The axiom "use it or lose it" is true at all ages, but it is particularly salient when discussing the care of older adults. Deconditioning results from physiological changes that occur following a period of inactivity, such as with bed rest or due to a sedentary lifestyle.
Deconditioning results in functional loss, declines in mental status and a reduced ability to accomplish activities of daily living.1 It is frequently associated with hospitalization in the elderly.
The most predictable effects of deconditioning are seen in the musculoskeletal system and include diminished muscle mass, decreases of muscle strength, muscle shortening changes in periarticular and cartilaginous joint structures, and marked loss of leg strength that seriously limits mobility.
Reversing deconditioning and its functional effects, once established, is difficult; therefore, prevention is the most desirable option. This requires a variety of strategies that include proper examination, evaluation and treatment.
There is no single test that can measure deconditioning in the older adult. A comprehensive geriatric assessment is recommended to obtain an overview of the function and quality of life of the geriatric client or patient.2 Some measures used include the Lawton Instrumental Activities Daily Living Scale,3 the Functional Independence Measure (FIM),4 the Timed Up and Go Test5 and the 2-Minute Walk Test.6
The Proper Test
The Lawton Instrumental Activities Daily Living Scale is intended to be used among older adults, and can be used in community or hospital settings. The instrument is not useful for institutionalized older adults. It can be used as a baseline assessment tool and to compare baseline function to periodic assessments. The instrument is most useful for identifying how a person is functioning at the present time, and to identify improvement or deterioration over time. There are eight domains of function measured with the Lawton IADL scale. Women are scored on all eight areas of function; historically, for men, the areas of food preparation, housekeeping, and laundering are excluded.
Clients are scored according to their highest level of function in that category. A summary score ranges from zero (low function, dependent) to 8 (high function, independent) for women, and zero through 5 for men.7
The FIM is used to measure the patient's progress and assess rehabilitation outcomes in rehabilitation settings. The FIM takes approximately 30 minutes to score, with items scored on the level of assistance required for an individual to perform activities of daily living. After training, the scale can be administered by a health care practitioner or lay person. The FIM has 18 items; 13 items are physical domains based on the Barthel Index and 5 are cognition items.
Each item is scored from 1 to 7 based on level of independence, where 1 represents total dependence and 7 indicates complete independence. Possible scores range from 18 to 126, with higher scores indicating more independence. Alternatively, the 13 physical items could be scored separately from the five cognitive items.5
The Timed Up and Go Test measures, in seconds, the time taken by an individual to stand up from a standard arm chair (approximate seat height of 46 cm/18 in, arm height 65 cm/25.6 in), walk a distance of 3 meters (118 inches, approximately 10 feet), turn, walk back to the chair and sit down.
Shumway-Cook et al. found that older adults who take longer than 14 seconds to complete the TUG have a high risk for falls.8 Podsiadlo and Richardson used a cutoff time of 30 seconds.
While not as highly researched as the test from which is was derived - the 12MWT, or the more commonly used 6MWT - there is evidence that suggests the 2-Minute Walk Test (2MWT) is effective in obtaining reliable information across the cardiorespiratory domain. Administration of the 2MWT is similar to the 6- and 12-minute walk tests and has been deemed to be the most efficient of the three tests.9
Of course, other combinations of tests can be utilized to obtain a comprehensive picture of the functional status and overall health of the elderly client/patient. It is up to the therapist to decide what measurement tools are reliable and valid, most cost efficient in terms of time, money and patient exertion, and will give the most information on the status of the patient.
Prevention of deconditioning does require a multifaceted approach and should include a thorough treatment plan, a sound nutritional plan, appropriate medical management and psychological support.
It is also important to mention that regular physical activity and exercise beginning in middle age does protect against many conditions prevalent in older age, including type II diabetes, osteoporosis, hypertension, cardiac disease and decline in aerobic power.
Maintenance of physical fitness and avoidance of a sedentary lifestyle with increasing age must therefore be an important goal of health programs across settings. So before they lose it, we should encourage patients to increase their physical activity and exercise levels in order to prevent the debilitating effects of deconditioning.
References available at www.advanceweb.com/PT or upon request.
Carole Lewis is a consulting clinical specialist for Professional Sportscare and Rehab and co-owner of The Center of Evidence. She lectures exclusively for GREAT Seminars and Books Inc. Her Website is www.greatseminarsandbooks.com. She is also editor-in-chief of Topics in Geriatric Rehabilitation (www.topicsingeriatricrehabilitation.com) and an adjunct professor at George Washington University Department of Geriatrics, College of Medicine. Keiba Shaw is associate professor at Nova Southeastern University College of Allied Health and Nursing, Physical Therapy Department Hybrid-Entry Level DPT Program.