Mar C. Bed rest: a potentially harmful treatment needing more careful evaluation. Lancet. 1999;354:1229-1233.
16. Lipnicki DM, Gunga HC, Belavy DL, Felsenberg D. Decision making after 50 days of simulated weightlessness. Brain Res. 2009;1280:84-89.
17. Lipnicki DM, Gunga HC. Physical inactivity and cognitive functioning: results from bed rest studies. Eur J Appl Physiol. 2009;105:27-35.
18. Fox MT, Sidani S, Brooks D. Perceptions of bed days for individuals with chronic illness in extended care facilities. Res Nurs Health. 2009;32:335-344.
19. Nigam Y, Knight J, Jones A. Effects of bedrest 3: musculoskeletal and immune systems, skin and self-perception. Nurs Times. 2009;105:18-22.
20. LeBlanc A, Rowe R, Evans H, West S, Shackelford L, Schneider V. Muscle atrophy during long duration bed rest. Int J Sports Med. 1997(18 suppl 4):S283-S285.
21. Hamburg NM, McMackin CJ, Huang AL, et al. Physical inactivity rapidly induces insulin resistance and microvascular dysfunction in healthy volunteers. Arterioscler Thromb Vasc Biol. 2007;27:2650-2656.
22. Gharib C, Maillet A, Gauquelin G, et al. Results of a 4-week head-down tilt with and without LBNP countermeasure: I. Volume regulating hormones. Aviat Space Environ Med. 1992;63:3-8.
23. Knight J, Nigam Y, Jones A. Effects of bedrest 2: gastrointestinal, endocrine, renal, reproductive and nervous systems. Nurs Times. 2009;105:24-27.
24. Kortebein P, Symons TB, Ferrando A, et al. Functional impact of 10 days of bed rest in healthy older adults. J Gerontol A Biol Sci Med Sci. 2008;63:1076-1081.
25. De Jonghe B, Sharshar T, Lefaucheur JP, et al; Groupe de Réflexion et d’Etude des Neuromyopathies en Réanimation. Paresis acquired in the intensive care unit: a prospective multicenter study. JAMA. 2002;288:2859-2867.



Ms. Wick is senior clinical research pharmacist at the National Cancer Institute, National Institutes of Health, Bethesda, Maryland.
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