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Boltz, M., Capezuti, E., & Shabbat, N. (2011). Nursing staff perceptions of physical function in hospitalized older adults. Applied Nursing Research, 24(4), 215–222. doi:10.1016/j.apnr.2010.01.001. Evidence Level IV.

As stated in Chapter 6, Age-Related Changes in Health: To restore or maximize physical functioning, prevent or minimize decline in ADL function, and plan for transitions of care.

Boltz PhD, RN, GNP-BC, FGSA, FAAN, M., Capezuti PhD, RN, FAAN, E., Zwicker DrNP, APRN, BC, D., & Fulmer PhD, RN, FAAN, T. T. (2020). Evidence-Based Geriatric Nursing Protocols for Best Practice (6th ed.). Springer Publishing. Retrieved November 4, 2020, from https://www.springerpub.com/evidence-based-geriatric-nursing-protocols-for-best-practice-9780826188144.html#description

Buurman, B. M., van Munster, B. C., Korevaar, J. C., de Haan, R. J., & de Rooij, S. E. (2011). Variability in measuring (instrumental) activities of daily living functioning and functional decline in hospitalized older medical patients: A systematic review. Journal of Clinical Epidemiology, 64, 619–627. doi:10.1016/j.jclinepi.2010.07.005. Evidence Level I.

D.  Education of nursing staff and other members of the interdisciplinary team (e.g., social work, physical therapy) regarding (Boltz et al., 2010; Boltz, Capezuti, et al., 2011; Gillis et al., 2008; Resnick, Galik, Enders, et al., 2011):

G.  Leadership commitment to rehabilitative values is essential to support a social climate conducive to the promotion of function (Boltz, Capezuti, et al., 2011; King & Bowers, 2013).

Capezuti, E., Wagner, L. M., Brush, B. L., Boltz, M., Renz, S., & Secic, M. (2008). Bed and toilet heights as potential environmental risk factors. Clinical Nursing Research, 17(1), 50–66. doi:10.1177/1054773807311408. Evidence Level IV.

Betrabet Gulwadi, G., & Calkins, M. (2008). The impact of healthcare environmental design on falls. Concord, CA: Center for Healthcare Design. Evidence Level V.

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Brown, C. J., Redden, D. T., Flood, K. L., & Allman, R. M. (2009). The underrecognized epidemic of low mobility during hospitalization of older adults. Journal of the American Geriatrics Society, 57(9), 1660–1665. doi:10.1111/j.1532-5415.2009.02393.x. Evidence Level IV.

Gillis, A., MacDonald, B., & MacIsaac, A. (2008). Nurses’ knowledge, attitudes, and confidence regarding preventing and treating deconditioning in older adults. Journal of Continuing Education in Nursing, 39(12), 547–554. doi:10.3928/00220124-20081201-07. Evidence Level IV.

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D.  Patient risk factors for functional decline include prehospitalization functional loss; the presence of two or more comorbidities; taking five or more prescription medications; having had a hospitalization or emergency department visit in the previous 12 months; depression; impaired cognition, including delirium; pain; nutritional problems; adverse medication effects; fear of falling; low self-efficacy, outcome expectations, and attitudes toward functional independence; and views on hospitalization (Boltz, Resnick, Capezuti, Shabbat, & Secic, 2011; Brown et al., 2007; Buurman et al., 2011, 2012; Inouye et al., 1999; McAuley et al., 2006; McCusker et al., 2002).

Kortebein, P., Symons, T. B., Ferrando, A., Paddon-Jones, D., Ronsen, O., Protas, E., … Evans, W. J. (2008). Functional impact of 10 days of bed rest in healthy older adults. Journals of Gerontology: Series A, 63(10), 1076–1081. doi:10.1093/gerona/63.10.1076. Evidence Level III.

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Kleinpell, R. (2007). Supporting independence in hospitalized elders in acute care. Critical Care Nursing Clinics of North America, 19(3), 247–252. doi:10.1016/j.ccell.2007.05.009. Evidence Level V.

Resnick, B., Galik, E., Boltz, M., & Pretzer-Aboff, I. (2011). Restorative care nursing for older adults: A guide for all care settings. New York, NY: Springer Publishing Company. Evidence Level VI.

Creditor, M. V. (1993). Hazards of hospitalization of the elderly. Annals of Internal Medicine, 118(3), 219–223. doi:10.7326/0003-4819-118-3-199302010-00011. Evidence Level VI.

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Buurman, B. M., Hoogerduijn, J. G., van Gemert, E. A., de Haan, R. J., Schuurmans, M. J., & de Rooij, S. E. (2012). Clinical characteristics and outcomes of hospitalized older patients with distinct risk profiles for functional decline: A prospective cohort study. PLoS One, 7(1), e29621. doi:10.1371/journal.pone.0029621. Evidence Level IV.

Volpato, S., Onder, G., Cavalieri, M., Guerra, G., Sioulis, F., Maraldi, C., … Fellin, R.; Italian Group of Pharmacoepidemiology in the Elderly Study. (2007). Characteristics of nondisabled older patients developing new disability associated with medical illnesses and hospitalization. Journal of General Internal Medicine, 22(5), 668–674. doi:10.1007/s11606-007-0152-1. Evidence Level IV.

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A.  Functional decline is a common complication in hospitalized older adults, even in those with good baseline function (Gill et al., 2010).

Boltz, M., Capezuti, E., Shabbat, N., & Hall, K. (2010). Going home better not worse: Older adults’ views on physical function during hospitalization. International Journal of Nursing Practice, 16(4), 381–388. doi:10.1111/j.1440-172X.2010.01855.x. Evidence Level V.

H.  FFC educational intervention on medical–surgical units has shown improvements in knowledge and outcome expectations associated with function-promoting care (Resnick, Galik, Enders, et al., 2011; Resnick, Galik, Boltz, et al., 2011; Resnick et al., 2015).

Wakefield, B. J., & Holman, J. E. (2007). Functional trajectories associated with hospitalization in older adults. Western Journal of Nursing Research, 29(2), 161–177. doi:10.1177/0193945906293809. Evidence Level IV.

Boyd, C. M., Landefeld, C. S., Counsell, S. R., Palmer, R. M., -Fortinsky, R. H., Kresevic, D., … Covinsky, K. (2008). Recovery of activities of daily living in older adults after hospitalization for acute medical illness. Journal of the American Geriatrics Society, 56, 2171–2179. doi:10.1111/j.1532-5415.2008.02023.x. Evidence Level IV.

Boltz, M., Chippendale, T., Resnick, B., & Galvin, J. (2015b). Testing family centered, function-focused care in hospitalized persons with dementia. Neurodegenerative Disease Management, 5(3), 203–215. doi:10.2217/nmt.15.10. Evidence Level III.

Resnick, B., Galik, E., Wells, C., Boltz, M., & Holtzman, C. (2015). Optimizing function and physical activity post trauma: Overcoming system and patient challenges. International Journal of Orthopaedic and Trauma Nursing, 19(4), 194–206. doi:10.1016/j.ijotn.2015.03.007. Evidence Level V.

F.   Clinical assessment and interventions (Boltz et al., 2015b; Boltz, Capezuti, et al., 2011; Boltz, Resnick, Chippendale, et al., 2014; Nolan & Thomas, 2008; Resnick, Galik, Enders, et al., 2011; Wakefield & Holman, 2007)

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Boltz, M., Resnick, B., Chippendale, T., & Galvin, J. (2014). Testing a family-centered intervention to promote functional and cognitive recovery in hospitalized older adults. Journal of the American Geriatrics Society, 62(12), 2398–2407. doi:10.1111/jgs.13139. Evidence Level III.

Hoenig, H. M., & Rubenstein, L. Z. (1999). Hospital-associated deconditioning and dysfunction. Journal of the American Geriatrics Society, 39, 220–222. doi:10.1111/j.1532-5415.1991.tb01632.x. Evidence Level IV.

Brown, C. J., Friedkin, R. J., & Inouye, S. K. (2004). Prevalence and outcomes of low mobility in hospitalized older patients. Journal of the American Geriatrics Society, 52, 1263–1270. doi:10.1111/j.1532-5415.2004.52354.x. Evidence Level IV.

Resnick, B., Galik, E., Enders, H., Sobol, K., Hammersla, M., Dustin, I., … Trotman, S. (2011). Impact nursing care of older adults: Pilot testing of function focused care-acute care intervention. Journal of Nursing Care Quality, 26(2), 169–177. doi:10.1097/NCQ.0b013e3181eefd94. Evidence Level III.

Boltz, M., Resnick, B., Capezuti, E., Shuluk, J., & Secic, M. (2012). Functional decline in hospitalized older adults: Can nursing make a difference? Geriatric Nursing, 33(4), 272–279. doi:10.1016/j.gerinurse.2012.01.008. Evidence Level IV.

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A.  Hospital care processes (Boltz, Resnick, Chippendale, et al., 2014; Jacelon, 2004; Resnick, Galik, Enders, et al., 2011)

Inouye, S., Schlesinger, M., & Lydon, T. (1999). Delirium: A symptom of how hospital care is failing older persons and a window to improve quality of hospital care. American Journal of Medicine, 106, 565–573. doi:10.1016/S0002-9343(99)00070-4. Evidence Level VI.

McAuley, E., Konopack, J. F., Motl, R. W., Morris, K. S., -Doerksen, S. E., & Rosengren, K. R. (2006). Physical activity and quality of life in older adults: Influence of health status and self-efficacy. Annals of Behavioral Medicine, 31, 91–103. doi:10.1207/s15324796abm3101_14. Evidence Level IV.

F.   Interprofessional rounds support promotion of function by addressing functional assessment (baseline and current), evaluate potentially restrictive devices and agents, and yield a plan for progressive mobility (Boltz, Resnick, Chippendale, et al., 2014).

Fortinsky, R. H., Covinsky, K. E., Palmer, R. M., & Landefeld, C. S. (1999). Effects of functional status changes before and during hospitalization on nursing home admission of older patients. Journals of Gerontology: Series A, 54, M521–M526. doi:10.1093/gerona/54.10.M521. Evidence Level IV.

C.  Physical design (Betrabet Gulwadi & Calkins, 2008; Boltz, Resnick, Capezuit, & Shuluk, 2014; Boltz et al., 2015b; Capezuti et al., 2008; Ulrich et al., 2008)

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C.  Functional decline may result from the acute illness and can begin before admission (Fortinsky et al., 1999) and continue after discharge. Baseline function serves as a useful benchmark when developing discharge goals (-Wakefield & Holman, 2007).

Harper, C. M., & Lyles, Y. M. (1988). Physiology and complications of bed rest. Journal of the American Geriatrics Society, 36, 1047–1054. doi:10.1111/j.1532-5415.1988.tb04375.x. Evidence Level VI.

Jacelon, C. S. (2004). Managing personal integrity: The process of hospitalization for elders. Journal of Advanced Nursing, 46(5), 549–557. doi:10.1111/j.1365-2648.2004.03029.x. Evidence Level IV.

Several resources are now available to guide adoption of evidence-based nursing interventions to enhance function in older adults.

Boltz, M., Chippendale, T., Resnick, B., & Galvin, J. (2015a). Anxiety in family caregivers of hospitalized persons with dementia: Contributing factors and responses. Alzheimer Disease & Associated Disorders, 29(3), 236–241. doi:10.1097/WAD.0000000000000072. Evidence Level IV.

Nolan, J., & Thomas, S. (2008). Targeted individual exercise programmes for older medical patients are feasible, and may change hospital and patient outcomes: A service improvement project. BMC Health Services Research, 8, 250. doi:10.1186/1472-6963-8-250. Evidence Level V.

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King, B., & Bowers, B. J. (2013). Attributing the responsibility for ambulating patients. International Journal of Nursing Studies, 50, 1240–1246. doi:10.1016/j.ijnurstu.2013.02.007. Evidence Level IV.

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Boltz, M., Resnick, B., Capezuti, E., & Shuluk, J. (2014). Activity restriction vs. self-direction: Hospitalized older adults’ response to fear of falling. International Journal of Older People Nursing, 9(1), 44–53. doi:10.1111/opn.12015. Evidence Level IV.

Gill, T. M., Allore, H. G., Gahbauer, E. A., & Murphy, T. E. (2010). Change in disability after hospitalization or restricted activity in older persons. Journal of the American Medical Association, 304(17), 1919–1928. doi:10.1001/jama.2010.1568. Evidence Level IV.

B.  Policy and procedures to support function promotion (Boltz et al., 2010; Boltz, Capezuti, & Shabbat, 2011, 2015b; Kleinpell, 2007)

Boyd, C. M., Xue, Q., Guralik, J. M., & Fried, L. P. (2005). Hospitalization and development of dependence in activities of daily living in a cohort of disabled older women: The Women’s Health and Aging Study. Journal of Gerontology: Series A, 60, 888–893. doi:10.1093/gerona/60.7.888. Evidence Level IV.

Brown, C. J., Williams, B. R., Woodby, L. L., Davis, L. L., & -Allman, R. M. (2007). Barriers to mobility during hospitalization from the perspective of older patients, their nurses and physicians. Journal of Hospitalist Medicine, 2(5), 305–313. doi:10.1002/jhm.209. Evidence Level IV.

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Ulrich, R., Zimring, C., Zhu, X., DuBose, J., Seo, H. B., Choi, Y. S., … Joseph, A. (2008). A review of the research literature on evidence-based health care design. Health Environments Research and Design Journal, 1(3), 61–125. doi:10.1177/193758670800100306. Evidence Level V.

E.  Bed rest results in loss of muscle strength and lean muscle mass, decreased aerobic capacity, diminished pulmonary ventilation, altered sensory awareness, reduced appetite and thirst, and decreased plasma volume (Creditor, 1993; Harper & Lyles, 1988; Hoenig & Rubenstein, 1999; Kortebein et al., 2007, 2008). Care processes, such as curtailing mobility, imposing restraints, and tethering devices, which are associated with low mobility, lead to a higher rate of ADL decline, new institutionalization, and death (Boltz et al., 2010; Boltz, Resnick, et al., 2011; Brown et al., 2004, 2009; Zisberg et al., 2011).

Kortebein, P., Ferrando, A., Lombeida, J., Wolfe, R., & Evans, W. J. (2007). Effect of 10 days of bed rest on skeletal muscle in healthy older adults. Journal of the American Medical Association, 297, 1772–1774. doi:10.1001/jama.297.16.1772-b. Evidence Level III.

Chapter 18:   Boltz, M., Resnick, B., & Galik, E. (2021) Preventing Functional Decline in the Acute Care Setting.  In M. Boltz, E. Capezuti, D. Zwicker & T. Fulmer (eds.).  Evidence-Based Geriatric Nursing Protocols for Best Practice (6th ed. pp 281-294).  New York: Springer.

B.  Loss of physical function is associated with poor long-term outcomes, including increased likelihood of being discharged to a nursing home setting (Fortinsky et al., 1999), increased mortality (Boyd et al., 2005; Rozzini et al., 2005), increased rehabilitation costs, and decreased functional recovery (Boyd et al., 2005, 2008; Volpato et al., 2007). The immobility associated with functional decline results in infections, pressure ulcers, falls, a persistent decline in function and physical activity, and nonelective rehospitalizations.

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Zisberg, A., Shadmi, E., Sinoff, G., Gur-Yaish, N., Srulovici, E., & Admi, H. (2011). Low mobility during hospitalization and functional decline in older adults. Journal of the American Geriatrics Society, 59(2), 266–273. doi:10.1111/j.1532-5415.2010.03276.x. Evidence Level IV.

Rozzini, R., Sabatini, T., Cassinadri, A., Boffelli, S., Ferri, M., -Barbisoni, P., … Trabucchi, M. (2005). Relationship between functional loss before hospital admission and mortality in elderly persons with medical illness. Journals of Gerontology: Series A, 60, 1180–1183. doi:10.1093/gerona/60.9.1180. Evidence Level IV.

Boltz, M., Resnick, B., Capezuti, E., Shabbat, N., & Secic, M. (2011). Function-focused care and changes in physical function in Chinese American and non-Chinese American hospitalized older adults. Rehabilitation Nursing, 36(6), 233–240. doi:10.1002/j.2048-7940.2011.tb00088.x. Evidence Level IV.

McCusker, J., Kakuma, R., & Abrahamowicz, M. (2002). Predictors of functional decline in hospitalized elderly patients: A systematic review. Journals of Gerontology: Series A, 57, M569–M577. doi:10.1093/gerona/57.9.M569. Evidence Level I.

E.  Education of patients and families regarding FFC, including the benefits of FFC, the safe use of equipment, and self-advocacy (Boltz, Resnick, Chippendale, et al., 2014; Boltz et al., 2010, 2015b; Resnick et al., 2015)