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The 4M's Framework: MOBILITY with Tahira I. Lodhi MD "MOBILITY is a critical aspect of the 4M's framework because you have to safely move every day to maintain your function - in order to do WHAT MATTERS."-Melissa Batchelor, PhD, RN, FNP-BC, FGSA, FAAN Strength and mobility are vital facets of life, but they are often taken for granted. When you experience a mobility restriction, that's when people become more mindful of its value. For older adults, mobility issues are strongly linked to falls, social isolation, feelings of loneliness, stress, chronic disease, weight deterioration, and loss of bone mass. Mobility restrictions are also known predictors of mortality. Older adults prefer to be independent, but this may be difficult if they are experiencing mobility problems. In today's episode, we will discuss MOBILITY as a continuation of our special series on the 4M's Framework of the Age-friendly Health Care Systems. With me is Dr. Tahira I. Lodhi, and we're inviting you to join us and discover how to implement MOBILITY in your care plan for older adults properly. Part One of 'The 4M's Framework: MOBILITY'. About Tahira I. Lodhi MD Tahira I. Lodhi, MD, is an assistant professor at the University of George Washington for Geriatrics and Palliative Care. In 1999, she graduated from medical school and received her Family Medicine training at Virginia Commonwealth University and her Geriatrics Fellowship Training at George Washington University. Dr. Lodhi's expertise is in the training and practice of primary care geriatrics. She's often involved in developing workflows in healthcare systems and aims to support her patients to receive streamlined, patient-centered services. What MOBILITY is All About? When we say MOBILITY, we're talking about the movement of patients in their environment. It is an indicator of how well your patient can live independently in the community and their own homes. Moreover, MOBILITY for older adults is about moving naturally. It's not like training for marathons. But the movement is essential. It has to do with how well they walk and their balance and strength—how well older adults can get around matters. "For every day that an older adult spends in bed, it takes them about three weeks to recover. So daily movement is essential." -Melissa Batchelor, PhD, RN, FNP-BC, FGSA, FAAN. How to Maintain MOBILITY: What To Do and Things To Look Out For Awareness of Your Patient's Life Space Your patient's living space tells you how mobile or interactive they are with their surroundings. Care providers must know whether the patient is traveling in the community, taking public transport, going places, or confined to the home to assisted living or nursing home. That life space concept is essential to determine how functional your patients are. A clear understanding of your patient's life space minimizes the onset of disability in the future and has been associated with a decline in certain medical conditions like COPD (Chronic Obstructive Pulmonary Disease). Looking Out for Elements that may Cause Falls The primary goal of incorporating MOBILITY into older adults' health care plans is for them to be independent and have ease in moving around. As their care providers, make sure the environment they are in is safe enough and there are not, for example, area rugs that could cause potential falls. See to it that your patients have spaces where they can move around in their environment. Likewise, consider your patient's engagement with the broader community, their neighborhood, and also within their own home. These are built environments that need safety assessments. Like how safe are the sidewalks? Do they need adaptive equipment? Encourage Daily Movement Another way to maintain MOBILITY among older adults is by encouraging them to move daily. Any increased activity level from baseline is best, but the goals and targets for older adults are 30 minutes of regular to moderate level physical activity, five days a week. That could be something as simple as walking on a level surface for 30 minutes a day. "What I tell my patients is if they aren't doing that level of activity, they can start with as low as five minutes a day and build it up slowly," says Dr. Tahira I. Lodhi Take Advantage of Technology to Monitor the MOBILITY In helping your patients reach the goal of walking at least 30 minutes continuously, some technologies can help. An Apple Watch, for instance, will tell you when it's time for them to get up and do something. Both the Apple watch and FitBits, when worn on the wrist, monitor the number of steps taken, prompts the user to walk, documents sleep, and in some versions analyzes heart rates. Managing Impairments that Reduces MOBILITY Some medications may have side effects that reduce MOBILITY. This goes true with patients who are on blood pressure medications. It would be best if you check on your patient and ensure they're not getting dizzy when they get up from a seated position. Because of all the risks, secure the lighting for them to see clearly if they're using glasses, and they can walk around easily. Furthermore, teach and educate your patients about mobility devices if they're using one: these devices are their friends. Part Two of 'The 4M's Framework: MOBILITY'. Assessment Care Providers Can Use to Gauge MOBILITY There are several assessments that care providers can use to gauge an older adult's mobility. Three of the commonly used tools are the Timed Get Up and Go, Fall Risk Assessment, and Home Safety Assessment. Timed Get Up and Go The Timed Get Up and Go (TUG) assessment is a practical mobility performance-based test primarily used in older adults to diagnose mobility and balance impediments. The test allows the patient to rise from a chair, move 3 meters to a target set on the floor at a comfortable rate, turn around the 3-meter marker, walk back to the starting position, and return to sitting in the chair. The test score is the duration it takes for the patient to complete the test. Fall Risk Assessment The American Geriatrics Society and British Geriatrics Society issued guidance for clinical practice on fall risk screening, evaluation, and treatment. The guidelines advise that all individuals 65 years of age and older be tested regularly for fall risk(s). This assessment involves asking patients if they have collapsed two or more times over the past year, have pursued medical treatment after a fall; or if they appear unsteady while moving if they have not fallen. There is an elevated likelihood of declines among patients who react positively to these concerns and may undergo more evaluation. People who have fallen previously without damage must have their posture and gait assessed. Also, providers should do a further assessment of those with gait or balance abnormalities. Home Safety Assessment As healthcare providers, your patient's home needs to be safe for them to move around. To do that, it would be best for family members or caregivers to implement the following suggestions: Be sure that hallways, staircases, and ramps are well illuminated. Some rails and banisters can be used when moving up and down the stairs. Never put scattered rugs at the base or top of the stairs. Secure rugs and carpets to the floor such that they do not move as you step on them. Use double-sided tapes to fasten area rugs. Rearrange furniture to make way for unobstructed walking pathways. Make light switches accessible by positioning them not so high. Enhance overall home illumination. Wherever possible, add work lights and night lights. Use levered handles to replace doorknobs or install doorknob grips. In a high-contrast color, label differences in floor area with paint or tapes. Remove any electronic wire and extension cables passing across or around walkways. Place electrical cords behind the furniture, if possible. To enable shifting from sit-to-stand smoother, swap precarious chairs with chairs that have strong sides. "Movement is important; it has something to do with how well you walk and your balance and strength. How well you can get around matters." -Melissa Batchelor, PhD, RN, FNP-BC, FGSA, FAAN Intervene Effectively After completing mobility assessment procedures, follow up with patient-specific interventions to help older adults address modifiable risk factors and stay safe. Here's what you can do to intervene effectively; Refer your Patients to Physical Therapy Physical therapy helps preserve the flexibility of older adults, whether treating long-term conditions or maintaining fitness and mobility. The aim of physical therapy is always to regain and strengthen functionality, minimize discomfort and enhance mobility. Suggests Personal Adaptive Equipment to Promote MOBILITY Assistive devices cover aids like canes and walkers and sophisticated structures like computer applications and motorized wheelchairs. It's beneficial to consider this broad range of assistive technologies and choose what best fits your patient's needs. Mobility devices that assist patients in moving or walking include: canes crutches tricycles walkers walking frames Also, having a medical alert system in operation can ease any burden on caregivers and families. This system immediately alerts family members or caregivers whenever something's wrong with the patient. Most medical alert systems provide functions such as an instant update if a fall is detected. Recommend the HELP (Hospital Older Elder Program) Mobility Change Package and Toolkit The Mobility Change Package and Toolkit was developed in collaboration with The Hospital Elder Life Program(HELP) and Health and Aging Policy Fellowship. It is a structure, blueprint, and step-by-step guide for executing a mobility initiative. The program contains a comprehensive toolkit, including mobility guidelines, instructions for monitoring and documenting mobility results, model patient brochures, target indicators, and accounts from platforms with valuable Mobility Programs. About Melissa Batchelor, PhD, RN, FNP-BC, FGSA, FAAN]: I earned my Bachelor of Science in Nursing ('96) and Master of Science in Nursing ('00) as a Family Nurse Practitioner (FNP) from the University of North Carolina Wilmington (UNCW) School of Nursing (SON). I genuinely enjoy working with the complex medical needs of older adults. I worked full-time for five years as FNP in geriatric primary care across many long-term care settings (skilled nursing homes, assisted living, home, and office visits), then transitioned into academic nursing in 2005, joining the faculty at UNCW SON as a lecturer. I obtained my Ph.D. in Nursing and a post-master's Certificate in Nursing Education from the Medical University of South Carolina College of Nursing ('11). I then joined the faculty at Duke University School of Nursing as an Assistant Professor. My family moved to northern Virginia in 2015 and led to me joining the George Washington University (GW) School of Nursing faculty in 2018 as a (tenured) Associate Professor. I am also the Director of the GW Center for Aging, Health, and Humanities. Please find out more about her work at https://melissabphd.com/.