1.3 contact hours will be awarded by Villanova University College of Nursing upon successful completion of this activity. A contact hour is a unit of measurement that denotes 60 minutes of an organized learning activity. This is a learner-based activity. Villanova University College of Nursing does not require submission of your answers to the quiz. A contact hour certificate will be awarded once you register, pay the registration fee, and complete the evaluation form online at https://villanova.gosignmeup.com/dev_students.asp?action=browse&main=Nursing+Journals&misc=564. To obtain contact hours you must:

Read the article, “Study of Activity in Older Adult ICU Patients: An Integrative Review” found on pages 12–25, carefully noting any tables and other illustrative materials that are included to enhance your knowledge and understanding of the content. Be sure to keep track of the amount of time (number of minutes) you spend reading the article and completing the quiz.

Read and answer each question on the quiz. After completing all of the questions, compare your answers to those provided within this issue. If you have incorrect answers, return to the article for further study.

Go to the Villanova website listed above to register for contact hour credit. You will be asked to provide your name; contact information; and a VISA, MasterCard, or Discover card number for payment of the $20.00 fee. Once you complete the online evaluation, a certificate will be automatically generated.

Villanova University College of Nursing is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

Identify the factors that contribute to muscle breakdown and loss of function in older intensive care unit (ICU) patients.

Discuss the types of activity that have been used in the study of early mobilization in ICU patients.

The purpose of this study was to review relevant literature on activity of older critically ill patients, including activity interventions conducted in this population, with a focus on activity measurement and technology. Literature published between 1996 and 2012 was reviewed using keywords older adults, inactivity, mobility, progressive mobility, rehabilitation, ambulation, early mobilization, ICU (intensive care unit), and accelerometry using CINAHL, MEDLINE, and the Cochrane Database of Systematic Reviews. Previous relevant research is discussed and includes intervention and nonintervention studies. Although studies have demonstrated the benefits of early mobilization in the ICU setting, this research has not focused on the high-risk older adult ICU population, nor has it addressed how best to quantify these clinical activities. Current technologies, such as accelerometry, may assist in measuring patient activity and in mobilizing high-risk patients during acute, critical illness. [Journal of Gerontological Nursing, 39(8), 12–25.]

Address correspondence to Colleen M. Casey, PhD, ANP-BC, CNS, Assistant Professor, 3181 SW Sam Jackson Park Road, L-475, Portland, OR 97239; e-mail: caseyc@ohsu.edu.

1.3 contact hours will be awarded by Villanova University College of Nursing upon successful completion of this activity. A contact hour is a unit of measurement that denotes 60 minutes of an organized learning activity. This is a learner-based activity. Villanova University College of Nursing does not require submission of your answers to the quiz. A contact hour certificate will be awarded once you register, pay the registration fee, and complete the evaluation form online at https://villanova.gosignmeup.com/dev_students.asp?action=browse&main=Nursing+Journals&misc=564. To obtain contact hours you must:

Read the article, “Study of Activity in Older Adult ICU Patients: An Integrative Review” found on pages 12–25, carefully noting any tables and other illustrative materials that are included to enhance your knowledge and understanding of the content. Be sure to keep track of the amount of time (number of minutes) you spend reading the article and completing the quiz.

Read and answer each question on the quiz. After completing all of the questions, compare your answers to those provided within this issue. If you have incorrect answers, return to the article for further study.

Go to the Villanova website listed above to register for contact hour credit. You will be asked to provide your name; contact information; and a VISA, MasterCard, or Discover card number for payment of the $20.00 fee. Once you complete the online evaluation, a certificate will be automatically generated.

Villanova University College of Nursing is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

Identify the factors that contribute to muscle breakdown and loss of function in older intensive care unit (ICU) patients.

Discuss the types of activity that have been used in the study of early mobilization in ICU patients.

The purpose of this study was to review relevant literature on activity of older critically ill patients, including activity interventions conducted in this population, with a focus on activity measurement and technology. Literature published between 1996 and 2012 was reviewed using keywords older adults, inactivity, mobility, progressive mobility, rehabilitation, ambulation, early mobilization, ICU (intensive care unit), and accelerometry using CINAHL, MEDLINE, and the Cochrane Database of Systematic Reviews. Previous relevant research is discussed and includes intervention and nonintervention studies. Although studies have demonstrated the benefits of early mobilization in the ICU setting, this research has not focused on the high-risk older adult ICU population, nor has it addressed how best to quantify these clinical activities. Current technologies, such as accelerometry, may assist in measuring patient activity and in mobilizing high-risk patients during acute, critical illness. [Journal of Gerontological Nursing, 39(8), 12–25.]

Address correspondence to Colleen M. Casey, PhD, ANP-BC, CNS, Assistant Professor, 3181 SW Sam Jackson Park Road, L-475, Portland, OR 97239; e-mail: caseyc@ohsu.edu.

The aging of Americans presents many challenges to the U.S. health care system. Older adults are hospitalized more frequently and have longer hospital lengths of stay than any other age group, accounting for more than half of the nation’s hospital bill (Buie, Owings, DeFrances, & Golosinskiy, 2010; Carson & Bach, 2002). Estimates of the older population (>65) in the intensive care unit (ICU) setting range from 48% to 58%, their mortality rates vary between 20% and 50%, and they make up more than half of chronically critically ill patients (Carson & Bach, 2002; Cuthbertson, Roughton, Jenkinson, Maclennan, & Vale, 2010).

Many older adults recover from critical illness (Garrouste-Orgeas et al., 2006; Montuclard et al., 2000). However, studies show that as many as three quarters of older hospitalized patients experience some loss in function during hospitalization that persists beyond the hospital stay (Boyd et al., 2008; Covinsky et al., 2003; Wu et al., 2000). Patients who have an ICU stay, particularly those who are chronically critically ill, are especially vulnerable to physical deconditioning during lengthy hospitalizations because they are often older, frequently postoperative, and at a higher risk for morbidity, hospital readmissions, and mortality (Carson & Bach, 2002). The resultant functional limitations and related disability translate into significant personal and societal costs that may include nursing home placement, increased demands on family caregivers, and the potential for a decreased quality of life (Carson, 2003; Carson & Bach, 2002; Cuthbertson et al., 2010; Zanni et al., 2010).

Hospitalized patients are likely to spend much of their time in bed and alone (Bernhardt, Dewey, Thrift, & Donnan, 2004; Brown, Friedkin, & Inouye, 2004; Goldhill, Badacsonyi, Goldhill, & Waldmann, 2008). Spontaneous physical activity decreases by as much as 50% in patients following hospital admission, remains low during hospitalization, and is significantly less than age- and gender-matched community-dwelling older adults (Browning, Denehy, & Scholes, 2007). The reasons for such immobility, in addition to physiological instability of the patient, are complex. Bed rest orders are often the default activity order on admission, are sometimes not revised during hospitalization, and may not have documented medical indications for such bed rest (Brown et al., 2004; Needham, 2008). Despite commonly accepted standards of care, minor activities, such as turning every 2 hours, may happen as infrequently as every 5 hours (Goldhill et al., 2008; Krishnagopalan, Johnson, Low, & Kaufman, 2002), putting the ICU patient at increased risk for musculoskeletal, cardiovascular, respiratory, and integumentary sequelae.

Inactivity, age, and the inflammatory process that occurs during critical illness conspire to promote muscle breakdown and loss in physical function in older hospitalized patients (Figure 1). Muscle breakdown occurs as early as several hours from the onset of immobility or disuse, independent of any injury or illness (Hirsch, Sommers, Olsen, Mullen, & Winograd, 1990; Kasper, 2003; Winkelman, 2009). The process of muscle breakdown related to inactivity further compounds the inflammation characteristic of critical illness. During this time, an increased release and action of proinflammatory cytokines promote further muscular atrophy through several complex, interrelated pathways (Winkelman, 2004). Increased proteosomal proteolytic activity, such as occurs in sepsis, also causes protein degradation and muscle loss in critically ill patients (Klaude et al., 2007). Neuromuscular pathologies caused by and acquired during critical illness are increasingly recognized as phenomena specific to ICU patients. These pathological changes occur along a clinical spectrum, with the most severe manifestations termed critical illness polyneuropathy (CIP) and critical illness myopathy (CIM). Even less severe neuromuscular deficits than CIP and CIM are often overlooked or misdiagnosed and delay patient recovery (Stevens et al., 2007).

Pharmacological interventions and other treatments common in the ICU setting, such as the use of exogenous corticosteroids, muscle relaxants, neuromuscular blockers, and antibiotic agents, can be toxic to nerves and muscles, further exacerbating skeletal muscle atrophy (Kasper, 2003). Wagenmakers (2001) found that ICU patients can lose more than 1.5 kg of skeletal muscle mass per day, with up to a 50% loss in total muscle mass in 2 weeks. Clinically, these losses often result in global muscle wasting, foot drop, joint immobility, dyspnea, and weakness (Clavet, Hébert, Fergusson, Doucette, & Trudel, 2008; Needham, 2008).

The rate of muscle atrophy resulting from inactivity or critical illness is even more rapid than that of normal aging. For the older ICU patient, the muscle wasting induced by critical illness compounds the 40% reduction in muscle cross-sectional area that occurs as part of the natural aging process between the ages of 20 and 80, leaving the older ICU patient less protein reserve (Griffiths, 1996; Winkelman, 2004). Moreover, the ability of specialized muscle cells to regenerate muscle to divide and proliferate is finite, decreasing with age (Kasper, 2003). These age-related changes, along with the high levels of inactivity documented and the inflammation of critical illness, put inactive and critically ill older adults at high risk for a compromised recovery.

Prior systematic reviews of progressive mobility in the ICU and early mobility interventions have primarily focused on patients receiving prolonged mechanical ventilation (Choi, Tasota, & Hoffman, 2008), approaches to weaning protocols (Clini & Ambrosino, 2005), the influence of neuromuscular weakness (Truong, Fan, Brower, & Needham, 2009), and the timing of early versus delayed intervention (Thomas, 2011). No reviews have specifically focused on older ICU patients, nor has any review evaluated the way in which activity has been measured. The purpose of this integrative review was to review relevant literature regarding inactivity and activity of critically ill patients, particularly older ICU patients. This review also focuses on how activity and activity interventions have been measured. The following questions were addressed:

This review followed the integrative literature review process outlined by Whittemore and Knafl (2005), which allows for the inclusion of diverse methods and the simultaneous inclusion of experimental and nonexperimental research to more fully describe varied perspectives on a phenomenon. Published studies were retrieved from CINAHL, MEDLINE, and the Cochrane Database of Systematic Reviews from 1996 to 2012. The search included the following keywords: older adults, inactivity, mobility, progressive mobility, progressive activity, functional status, rehabilitation, ambulation, early mobilization, ICU, and accelerometry. Studies were limited to those in the English language and involving human participants 18 and older primarily in an ICU or respiratory care unit setting. Additionally, an ancestry approach was used, analyzing reference lists of retrieved reports. Abstracts of conference presentations, personal communications, case studies, and scholarly dissertations and theses were not included. Other exclusion criteria included studies that had fewer than 10 participants; did not describe participants’ age; used solely inspiratory (versus whole body) muscle training as an intervention; did not study activity as a primary variable; and included ICU survivors beyond hospital discharge.

A total of 16 studies meeting the criteria were retrieved: 5 were randomized controlled trials, 5 were experimental quantitative studies, and 6 were observational studies. Data were reduced by determining an overall classification system fitting the previous relevant research (Whittemore & Knafl, 2005). Study elements were summarized into a matrix (Table 1 and Table 2) for easy comparison across all primary sources. Studies meeting the selection criteria were evaluated for setting, appropriate description of methods used in the study, effect of the intervention when applicable, and conclusions. This review discusses only components of interventions involving activity, although some multicomponent interventions also included cognitive or respiratory rehabilitation.

Research on early mobilization in the ICU has developed primarily in the past 5 to 10 years. Most of the activity interventions occurred in special respiratory care units or medical ICUs, involving only patients who were mechanically ventilated (MV). Only a single study occurred in a surgical ICU (Burtin et al., 2009), and no published studies of progressive mobility have occurred in trauma or cardiac ICUs. Burtin et al. (2009), Schweickert et al. (2009), and Pohlman et al. (2010) studied a standardized early exercise training intervention in the early ICU phase when many patients are still sedated. However, most interventions occurred in patients who had been MV for at least 5 days or longer.

Mobility interventions within these studies typically included the use of clinical care activities such as range of motion (ROM), turning, dangling/sitting on the edge of the bed, transferring, sitting in a chair, and walking, often termed “progressive mobility” or “early mobilization” (Needham, Truong, & Fan, 2009). A few studies used less common interventions such as cycle ergometry or electrical stimulation (Burtin et al., 2009; Martin, Hincapie, Nimchuk, Gaughan, & Criner, 2005; Zanotti, Felicetti, Maini, & Fracchia, 2003). Each study’s definition of activity was slightly different. In one study, activity included sitting on the bed, sitting in a chair, and ambulating, but excluded turning and ROM (Bailey et al., 2007). Patient movement to a chair position in bed, to a “cardiac” chair, and passive ROM were variably considered intervention activities across the studies, even though these activities are traditionally considered part of progressive mobility for ICU patients (Morris et al., 2008).

Most of the studies established the merits of early mobilization by demonstrating some combination of increased mobility, improved physical function, and even decreased resource utilization. Activity-specific outcomes measures included muscle strength score (Burtin et al., 2009; Chiang, Wang, Wu, Wu, & Wu, 2006; Martin et al., 2005; Schweickert et al., 2009; Zanotti et al., 2003), timed walk test (Burtin et al., 2009; Chiang et al., 2006; Nava, 1998), distance ambulated (Bailey et al., 2007; Schweickert et al., 2009; Thomsen, Snow, Rodriguez, & Hopkins, 2008), receipt of physical therapy (PT) (Morris et al., 2008; Needham et al., 2010; Pohlman et al., 2010), days to out of bed (Morris et al., 2008; Schweickert et al., 2009), and functional status (Burtin et al., 2009; Chiang et al., 2006; Schweickert et al., 2009). Sedative use was associated with a 2-fold decrease in likelihood of ambulation in patients with acute respiratory distress syndrome in one study (Thomsen et al., 2008); Needham et al. (2010) similarly found decreased sedation to positively correlate to activity levels. In Schweickert et al.’s (2009) and Pohlman et al.’s (2010) study of early mobility, sedation infusions were stopped before 83% of therapy sessions; agitation after sedative interruption required stopping therapy in less than 10% of sessions.

Schweickert et al. (2009) found that despite substantial differences between functional measurements, the intervention did not produce any significant differences in manual muscle testing or hand grip strength. Morris et al. (2008, 2011) found that in addition to shorter hospital stays, intervention patients progressed more quickly to active PT, were out of bed earlier, experienced no adverse events during ICU therapy sessions, and had fewer hospital readmissions or death during the first year. Importantly, some of the studies measured adverse outcomes, such as a change in clinical status, falls, and accidental extubation, all concluding that based on minimal adverse events, early mobilization can be performed safely in the MV population (Bailey et al., 2007; Morris et al., 2008; Pohlman et al., 2010; Stiller, 2007).

In addition to establishing the positive outcomes of early mobilization, numerous intervention studies documented the magnitude of inactivity across ICUs. Morris et al. (2008), for example, reported that even for ICU patients assigned to a mobility protocol, it took 5 days (SD = 0.9) to touch their feet to the floor as compared to 11.3 days (SD = 2.1) for a control group receiving usual care. Similarly, the time to activity from initial ICU admission to activity was 6.6 days (SD = 5.5) to sit on the edge of the bed, 8.8 days (SD = 7.6) to sit in a chair, and 11.3 days (SD = 10.1) to walk (Bailey et al., 2007). Morris et al. (2008) also found that only 6% of 135 MV patients received PT in the ICU. Needham et al. (2010) found that 24% of patients received PT/occupational therapy (OT), but prior to any intervention, averaged only one treatment per patient per ICU stay.

None of the reviewed studies specifically examined activity in older ICU patients. Interestingly, although activity interventions within the acute care setting focus on older adults (Inouye, Bogardus, Baker, Leo-Summers, & Cooney, 2000; Prvu Bettger & Stineman, 2007), the ICU-based studies mostly took place on younger, MV patients, with mean ages in the 50s (Bailey et al., 2007; Burtin et al., 2009; Martin et al., 2005; Morris et al., 2008; Needham et al., 2010; Schweickert et al., 2009; Thomsen et al., 2008). Only three intervention studies reported mean ages of the sample ⩾65; mean ages were 75, 65, and 66, respectively (Chiang et al., 2006; Nava, 1998; Zanotti et al., 2003). Two intervention studies included patients as old as 89 (Thomsen et al., 2008) and 91 (Bailey et al., 2007). Bahadur, Jones, and Ntoumenopoulos’ (2008) work was the only observational study to study older patients (mean age = 68). No study described an upper age limit as part of any exclusion criteria.

Most of the intervention studies did not discuss age as a covariate in the analysis of their findings. Burtin et al. (2009) reported that the three patients who dropped out of the ergometer intervention were older. Bailey et al. (2007) examined various activities by age (<65 versus ⩾65) and found that older age did not preclude participation in activity. Although 74% of patients 100 feet, 64% of older adults did the same. The same study did find that older patients participated in more sedentary (sitting in chair or bed) activity but did not provide statistical significance for these differences. Bahadur et al. (2008) found that patients who were not mobilized tended to be older (70 versus 66); these results were not statistically significant.

As described above, many intervention studies measured the frequency of rehabilitation, for example, three times daily passive ROM or twice daily PT. Needham’s (2008) study of patients with acute respiratory distress syndrome found that patients received activity beyond bed rest in only 11% of 2,470 ICU days observed. Furthermore, studies showed that patients did not routinely receive PT or OT consultation as part of their usual care (Morris et al., 2008; Needham et al., 2007; Zanni et al., 2010). Although distance ambulated was commonly reported, duration of both non-walking and walking activities was often not reported. Recent studies have pointed to higher-intensity rehabilitation leading to greater benefit but have not objectively measured the activity itself except to describe the activity (sitting, walking) and document the distance walked and duration of activity. Zanni et al.’s (2010) prospective observational study measured duration of unsupported sitting at the edge of the bed and maximum distance ambulated. However, other than scoring a patient as “unlimited” if they could sit for more than 30 minutes or ambulate more than 600 feet, the study provided no additional detail for patients not achieving this benchmark.

A number of non-intervention, observational studies have examined the influence of ICU clinical care activities on a variety of physiological parameters, such as SvO2, heart rate, blood pressure, and cytokines (Gawlinski & Dracup, 1998; Verderber & Gallagher, 1994; Winkelman, 2010). This attention underscores the important role activity plays in the relationship to various physiological indicators, especially during a critical illness. However, most of these studies have not measured the activities themselves beyond chart review, observation, or nurse recall, nor have they studied the effect of activities on overall physical functioning.

Additional efforts have been made to quantify activity in the critical care setting through the use of accelerometry, which measures activity counts noninvasively during rest and activity. Grap, Borchers, Munro, Elswick, and Sessler (2005) found accelerometry to correlate well with observed activity levels and subjective reports of agitation and sedation in 20 ICU patients. The study included only a 2-hour time period and measured associated physiological parameters, such as blood pressure, invasively and separately. Winkelman (2010) and Winkelman, Higgins, and Chen (2005) found acceptable agreement between accelerometry and observation. Although accelerometry did not differentiate the type of activity, it did distinguish activity from rest or bed rest. Given limited observation periods, only turning and ROM were actually observed as activities in one study (Winkelman et al., 2005), while turning, ROM, dangling, sitting, and walking were observed in the second study (Winkelman, 2010).

Both standard, as well as custom-designed, equipment have been adapted to facilitate physical activity in ICU patients. Unfortunately, only preliminary study has occurred on most of these technologies with hospitalized or critically ill patients (Needham et al., 2009). Equipment developed with the intent of helping intubated and sedated patients move includes continuous lateral rotation therapy (CLRT) as well as modified bedside cycle ergometry (Burtin et al., 2009; Delaney, Gray, Laupland, & Zuege, 2006; Goldhill, Imhoff, McLean, & Waldmann, 2007). CLRT was developed in the 1970s specifically in an effort to reduce pulmonary complications of immobility and has been shown to be effective when initiated early and used for at least 18 hours per day (Delaney et al., 2006). Bedside ergometry has been introduced more recently in the ICU setting to prevent joint contractures and maintain lower extremity strength, with prior clinical studies in patients with chronic obstructive pulmonary disease (COPD) and patients during hemodialysis (Burtin et al., 2009). Neuromuscular electrical stimulation (NMES) creates passive contraction of skeletal muscle using electrodes that deliver a low-voltage electrical impulse to target muscle groups (Bax, Staes, & Verhagen, 2005). Thought to mimic the effects of repetitive muscle contractions in mild exercise, NMES has yet to be studied in the ICU setting, although preliminary study suggests its use as a potential rehabilitation adjunct (Needham et al., 2009; Zanotti et al., 2003).

Technology aimed at quantifying movement has also been only minimally studied in the ICU setting. In the 1970s, Halstead (1978) studied “time out of bed” of quadriplegic patients using the Rest Time Monitor, finding that longitudinal activity monitoring could be a useful clinical tool. Unfortunately, little progress has been made in the past 30 years to promote routine incorporation of activity monitoring into both research and clinical practice. In a study by Browning et al. (2007), researchers used a positional activity device, worn on the leg, to study “uptime,” the quantity of time spent in an upright position, in a post-surgical population across hospital and ICU settings (mean age = 61; SD = 12 years; n = 6 [12%] were ICU patients). Overall, daily uptime duration was low (30 minutes on Day 4 postoperative). Despite finding that daily uptime was low and predicted length of stay, the device did not discriminate between sitting out of bed and standing and walking.

These efforts were precursors to the study of accelerometers. As described previously, although accelerometers have been used minimally to study ICU activity (Grap et al., 2005; Winkelman, 2010; Winkelman et al., 2005), they have been used clinically to monitor physical activity patterns of cardiac rehabilitation patients (Ayabe et al., 2004), patients with spinal cord injury (Warms & Belza, 2004), COPD patients (Pitta, Troosters, Spruit, Decramer, & Gosselink, 2005; Steele et al., 2003), patients after stroke (Haeuber, Shaughnessy, Forrester, Coleman, & Macko, 2004), and postoperative patients in the hospital setting (Inoue et al., 2003). Accelerometry has only begun to be used in older hospitalized adults (Culhane, O’Connor, Lyons, & Lyons, 2005), but has been shown to adequately measure physical activity in nonhospitalized, community-dwelling older adults (Gerdhem, Dencker, Ringsberg, & Akesson, 2008).

Lastly, because of the technologically intense environment of the ICU, which serves as a barrier to patients actually moving their bodies, technology has been specially designed to address the equipment-laden patient. Most simply, newer ICU bed frames can be positioned to place patients in a feet-down, head up posture to provide gravitational loading (Winkelman, 2009). The ICU Moving Our Patients for Very Early Rehabilitation (MOVER) Aid, developed at Johns Hopkins University by biomedical engineering students, includes a more elaborate mobility aid that combines the support of a walker with the safety features of a wheelchair (for rest breaks) as well as a separate wheeled tower for life-support equipment (Sneiderman, 2008). Importantly, the MOVER Aid eliminates the staffing requirement to mobilize a patient from four to two, a significant clinical and resource concern and current barrier to patient mobility (see http://www.mobilization-network.org/Network/Links.html for more information on the MOVER Aid).

The ICU activity intervention studies in the past 10 years come amidst a transition away from a culture of deep sedation and bed rest that has persisted despite historical evidence of the physical and psychological benefits of early mobilization (Needham, 2008). Increasingly, early mobilization has been established as safe, feasible, beneficial, and financially sound (Bailey et al., 2007; Lord et al., 2013; Stiller, 2007). Theoretically, because ICU-related weakness and debility is more “acquired” than “degenerative,” patients who receive early mobility during critical illness have a large potential to benefit from rehabilitation (Jackson et al., 2012).

Findings of this integrative review demonstrate that ICU-based studies have not specifically examined activity in older ICU patients, who are frequent users of critical care and are known to be at high risk for complications and decreased functional outcomes related to critical illness. Moreover, because many of the studies tested interventions in special respiratory care units, the results have limited generalizability to non-MV, critically ill patients, and broader critically ill patient populations, such as surgical or trauma patients. Non-respiratory care units may have different unit cultures around mobilizing patients and different staffing and interdisciplinary structures that influence the delivery of physical therapy to patients. These studies also did not continue the interventions beyond the ICU into the general hospital setting upon the patient’s discharge from the ICU, although a recent study has found this type of intervention beyond ICU discharge to be beneficial and feasible (Jackson et al., 2012).

Even with positive findings that activity in the ICU is beneficial and safe, along with compelling evidence from multisite randomized controlled trials (Schweickert et al., 2009), these studies do not agree on what constitutes meaningful clinical activity. Most studies objectively quantified the interventions by counting the number of PT sessions, duration of some activities, and time to certain milestones. Studies of activity and inactivity in the hospital have relied mostly on subjective measures of activity such as observation, recall, self-report, and chart review. Observation methods suffer from subjectivity, expense, and the potential for a testing effect. Chart review is problematic as a research method because of the lack of standardized documentation for activity and a lack of uniform protocols outlining activity orders. These methods also cannot capture the variation in activity levels that occurs based on a patient’s severity of illness and ability to participate.

Studies have often used invasive measures of physiological responses to activity but have not measured or quantified the activity itself. Without robust measurement of individual activities, it is difficult to assess the dosage and intensity of such activities to determine effectiveness in maintaining physical functioning in ICU patients. Furthermore, measuring individual exercise sessions by occurrence cannot account for the cumulative effect and benefit of such activity. Unfortunately, only preliminary work using such devices as accelerometry or uptime devices has been conducted to systematically and objectively assess activity levels (Browning et al., 2007; Grap et al., 2005; Winkelman, 2010; Winkelman et al., 2005). As activity interventions have been shown to significantly influence a variety of outcomes, such as length of stay, days until first activity, and even mortality, measuring the activity is critical (Morris et al., 2008). Even studies that attempted to measure more objective outcomes such as muscle testing or ROM found that the results were either not meaningful or that they were too time consuming to be clinically practical (Schweickert & Kress, 2011; Zanni et al., 2010). These findings emphasize the lack of validated measures of activity and physical function in the ICU setting with a low enough burden to be practical for either research or clinical practice.

Severity of illness, safety concerns, multiple device access, sedation, time constraints, staffing issues, shorter lengths of stay, and cost all contribute to the lack of progressive activity in the ICU (Bailey, Miller, & Clemmer, 2009; Bernhardt et al., 2004; Stiller, 2007). These barriers highlight the important role the ICU culture and a multidisciplinary focus play in successfully mobilizing patients (Bassett, Vollman, Brandwene, & Murray, 2012; Hopkins, Spuhler, & Thomsen, 2007). Safety concerns must always be prioritized and guidelines developed to assess safety and appropriateness for early mobility activities based on physiological data and clinical experience (Stiller, 2007; Winkelman, 2011).

Time constraints of ICU clinical staff must be recognized and addressed (Hopkins et al., 2007). Interventions, such as the cycle ergometer that take 30 to 40 minutes to set up, may not be feasible in many ICUs (Burtin et al., 2009). Four staff may be required to be involved to ambulate a MV patient, with significant staffing implications (Needham et al., 2009). However, technology like the MOVER Aid creatively addresses how to promote mobility in relationship to staffing and equipment considerations (Sneiderman, 2008), and at least one study showed that a dedicated mobility team did not add to hospital costs (Morris et al., 2008). A quality improvement project found that other aspects of routine clinical practice could also be substantially and rapidly improved by changing default activity level from “bed rest” to “as tolerated”; changing continuous infusion of sedatives to “as needed”; establishing simple guidelines for PT/OT consultation; and changing staffing to include full-time PT and OT and a part-time rehabilitation assistant (Needham et al., 2010). In a culture that promotes mobility, nurses and therapists should not have to obtain a new physician order to progressively mobilize an appropriate patient.

Guidelines now exist regarding physical activity in critically ill patients that are based on expert consensus and existing research, including the 2009 NICE Clinical Guidelines for Rehabilitation after Critical Illness (Tan, Brett, & Stokes, 2009) and the European Respiratory Society and European Society of Intensive Care Medicine (Gosselink et al., 2008). These guidelines advocate for early mobilization with active and passive exercise in all critically ill patients (Gosselink et al., 2008). Recently, uniform categories of activity levels were developed at a meeting of the International ICU Physical Medicine and Rehabilitation to promote standardization across studies (see http://www.mobilization-network.org/Network/Documents.html). Figure 2 depicts a progressive mobility algorithm developed through a multicenter mobility collaborative to promote consistent mobility practices across ICUs (Bassett et al., 2012). Furthermore, some of the daily ICU checklists designed to promote consistent, comprehensive critical care now include mobility as a daily goal (Winters et al., 2009). For example, the “E” in the ABCDE bundle, described elsewhere in this issue, stands for “exercise and early mobility” (Vasilevskis et al., 2010). More globally, models developed at a systems level can help translate research knowledge into routine practice by combining rigorous measurements with culture change across local interdisciplinary teams to improve patient health and outcomes (Pronovost, Berenholtz, & Needham, 2008).

Figure 2. Progressive mobility algorithm developed through a multicenter mobility collaborative to promote consistent mobility practices across intensive care units (ICUs). Reprinted with permission from Rick Bassett, MSN, RN, APRN, ACNS-BC, CCRN. Note. RR = respiratory rate; HR = heart rate; MAP = mean arterial pressure; SBP = systolic blood pressure; RASS = Richmond Agitation Sedation Scale; ROM = range of motion; HOB = head of bed; UAP = unlicensed assistive personnel; CLRT = continuous lateral rotation therapy; PT = physical therapy; OT = occupational therapy; prn = as needed; RT = respiratory therapy; ADLs = activities of daily living; OOB = out of bed.

The individual nurse can adopt early mobility as a daily goal for patients, whether that is passive or active ROM or more intensive activity. The nurse must first identify and address any barriers to mobilizing patients so that the needed staff, required equipment, and timing of activity works for the patient, the nurse, and other staff. Any activity must be planned as part of the clinical day. Knowledge of the progressive steps of mobility, as well as any contraindications to progressing activity, is important (Figure 2). Resources continue to be developed to support nurses and their colleagues to increase early mobility efforts in the ICU (see http://www.mobilization-network.org/Network/Welcome.html for more information).

The problems and costs of inactivity in older hospitalized patients are well documented. Although studies have begun to show the benefits of early mobilization in the ICU setting, most of these studies have focused only on MV patients and have not explicitly studied older critically ill patients. Because older adults who become critically ill are at increased risk for muscle breakdown, deconditioning, and associated functional decline, future study should target this group as an at-risk population. Furthermore, from a scientific perspective, the ICU environment, the variability of ICU patients, and the different possible combinations of early mobilization protocols make it difficult to standardize interventions in such a way that consistently measures both the intervention and associated outcomes. Better measurement could lead to improved processes around how much, how frequently, and what types of activities should be used to progressively mobilize patients, especially those older and most at risk for physical deconditioning. More multi-site and longitudinal studies, as well as studies that measure the activities themselves, are needed. Only with a more solid scientific foundation can progress be made to describe particularly vulnerable periods of inactivity, develop interventions to mitigate inactivity, and identify the appropriate dosing and tailoring of activities that provide the most benefit.

Casey, C.M. (2013). The Study of Activity in Older ICU Patients: An Integrative Review. Journal of Gerontological Nursing, 39(8), 12–25.

Age-related changes causing muscle atrophy, muscle loss from inactivity while in the hospital, and muscle breakdown caused by inflammatory mediators all contribute to muscle wasting and weakness in critically ill older adults, often causing an irreversible decline in function.

Intensive care unit (ICU)-based activity studies have so far not specifically examined activity in older ICU patients despite this patient group’s risk for complications and decreased functional outcomes related to critical illness.

Increasingly, the study of progressive mobility in the past 10 years has established that early activity in the ICU setting is safe, feasible, and beneficial to patients although has not uniformly defined or measured levels of activity.

Individual nurses can promote early mobility as a goal for patients by learning the progressive steps of mobility, identifying the barriers and resources required to mobilize patients, and planning some level of activity as part of every clinical day.

Figure 2. Progressive mobility algorithm developed through a multicenter mobility collaborative to promote consistent mobility practices across intensive care units (ICUs). Reprinted with permission from Rick Bassett, MSN, RN, APRN, ACNS-BC, CCRN. Note. RR = respiratory rate; HR = heart rate; MAP = mean arterial pressure; SBP = systolic blood pressure; RASS = Richmond Agitation Sedation Scale; ROM = range of motion; HOB = head of bed; UAP = unlicensed assistive personnel; CLRT = continuous lateral rotation therapy; PT = physical therapy; OT = occupational therapy; prn = as needed; RT = respiratory therapy; ADLs = activities of daily living; OOB = out of bed.

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