Immobility refers to a state in which an individual experiences limitation of physical movement (Faria, 1998). Older adults are at a high risk for unintended consequences of prolonged hospitalization resulting in immobility because of prolonged bed rest. Almost one third of older adults discharged from acute care have a level of function that is worse than before admission (Lafreniere et al., 2017). Immobility and poor functional outcomes from deconditioning are associated with new nursing home placement and increased mortality (Brown et al., 2009; Wu et al., 2018). Hospital-associated deconditioning refers to deficits in physical function that result from immobility after hospitalization (Falvey et al., 2015). Although a serious condition, hospital-associated deconditioning may be overlooked because of more pressing health concerns at discharge.
Bed rest with lower levels of mobility, coupled with the loss of muscle mass and strength that normally occurs with aging, can create weakness and dysfunction and, at its extreme, irreversible functional decline to the extent that older adults may no longer be able to walk unassisted or complete activities of daily living (Gordon et al., 2019; Springer et al., 2017). Yet, the recovery path that older adults face at home is understudied. Few qualitative studies have reported the early mobility experience of older adults, and all were with intensive care unit survivors (Corner et al., 2019; Laerkner et al., 2019). Furthermore, qualitative research reporting the early mobility experience of older adults posthospitalization is absent in the literature. The objective of this focused ethnography study was to explore the experiences of loss of mobility and challenges of recovery in the common experiences of older adults with immobility posthospitalization.
Methodology and Method
Focused ethnography was the methodology used for this study. The process emerged as a method to apply ethnography to shared cultural experiences in defined settings and give attention to small components and activities in which people engage (Cruz & Higginbottom, 2013). A commitment of focused ethnography is to gain the most complete understanding possible of people who are within a certain culture.
Focused ethnography is distinguished from conventional ethnography by several characteristic features. These features include having a focused issue; short-term field visits; the researcher in a field observer role with background knowledge; notes, audio or visual recordings, and transcripts; and time-intensive data analysis using coding and sequential analysis (Roper & Shapira, 2000). Therefore, focused ethnography was appropriate to identify the shared experiences of immobility in older adults posthospitalization.
Setting and Sample
Four interviews were conducted in-person; and six, by telephone. Participants were in their own homes when interviewed. There were seven women and three men, aged 69-82 years. All participants were White. Participants were recruited by snowball sampling and by professional contacts. One participant recommended five potential participants, and two professional contacts recommended five more potential participants, all of whom accepted. Inclusion criteria included adults 60 years old and older who had been in the hospital for at least 1 week because of a medical condition. Exclusion criteria included a lack of weakness at hospital discharge. University Institutional Review Board approval was obtained for this study. Each participant gave written informed consent before the interview. Pseudonyms were assigned by the researcher to preserve the confidentiality of study participants.
Data Collection
Data were collected by the primary investigator and included multiple data sources: prestudy mobility field observations conducted in the hospital, observations in the home, field notes, and in-depth interviews that were audio-recorded. Interviews with semistructured questions were conducted to answer the following research question: What are the shared early mobility experiences of older adults posthospitalization who have experienced a decrease in mobility related to hospital-associated deconditioning?
Each interview lasted approximately 1 hour. The primary focus of the interview was what it was like to be immobile after at least 1 week of hospital-associated deconditioning related to reduced physical activity. Data were collected until enough information was obtained to fully answer the research question and provide rich representations of experience. Deidentified data were transcribed and stored in secure digital sites available only to the analytical team. Participants received a $20 gift card upon completion of the interview.
Data Analysis
A team of three researchers analyzed the data using a constructivist/interpretivist approach. The research team read the field notes, which included observational descriptions; transcribed and verified the interview texts verbatim; and read them several times to become familiar with the data. The team noted similar, as well as different, words and phrases. All members of the analysis team agreed that the interpretations were a direct reflection of the text. To enhance trustworthiness, the analysts were all experts in chronic or rehabilitative care; one was an expert in qualitative methodology. We used multiple sources of data to reveal the complexity of the phenomenon and contribute to an audit trail (Fusch et al., 2018). We produced a documented record of the research study, including all aspects of data collection. The team analyzed the data together, which added rigor and trustworthiness to the data analysis.
Findings: Mobility Is Life
The current study revealed one overarching pattern, Mobility is Life, which subsumed two subpatterns, The Crushing Assault: Consequences of Immobility and The Rocky Road to Regaining Mobility. Participants shared experiences about the residual effects resulting from the hospital-associated deconditioning that they experienced at home and the challenges encountered while recovering. The hospitalizations occurred 8 months to 12 years before the interviews, yet all participants had vivid recall.
The overarching pattern, Mobility is Life, focused on the participant's reflections on the importance of being mobile and living life as they had in the past. They were asked to describe their lives before becoming sick and were quick to recall the active lives they had before the hospitalization. Life abruptly switched from normal to one with limited mobility. After coming home, the participants reflected on their hospitalization and the resulting loss of mobility. One participant shared that she regretted her decision to have a potentially life-saving surgery when she said, "I don't like this. I don't want this. I wish I hadn't done it" (Geneva).
The participants did not anticipate the impact that the hospital-associated deconditioning would have on their lives. The possibility of not recovering function was a consistent undertone of the group. One participant recounted the importance of mobility in his life when he talked to the doctor about amputating his leg. After 10 months of making no progress with non-weightbearing treatment and still not being able to walk, he told the doctor, "I'm done. Take-take the leg. I want to have my life" (Tom). Participants voiced apprehension about an uncertain future and impaired ability to resume life as they knew it. A shared concern was the inability to fulfill their perceived responsibilities, such as working. Half of the participants were still working outside the home when they were hospitalized, yet no participants were able to return to their jobs.
Some participants wondered if they would survive the abrupt change. Many questioned the value of life itself and wondered if life would be worthwhile with only limited mobility. One participant said, "Sometimes I lay in bed at night, and I think: God, is it even worth it? You know, wouldn't it have just been better off if I would have bled out?" (Dolly).
The Crushing Assault: Consequences of Immobility
This subpattern focuses on the older adult's accounts of the difficulty they faced with hospital-associated deconditioning and immobility after discharge. Participants were asked to describe how walking was different for them. The responses from the participants uncovered two themes: physiological consequences and a change in identity.
Physiological Consequences
The older adults shared a common threat, the crushing assault, which reduced their ability to be mobile. All participants experienced a significant decline in their level of mobility after discharge. The differences in physical ability prehospitalization and posthospitalization were compelling, and participants were not prepared for the abrupt change in their lives.
A shared experience of the older adults was being overcome with weakness, resulting in difficulty moving their extremities. Most participants described being too weak to provide their self-care or do household chores. The reduced physical activity resulted in a loss of functioning and a feeling of being "just completely helpless" (Betty). The loss of functioning and independence was distressing to the participants. One participant described a similar unfamiliar experience she had after her abdominal surgery: "I've always been kind of strong. And then all at once, you're just-it's-it's like your body is kind of like a marshmallow" (Alice). One participant recalled a sense of disconnection between her brain and her body as she described the weakness she experienced: "The body was there, the mind was ready, and the heart was ready to go, but I just couldn't get everything to cooperate to go with what I was wanting to try to do" (Vera).
One participant was asked about the first time she walked at home. She replied, "I couldn't. They had to carry me into the house from the car" (Betty). She described the extent of her weakness and the obstacles she had to overcome to simply move her body: "At first, it was too much. I was too weak to roll over in bed. They had to roll me over in bed" (Betty).
A Change in Identity
The difference in what participants could accomplish after coming home from the hospital, compared with before the hospital admission, was striking and affected their self-perception. Participants had been accustomed to providing care for family members but were now dependent on others, which felt burdensome. Participants shared that they did not feel like the same person they were before they went into the hospital. The change in identity was uncomfortable for participants, and they struggled with the difference.
These older adults shared how the change in their lives affected their outlook. One participant expressed sadness that she was no longer able to get up in the morning, take a quick shower, go to work, and do the things that she used to do on the weekends. After coming home from the hospital, she needed help with all aspects of her care. Her voice cracked as she shared that she felt like she lost herself when she said, "I lost my independence. I lost-I felt like I lost, not family or anything because they were supportive, but I just felt like I lost myself sometimes because I couldn't do anything for myself" (Dolly).
The Rocky Road to Regaining Mobility
This subpattern emerged based on the participants' descriptions of the rehabilitation experience to regain their lost mobility after returning home from the hospital. These experiences exemplify the efforts, or the lack of efforts, taken to resolve the loss of mobility resulting from the crushing assault. Participants were variously able to overcome their immobility and continue on a path of improvement to regain the lost mobility.
The participants' descriptions of walking after the hospitalization were memorable, lucid, and rich in detail. Three themes emerged from their descriptions of the recovery: physiological responses to regaining mobility, the influence of attitude on recovery and regaining mobility, and resources and strategies to regain mobility.
After the hospitalization, walking required a deliberate and calculated effort and more exertion than walking before the hospitalization. Purposeful movement and walking represent the difficulty of rehabilitation because these activities are so central to the concept of mobility. "I have to think about everything I do. Even bending down picking up a piece of paper that falls on the floor, you know. I mean, it's just not the same" (June). As a result of the increased effort to move, participants found it tempting to delay the important task of walking. At times, participants would bargain with the therapists to avoid the work of therapy.
I told them, you look awful good today. Can't we just sit here, and I'll just-I'll just stare at you, and I promise, we'll do this tomorrow. And she [physical therapist] says, no, we're doing it today, and we'll do it again tomorrow (Nadine).
Physiological Responses to Regaining Mobility
The weakness experienced from the crushing assault took on a new meaning as participants began the rocky road to regaining their mobility. Participants actively struggled to overcome the weakness and loss of strength that accompanied their work of recovery. A shared finding of the group was that participants did not anticipate the length of the recovery period. One participant spoke for the group when he said, "You can lose it in a hurry, but it takes a long time to get it back" (Al). Geneva was not able to regain her strength, even after 3 months: "I still wasn't totally myself when I went to my niece's wedding, and then I fell[horizontal ellipsis]. It was like dominos. I broke my elbow and my pelvis. It was not good" (Geneva). The exertion required to overcome the loss of strength is overwhelming and often results in an incomplete recovery.
The Influence of Attitude on Recovery and Regaining Mobility
Members of the group had different attitudes toward their recovery. Some participants had a pessimistic attitude toward their recovery and focused more on their state of illness and dependency instead of their recovery. These participants described feelings of frustration, anger, and dependency. Several voiced regrets about the outcome or their choice to have surgery. Interviews with this group of participants were full of can'ts, regrets, and occasional blame. These participants did not make as much self-reported progress as the participants who had an optimistic attitude toward recovery.
Exercise could potentially have helped Dolly to build her strength. She had the opportunity to go to the local recreation center; however, she lacked motivation. She described the amount of energy required to go to the gym as "But to do it is just exhausting, and it's just like, why bother? You know, it's like if this is as good as it's gonna get, why bother?" (Dolly). In contrast, John had an optimistic attitude and shared his motivation to get better.
I wanted to get well. There's a lot of places that we like to go. I'm a-I like to travel a lot and go places, and there's a lot of neat things I want to do, and I can't do them if I'm laying in a bed or in a wheelchair.
Resources and Strategies to Regain Mobility
A common finding of the group was that the work of rehabilitation was hard. Multiple resources to support the recuperating older adult promoted the rehabilitation. Family, the healthcare team and the use of various assistive devices aided the participants in overcoming their hospital-associated deconditioning. In addition, personal strategies developed by the recovering participants facilitated the rehabilitation process in the transition from hospital-associated deconditioning to regaining mobility.
Geneva's family purchased a chair for the shower without consulting her. Initially, she was angry but soon changed her mind. Geneva said to her family: "I don't want it[horizontal ellipsis]. So, before long, I said, now, I've changed my mind. I do need that." These examples suggest that, initially, the older adult had difficulty recognizing the effects of immobility; therefore, the family's impression is important. One participant shared a creative approach. "I challenged myself. Just me doing it. I would put the walker down at the end of one of the halls, and just head out. And I knew that I would have the walls on either side, that I could kind of wall walk, if I had to" (Nadine).
Discussion
The effects of immobility are complex and deeply personal. The older adults in this study were not prepared for the intense weakness, loss of physical function, and extreme emotional changes they experienced after the hospitalization period. All participants struggled to overcome the effects of immobility. In addition, personal dignity was commonly affected. The findings of the current study support the early mobility qualitative studies that focused on intensive care unit patients and found that severe weakness and fatigue are common (Corner et al., 2019; Laerkner et al., 2019).
Healthcare professionals, including physicians, nurses, and physical therapists, care for the sick daily. Unfortunately, caregivers of hospitalized older adults may not recognize the subtle changes that result in physiological decline because older adults spend a large portion of their day in bed (Van Ancum et al., 2017). A systematic review of 38 studies of hospitalized adults found that inactivity prevailed, with 87%-100% of time being spent sitting or lying in bed (Fazio et al., 2020). Although more generally, most immobility-related pathophysiologic changes normalize upon mobilization, the effects on skeletal muscle do not completely reverse. Instead, there is muscle wasting and weakness (Parry & Puthucheary, 2015). The resultant changes significantly influence the older adult's ability to be mobile and may lead to irreversible functional decline (Gordon et al., 2019).
The transition from hospital to home and recovery are often difficult. Healthcare professionals do not anticipate the struggles that older adults face at home after hospital discharge and miss the fact that older adults decline at home in irreversible ways. Older adults should be prepared for the challenges of a continued recovery and the undesired potential of progressive functional decline.
Although the risk of developing immobility in older adults is high, the risk of not recovering function is even higher. Older adults encounter two potential paths of recovery. First, without intervention, the older adult commonly faces a trajectory of physiological decline. The only current treatment for loss of muscle mass and strength is resistance exercise, and many older adults are unable to exercise at an intensity adequate to restore muscle function (Fragala et al., 2019; Liguori et al., 2022). Therefore, it is important to minimize avoidable losses of muscle mass and strength from decreased physical activity at home to reduce the compounded effects of immobility and the inevitable losses that accompany the normal aging process.
Older adults who return home from the hospital frequently require treatment by a nurse or physical therapist for remobilization and other functional deficits (Falvey et al., 2015). As a result, the often-observed trajectory of decline can be redirected to the second path of recovery, the desired path of healing, to result in a successful course of regaining mobility and function. With this type of intervention, burdensome losses may be averted; immobility does not have to be inevitable.
Because there is no clear definition of "recovery," at some point, older adults will stop receiving supervised healthcare and are left on their own. Physician follow-up generally monitors medical conditions and may be scheduled at infrequent intervals. No specific attention to mobility is paid to older adults at home, in part because early signs of limited mobility do not require medical intervention (Musich et al., 2018). In the current study, we found there was no progressive program of activity prescribed at home to assist older adults in returning to their prehospital or optimal level of functioning.
Exercise is Medicine, an initiative affiliated with the American College of Sports Medicine, has a goal to make activity assessments and prescription an accepted part of disease prevention and treatment (Exercise is Medicine, 2021). In policy discussions, resistance exercise should be highlighted as a fundamental means to combat age-associated declines in physical function at home and enhance overall health (Tavoian et al., 2020).
The American College of Sports Medicine provides detailed recommendations for exercise in adults ages 65 years and older (Liguori et al., 2022). These are tailored to the patient's condition; a conservative approach may be needed for older adults who have experienced significant deconditioning. An individualized program that includes flexibility and gradual progressive resistance exercise is recommended as tolerated, at least 2 days a week.
To our knowledge, few studies have been conducted that focus on the experiences of mobility. Prior studies were conducted with intensive care unit survivors and focused on the intensive care experience and the relationship between patients and nurses (Corner et al., 2019; Laerkner et al., 2019). Our study revealed a change in identity resulting from immobility and the inability to function at previous levels, which parallels a lost sense of self and the need for self-recalibration in intensive care patients, a finding uncovered by Corner et al. (2019).
Our study was novel in that it focused on the mobility experiences outside the acute care setting. Each participant had a different reason for the loss of mobility. Participants in this study seemed eager to share their stories and often cried when they shared painful memories. All participants shared similar losses and struggled to recover, and some succeeded better than others.
The impact of factors such as safety, self-efficacy, frailty, and sarcopenia was not addressed directly by participants. Rather, they characterized their experience as a "shattering blow," which subsumed many of the outcomes that healthcare professionals are familiar with. The profundity of the overall experience can be overlooked by healthcare professionals. This study underscores the breadth of this experience.
The study had several limitations. All participants were White. Future studies should include broader demographic groups, such as increased numbers of men, more diverse racial groups, and additional age groups, including the old-old. Interviews with family members may add additional understanding. Future studies using phenomenology may provide insight into the meaning of the lived experience of immobility in older adults.
In summary, healthcare professionals can assist in preventing the negative effects of immobility. This includes providing important resources and support to promote recovery in the older adult at home, including nursing and physical therapy interventions for strength, flexibility, and aerobic activity to assist the older adult in regaining as much strength and function as possible. Creating an environment to support continued recovery to optimize long-term functional ability will require systematic changes to the healthcare delivery system with policies that support funding for needed services and delivery design changes to create pathways for integrated services from hospital to rehabilitation to home over an extended period. Maintaining functional ability in the home and community is critical to successful aging in place.
Implications for Practice
It is easier to prevent immobility in older adults than it is to recover from its effects. When possible, healthcare professionals should focus on increasing physical activity and limiting bed rest. If deconditioning occurs, it requires healthcare professionals to focus plans of care and therapies on preventing additional decline and promoting optimal recovery at home.
Recovering from immobility is a long-term process that requires extended intervention of the healthcare team to maximize the level of functional ability. Recovery cannot be rushed. Early remobilization that is too vigorous can lead to muscle weakness, tenderness, and even injury, which can delay or may even permanently inhibit recovery (Kasper & Xun, 2000).
Recovery is not only physical. Support from the healthcare team and family can help older adults focus on their accomplishments and set goals for the future. Knowing when and how much intervention is needed is not innate knowledge of older adults or their families; healthcare professionals can fill this gap by functioning as the liaison for recovery, translating the importance of rehabilitation for the older adult.
Conclusion
The findings from this study indicate that older adults perceive the ability to be mobile as a fundamental aspect of life. The sudden experience of immobility is therefore a life-changing event. It is overwhelmingly clear that mobility means more than moving from one point to another; maintaining mobility invites opportunity and increases meaning in the older adult's life. Mobility is also often key to an older adult's physical and social functioning and is at the heart of their very being. The experiences of older adults who have confronted immobility indicate that preserving function is critical.
Immobility can be a shattering blow to the older adult who is not prepared for an extended recovery, which may cause some to question their initial decision to seek healthcare. Recovering from immobility is physically and emotionally draining on the older adult. A critical component of recovery is a supportive system that includes family and members of the healthcare team. Healthcare professionals foster recovery with rehabilitative expertise and provide encouragement and emotional support that empower the older adult to continue when burdened with the daily demands of recovery. Our goal is to help older adults recover their maximal rehabilitative potential so they can live full and satisfying lives.
Key Practice Points
* Older adults at home are unprepared for the extent of loss of functioning and independence that may occur after hospitalization, and this is distressing to them.
* The loss of function often results in incomplete recovery with profound consequences including a change in identity and reduced social functioning.
* Rehabilitation nurses can provide guidance and support for older adults during discharge preparation for the transition to home to continue the recovery process from immobility.
* Policy decisions are necessary to determine which healthcare professionals should assist older adults at home and what payment options are available for this assistance.
Conflict of Interest
The authors declare no conflict of interest.
References