Mobility and self-care

Regardless of why an older person is admitted to hospital, their ability to move and care for themselves will determine the care and services they will need while in hospital and after discharge.

Older people in hospital are at risk of functional decline and de-conditioning as early as two days after admission¹. As clinicians, we should encourage older people to maintain or improve their mobility and self-care skills participating in activities.

This topic gives an overview of the importance of mobility and self-care, tools to identify issues, and strategies to improve an older person’s mobility and self-care. In addition to following health service policy and procedures, consider the following actions and discuss them with colleagues and managers.

Understanding how patients move

Functional mobility is the capacity to move from one position to another, enabling participation in normal daily routines and activities. It includes bed mobility, transfers, walking, wheelchair mobility, accessing toilets, getting in and out of a car, driving and taking public transport. It is important to be aware that mobility restrictions and using gait aids can have a significant impact on a person’s ability to access their home and local area. This can result in difficulty maintaining and initiating social connections within their community.

In hospital, functional mobility refers to your patient’s ability to get in and out of bed, to walk to and from the toilet and around the ward.

Self-care is the personal care carried out by a person. Common self-care activities while in hospital include eating, bathing, personal grooming and using the toilet. An older person may require assistance, supervision or guidance from healthcare workers for these tasks.

In hospital, mobility and self-care are often key measures we use to predict length of stay, discharge destination and need for support services. It is important that we understand our patients’ prior levels of ability and how they move and care for themselves in their usual living environments.

Wherever possible, we should ensure that our patients’ mobility and capacity for self-care is maintained or improved while they are in hospital. This will increase the likelihood that they can return to their previous levels of function, independence and social activities after leaving hospital.

Mobility and self-care support independence

By maintaining mobility and adequate self-care, it is possible for older people to maximise their opportunities for personal independence, social connectedness, security, activity and dignity.

During a hospital stay, a person-centred partnership with the older person is necessary to ensure mobility and self-care are maintained or improved. Mobility and self-care are fundamental to many of the other functional domains addressed on this website. For example, an older person's ability to walk to the toilet may help to maintain continence. Promoting or facilitating mobility and self-care is recommended for minimising the risk of depression, delirium, under-nutrition and can reduce the likelihood of falls and fall-related injuries and loss of confidence due to fear of falling.

Bed rest has considerable impacts on an older person’s ability to be independent. This includes impacts on self-care and walking. Bed rest during hospitalisation can lead to functional decline and deconditioning as early as two days after admission.

Effects of bed rest

Screening for mobility and self-care difficulties is often done in the context of screening for other issues such as falls or frailty. It is important that we identify our patients at risk of:

• de-conditioning – a decline in strength, balance or endurance
• falls
• loss of independence.

Assessment

A Comprehensive Geriatric Assessment (CGA) (initial and ongoing) will assist in identifying factors contributing to functional decline. A CGA includes an assessment of ADLs and Instrumental ADLs as well as other factors such as cognition, continence, vision and hearing, psychological wellbeing and social supports⁴.

Physiotherapists undertake a full assessment of mobility and occupational therapists undertake assessments of ADLs. You can use assessment tools to identify underlying risk factors and prompt a more detailed assessment.

Tools to identify underlying risk factors to prompt a more detailed assessment

Maintaining and improving mobility and self-care

We need to understand our patient’s prior level of mobility, independence in self-care and usual living situation if we are to implement appropriate and effective mobility and self-care interventions. For example, if a patient's mobility restrictions affected their ability to remain socially connected and manage their own affairs, we should develop a plan with them to rectify this.

Consider five areas of mobility and self-care interventions as part of an interdisciplinary strategy: incidental activity, exercise, retraining activities of daily living (ADLs), ensuring appropriate supervision, and environmental modifications.

Interventions should be discussed and implemented in partnership with the older person and their family and carer, as appropriate.

Incidental activity

Incidental activities are those where physical activity occurs as part of regular daily activities, for example, walking to the toilet, transferring and dressing. Performing regular daily activities, including self-care, is the easiest exercise for our patients to undertake in hospital. Self-care can be beneficial to your patient’s mobility.

Encourage your patients to:

• dress (consider the possibility of wearing their normal day clothes and footwear)
• get out of bed and move around the ward, with supervision or assistance and an appropriate gait aid if required
• sit out of bed as soon as it is considered safe to do so, as much as possible as appropriate to their condition
• walk to the toilet, with supervision or assistance if required
• eat meals out of bed, preferably in a communal dining room where available and appropriate
• undertake or participate in showering and other grooming and self-care activities.

As staff, we can:

• supervise or assist older people during walking, transfers and ADLs if required
• create a continence and mobility plan that fits with patients sitting out of bed for meals
• adjust bed height to allow for safe, independent transfers
• orient our patients to the ward, showing them where the toilet is
• provide a culture that encourages incidental exercise
• provide aids to assist with optimal transfers and mobility
• avoid using bed rails, which may limit mobility and be a hazard
• improve our understanding of the risks of restricting mobility and provide strategies to prevent de-conditioning.

Exercise

As part of an interdisciplinary intervention, an exercise program may benefit your patient.

Exercise programs can be administered in both individual and group settings and may include strength, balance, functional retraining and aerobic (or endurance) exercises. Group classes also provide an opportunity for social interaction and may help prevent loneliness.

We can refer older patients to physiotherapy for prescription of individual or group exercise.

Retraining ADLs

Our patients’ abilities to live independently may depend on retraining their skills in ADLs. We can:

• provide the minimal amount of assistance required to encourage optimal participation; assistance should be reduced as the person’s condition improves
• encourage and guide our patients to promote independence
• assist with alternative strategies for self-care, as necessary
• refer our patients to occupational therapy, as appropriate
• make sure aids are available to assist with optimal independence
• ensure bed and chair heights are optimal for independence
• recommend patients for self-care programs, such as cooking groups and self-care education sessions, as appropriate
• consider use of everyday clothes and footwear
• clear any clutter
• ensure obstacles to mobility or self-care are moved
• ensure any tools or aids for mobility or self-care are clean and maintained
• ensure bed and chair heights are optimal for independence
• avoid using bed rails, which may limit mobility and be a hazard.

Ensuring appropriate supervision during mobility and self-care tasks

We can:

• supervise patients who are acutely unwell during walking and transfers. It may be appropriate to reduce supervision as medical stabilisation occurs and familiarisation with the environment and equipment is achieved.
• consult physiotherapy if we are in doubt about the supervision needs of our patients. Use strategies such as a traffic light colour coding system, a common way to inform all care staff of an individual's mobility supervision needs.

Environmental modifications

The hospital environment is important in promoting mobility and self-care for older people. We should:

• clear any clutter
• ensure obstacles to mobility or self-care are moved
• ensure any tools or aids for mobility or self-care are clean and maintained
• ensure bed and chair heights are optimal for independence
• avoid using bed rails, which may limit mobility and be a hazard.

Mobility and self-care in discharge planning

Planning for discharge should occur as early as possible. Discharge planning should be person-centred and undertaken with the patient and their family and carers, as appropriate.

• Aim to create person-centred discharge plans that our patients and significant others understand and support
• Understand our patients’ normal daily routines and living arrangements and what supports they will require after discharge.
• Provide referrals to appropriate community services and equipment providers for older people who require assistance with self-care or who may be at risk of falls post discharge
• Consider referrals to community services if premorbid mobility and self-care levels have not been attained by discharge.
• Identify people at risk of becoming isolated on discharge because of immobility or changes in mobility. Encourage them to remain socially connected, for example by contacting their local library, council, Neighbourhood House or Men’s Shed as sources of neighbourhood activities.
• Provide appropriate written resources and ensure our patients and their significant others understand the resources.
• Encourage and facilitate physical activity beyond discharge.