Journal Reading

Man age ment of Immobilization and It s Complication

f or Elderly

by
Andri Hendratno
I11112058

Preceptor:
dr. Achmadi Eko Sugiri Sp.PD
Gerontology Department
dr. Ade Muhammad Djoen Hospital Sintang
Faculty of Medicine Tanjungpura University
2018
L
Management of Im
mobilization and I
ts Complication
for Elderly
Purwita W. Laksmi*, Kuntjoro Harimurti*, Siti Setiati*, Czere
sna H. Soejono*,
Wanarani Aries**, Arya Govinda Roosheroe*
Acta Med Indonesian Journal Interna Med
 Introduction
In 2020 aged 60 effect orising
In 2000, life
years will increase to precentage of elderly
expectancy Woman
11,4% or 25.5 million population & health
70 years
elderly.
Man 65 years problem associated with
(2000, i.e 7,4%)
(indonesia) elderly

Severe condition 
lay down on bed for
Immobilization will more than 3 days, infection  drain the
lead elderly to sitting down on remaining physiological
terminal state and wheel chair, unable supply of various organs
death. to move or to have in body
any activity unless
assisted.

Death frequently Cipto Mangunkusumo

88% people age > Hospital found that 5,7%
occurs in elderly with
65 years at least one hospitalized elderly patients
immobilization by
chronic medical at the acute geriatric ward
pulmonary
condition. had immobilization in 2007.
embolism.

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 • loss of anatomical movement due to
alteration of physiological function,
Immobilizatio  more than three days bed rest or i
n nability to perform mobile activity on
bed, transfer or ambulation.
Risk Factors o
f Immobilizati
on
Complication
Due to Immob
ilization
Complication Due to Immobilization

Immobilization cause
Degeneration process
venous congestion 
in all of organ system VTE, PE, fatal if no
inhibit the clearance
result of gravity prevention and
and dilution of
presure and optimal management
activated coagulation
decreased motor carried out.
factor, induce
function.
embolism

Decubitus ulcers are

VTE  manifest as
occur in immobilized Clasic clinical sign of
deep vein thrombosis
elderly patient due to DVT :
(DVT) or Pulmonary
prolongoed 1. Swelling,
embolism (PE)
compression on bony 2. Pain
prominence. 3. Change of Skin
colour on the
affected extremity On Physical Examination :
1.Thrombotic venous by
palpation,
2.Unilateral edema,
3.Warm Surface,
4.Homans sign (Pain during
plantar flexion of foot). 7
Wells Clinical Prediction Rule for DVT and PE

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Assessment to Identify risk Of Pressure Ulcer in Im
mobilized Elderly People

Score > 14 : Indicates

a very low risk.
Score 12-13 : Indicates
moderate risk
Score < 12 : Increased
risk of 50 times greater
for pressure ulcer
Score <14 : Indicates a
high risk of pressure
ulcers development.

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Shea Stagging Pressure Ulcer

10
Evaluating for Elderly Immobilization Patient

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 MANAGEMENT

• The training program and

remobilization should be
• Patients with hypokinesia problem commenced during a stable
 Giving adequate nutrition with con medical condition, including
sideration to fluid and fiber intake, a bedside mobility training, exercise
nd supplementation of vitamin and m on joint range of motion exercise
ineral . for muscle strength, exercise for
coordination/balance, transfer
with help and limited ambulant.

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 MANAGEMENT (2)

Prevention of venous thromboembolism may be performed through 2 methods, i.e.

mechanical
and pharmacolgoical method .
while to achieve the therapeutical goals, we can use several kinds of anticoagulants.

1. Mechanical methods  Graduated compression stocking

(GCS) by using elastic stocking. Which is girded on extremities
with using gradual tightness from tightest to less tight area, fro
m distal to proximal; intermitten pneumatic compression (IP
C); and venous foot pump (VFP)

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 MANAGEMENT (3)

2. As prophylaxis treatmen of DVT and PE  low-dose unfractionated heparin (U

HF) immediately 5000 unit subcutaneous every 8 or 12 hours, until patient able t
o be mobilized adequately.

While for DVT treatment, loading dose UFH is

administered by bolus of 80 unit/kgBW and maintained
further with 18 unit/kgBW per hour through continuous
drip.  monitor Activated partial tromboplastin time
(APTT), expected ATTT 1,5 or 2,0 times the control.

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 MANAGEMENT (4)

For secondary prevention, oral anticoagulants such as warfarin or other type of c

oumarin may be used with a goal of international normalized ratio (INR) between
2 and 3. As the effect of antithrombotic by warfarin will be obvious only after 72-
96 hours; therefore, warfarin is usually given for 3-4 days prior to diminution of h
eparin or other antithrombotic treatment.

Patients with massive PE or unstable hemodynamic condition, the treatment

usually involve thrombolitic agents in order to obtain the rapid
therapeutical effect. Thrombolitic agents used in such cases includes
alteplase by dose of 100 mg given through intravenous drip for 2 hours, or
streptokinase given at loading dose 250.000 IU and maintain at 100.000 IU
per hours for 24 jam.

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 MANAGEMENT (5)
Preventing pressure ulcer

1. Repositioning the patient’s back position, i.e. Turning the position at the angle
of 30o to the matress, alternately to the left or right side, and supine position in
every 2-3 hours for high-risked patients and 2-4 times daily for patients with lowe
r risk.

2. Using protective padding include pillows placed between extremities,

lower back and arm-supporting pad to maintain the optimal position,
preventing contact within bony prominence, extremities or with the
matress.

3. For Patient who must have head at stright position on their bed or for
patients who are wheel chair-bound, periodic repositioning for every 1 hour
should be performed or ask the patients to reposition himself altering his
weight point for every 15 minutes

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 MANAGEMENT (6)

4. To prevent skin maceration, keep the skin dry (using high absorbance
matress for incontinent patient) but yet lubricated by applying lubricant on
it, such as emolient, the cooking oil, or cream.

5. To prevent any friction, use the ankle and heel protective pad and the
patients should be elevated, do not move the patients by rubbing or pulling
movement off the mattress.

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What Should we do when pressure uler has occure
d?

1. Attention to the patient’s hydration status.

In malnourished patient with pressure ulcers, at least 30-35
calori/kgBW/day od nutrition should be provided, in additional to protein
intake of 1.25-1.5 g/kgBW/day to achieve the positive nitrogen balance.

2. Systemic antibiotics are indicated in patients with sepsis, cellulitis, and

osteomyelitis or as prophylaxis method to prevent bacterial endocarditis in
patients with heart-valve disease who need any wound debridement.

3. Use specialized mattress: air-fluidized bed, lowair-loss bed, or specialized

mattress that can automatically change the patient positioning.

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What Should we do when pressure uler has occure
d ? (2)

4. In general, stage I and stage II pressure ulcer does not need any topical
treatment, just maintain appropriate cleaning and moisture of the ulcers
and the ulcers are expected to have self-healing process.

5. Clean ulcers which do not heal or keep excreting exudates after 2-4
week optimal care may be treated with topical antibiotics such as silver
sulfadiazine for 2 weeks, but avoid to use the following agents, i.e.
povidone-iodine, iodophore, sodium hypochlorite hydrogen peroxide, and
acetic acid

6. Wound debridement if there is any necrotic tissue. There are several

methods including wound dressing, hydrotherapy, irigation, dextranomers,
enzymatic or autolytic therapy. Pain management should be considered.

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What Should we do when pressure uler has occure
d ? (3)

7. If necessary, surgical procedure may be commenced including wound

closure, skin graft, and myocutaneus flap as well as discarding the
prominent bone which
causing ulcer. Amputation is occasionally secessary in ulcer with
complicated or spreading infection.
8. Hyperbaric oxygen therapy and several kinds of topical treatment and
growth factor are being developed as a method to enhance the wound
healing.

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Attempting environmental support and available device for supporting
adequate mobility in patients with permanent disability.

Provide and give instruction about how to use the standing-supporting

device, ambulation as well as the management of micturition and
defecation, including using comod or toilet to facilitate straightening of
body posture.

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 Conclusion

Immobilization is one of common health problem in elderly population and

it may cause various lifethreatening complications.

In brief, the treatment of immobilization requires interdisciplinary team

work together with the patient participation and their family .

The treatment starts from commencing a complete geriatric review,

formulating functional goals, and constructing therapeutic plan.

Various conditions that probably act as the risk factors for immobilization
and complications resulting from immobilization as well as other
comorbidity should be recognized and managed comprehensively

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Thank you