Reduced mobility

Reduced mobility is a decline in the ability to move between positions and places, from slower walking to being bedbound. In older adults it is rarely a single disease. It is usually the final result of weakness, pain, sensory loss, breathlessness, cognitive impairment, low mood, medicines and environmental barriers, and each of these is partly treatable.

Clinical relevance. Loss of mobility predicts falls, hospital admission, institutional care and death. Immobility itself causes harm within days: deconditioning, pressure injury, venous thromboembolism, pneumonia, constipation, urinary retention, contractures, delirium and bone loss.

Measures.

• Gait speed over 4 metres (under 0.8 m/s abnormal, under 0.6 m/s high risk).
• Short Physical Performance Battery 0 to 12 (9 or less indicates limitation, and 6 or less marked limitation).
• Timed Up and Go (12 seconds or more indicates risk), and five chair stands (over 15 seconds abnormal).
• Barthel Index 0 to 100 (60 or less indicates dependence).

Classification by tempo.

• Acute (hours to days): stroke, fracture, spinal cord compression, infection, myocardial infarction, delirium, drug effect.
• Subacute (weeks): myopathy, polymyalgia rheumatica, heart failure, malignancy, deconditioning after illness, Guillain-Barre syndrome, depression.
• Chronic (months to years): osteoarthritis, parkinsonism, dementia, neuropathy, peripheral vascular disease, sarcopenia, frailty.

Classification by mechanism. Neurological, musculoskeletal, cardiorespiratory, metabolic and endocrine, cognitive and psychological, sensory, medicine related, and environmental or social.

Key distinctions. Separate weakness from pain, from fear, and from lack of effort or opportunity. A rapid decline over days needs an acute cause and urgent assessment.

History.

• Onset and trajectory, previous mobility, walking distance, aids used, stairs, transfers, and falls.
• Reason for limitation: pain, weakness, breathlessness, chest pain, claudication, dizziness, stiffness, fatigue, fear.
• Daily activities (Katz or Barthel items) and instrumental activities, continence, and the home layout.
• Medical history: stroke, Parkinson disease, arthritis, heart or lung disease, diabetes, cancer, osteoporosis, previous fractures.
• Drugs: sedatives, antipsychotics, antihypertensives, diuretics, statins, corticosteroids, anticholinergics, opioids.
• Mood, cognition, alcohol, nutrition, vision and hearing, social support and the person's own goals.

Examination.

• Vital signs, orthostatic blood pressure, hydration, weight and nutrition, anaemia, thyroid.
• Cardiorespiratory: heart failure, murmurs, chest signs, peripheral pulses and oedema.
• Musculoskeletal: joints (hips, knees, ankles), spine, shoulders, feet (deformity, ulcers, nails, footwear), muscle bulk, proximal strength by rising from a chair.
• Neurological: tone, power (MRC grade), reflexes, sensation, proprioception, cerebellar signs, parkinsonism, gait and posture.
• Skin and pressure areas, bladder and bowel (bladder scan, rectal examination), mental state, cognition.

Red flags.

• Sudden weakness, speech or facial change (stroke).
• Back pain with leg weakness, sensory level, saddle anaesthesia or sphincter change (cord or cauda equina compression).
• Ascending weakness with areflexia (Guillain-Barre syndrome) or fatigable weakness with bulbar symptoms (myasthenia gravis).
• Shortened externally rotated leg, or inability to bear weight after a fall (hip fracture).
• Unilateral leg swelling or sudden breathlessness (deep vein thrombosis, pulmonary embolism).
• Hot swollen joint, fever, or spinal tenderness.
• Muscle pain with dark urine (rhabdomyolysis).
• Weight loss, night pain or bone pain (malignancy, myeloma).
• Jaw claudication, scalp tenderness or visual symptoms (giant cell arteritis).

Special groups. Care home residents: ask about staffing, hoists and activity programmes. Patients in hospital: measure mobility on admission and daily, since a few days of bed rest can produce lasting loss.

Neurological.

• Stroke, subdural haematoma, normal pressure hydrocephalus.
• Parkinson disease, progressive supranuclear palsy, multiple system atrophy, vascular parkinsonism.
• Cervical spondylotic myelopathy, lumbar spinal stenosis, spinal cord compression, cauda equina syndrome.
• Peripheral neuropathy, Guillain-Barre syndrome, chronic inflammatory demyelinating polyneuropathy.
• Myasthenia gravis, motor neurone disease, cerebellar degeneration.
• Dementia.

Musculoskeletal.

• Osteoarthritis of hip and knee, hip fracture, vertebral and pelvic fracture, rheumatoid arthritis, gout, calcium pyrophosphate deposition disease.
• Polymyalgia rheumatica, inflammatory myositis, statin and steroid myopathy, osteomalacia, Paget disease, bone metastases, multiple myeloma.
• Foot disorders (bunion, ulcer, onychomycosis, deformity).
• Sarcopenia and frailty.

Cardiorespiratory and vascular. Heart failure, chronic obstructive pulmonary disease, interstitial lung disease, anaemia, atrial fibrillation, aortic stenosis, peripheral arterial disease, chronic venous insufficiency, lymphoedema, deep vein thrombosis, pulmonary embolism.

Endocrine and metabolic. Hypothyroidism, hyperthyroidism, hypercalcaemia, hypokalaemia, hyponatraemia, adrenal insufficiency, Cushing syndrome, diabetes with neuropathy or amyotrophy, vitamin D deficiency, B12 deficiency.

Infection and malignancy. Sepsis, pneumonia, urinary tract infection, osteomyelitis, discitis, tuberculosis, cancer cachexia.

Psychological. Depression, fear of falling, apathy, delirium.

Drug effects and deconditioning. Sedatives, antipsychotics, antihypertensives causing orthostatic hypotension, post-acute illness deconditioning, prolonged bed rest, and inadequate rehabilitation.

Environmental and social. Poor footwear, lack of aids, stairs, absent carers, pain from inadequate analgesia, and neglect.

Step 1. Establish tempo and exclude emergencies. Acute loss of mobility needs same day assessment for stroke, cord compression, fracture, infection and delirium.

Step 2. Quantify mobility with gait speed, Short Physical Performance Battery or Timed Up and Go, and record the function that matters to the patient.

Step 3. First line tests: full blood count, urea, creatinine, electrolytes, corrected calcium, phosphate, magnesium, alkaline phosphatase, albumin, glucose and HbA1c, TSH, B12, folate, ferritin, 25 hydroxyvitamin D, CRP and ESR, creatine kinase, urinalysis and ECG. Oxygen saturation and chest radiograph if cardiorespiratory symptoms are present.

Step 4. Targeted tests directed by the findings.

• Radiographs of the hip, pelvis, knee, spine or foot. MRI for occult hip fracture, cord compression, spinal stenosis or discitis. If a hip radiograph is normal but weight bearing is impossible, proceed to MRI or CT.
• Echocardiography and natriuretic peptide for heart failure. Spirometry for obstructive and restrictive disease.
• Serum protein electrophoresis and free light chains for unexplained anaemia, raised ESR, renal impairment, hypercalcaemia or bone pain.
• Nerve conduction studies and electromyography for neuropathy, myopathy or neuromuscular junction disease. Acetylcholine receptor antibodies for suspected myasthenia gravis.
• Doppler ultrasound for suspected deep vein thrombosis. Ankle brachial index for claudication or ulceration.
• DXA for bone mineral density and lean mass where sarcopenia or fracture risk matters. Temporal artery ultrasound or biopsy for giant cell arteritis.

Limitations. Radiographic osteoarthritis is poorly related to symptoms. Normal blood tests do not exclude deconditioning, which is a clinical diagnosis after exclusion of other causes. Gait speed is influenced by effort, pain and cognition.

Treat the cause. Reverse treatable causes: infection, anaemia, thyroid disease, hypercalcaemia, electrolyte disorders, heart failure, pain, depression and drug effects. Stop or reduce sedatives, anticholinergics and drugs causing orthostatic hypotension. Hip fracture surgery should take place within 36 hours of admission.

Mobilise early.

• Get the patient out of bed within 24 hours of admission when clinically stable, dressed in day clothes, and walking at least twice daily with assistance. Avoid bedrest orders.
• Progressive resistance and balance exercise two to three times weekly, supervised initially, and aimed at the patient's own goals.
• Physiotherapy for gait and strength, occupational therapy for transfers, home assessment and equipment, podiatry for foot problems, and appropriate walking aids and footwear.
• Treat fear of falling with graded exposure and confidence building.

Pain control. Paracetamol 1 g orally 30 to 60 minutes before mobilisation and every 6 hours as needed; maximum 4 g daily (3 g daily if weight under 50 kg, malnutrition, alcohol excess or liver disease); monitor liver tests with prolonged use. Avoid NSAIDs in older adults with kidney disease, heart failure or anticoagulant use.

Complications of immobility.

• Venous thromboembolism: enoxaparin 40 mg subcutaneously once daily until the patient is mobile or for 7 to 14 days if risk persists; maximum 40 mg daily for prophylaxis; monitor platelets at baseline and every 2 to 4 days from day 4 to day 14 (heparin induced thrombocytopenia), plus creatinine and haemoglobin; for CrCl 15 to 30 mL/min give 20 mg once daily, and for CrCl under 15 mL/min use unfractionated heparin 5000 units subcutaneously every 8 to 12 hours; avoid in active bleeding, platelets under 50 x 10^9/L, or recent neurosurgery, and add graduated compression only when pharmacological prophylaxis is contraindicated and there is no peripheral arterial disease.
• Pressure injury: reposition every 2 to 4 hours, float the heels, use a pressure redistributing mattress, keep skin clean and dry.
• Contracture and stiffness: daily passive and active range of motion and positioning.
• Constipation: macrogol 1 sachet daily or senna 7.5 to 15 mg orally at night, adjusted to bowel habit.
• Pneumonia and aspiration: sit upright for meals and for 30 minutes after, oral hygiene and chest physiotherapy.
• Orthostatic intolerance: gradual verticalisation using tilting, fluids and compression stockings.
• Bone loss: colecalciferol 800 to 1000 IU orally once daily, long term, for housebound or deficient patients; maximum maintenance 4000 IU daily; monitor calcium if risk of hypercalcaemia; caution in sarcoidosis, hypercalcaemia and renal stones.

Nutrition. Energy about 25 to 30 kcal/kg daily and protein 1.0 to 1.2 g/kg daily in well patients, rising to 1.2 to 1.5 g/kg daily in acute or chronic illness (reduce in advanced kidney disease), with dietitian input and oral nutritional supplements when intake is inadequate.

Monitoring. Record gait speed or Short Physical Performance Battery at baseline and every 4 to 6 weeks. Track weight, pressure areas, bowels, mood and falls. Review medicines at every contact.

Referral and escalation. Geriatrician for undiagnosed or multifactorial loss of mobility. Neurology for parkinsonism, myelopathy or neuromuscular disease. Rheumatology for inflammatory disease. Orthopaedics for fracture and joint replacement. Vascular surgery for ischaemia. Spinal surgery for cord compression, which is an emergency. Rehabilitation or intermediate care teams for recovery after acute illness. Palliative care for progressive disease.

Admission criteria. Acute neurological deficit, fracture, cord compression, sepsis, suspected venous thromboembolism, rhabdomyolysis, unsafe discharge, inability to transfer with available help, or carer breakdown.

Discharge and safety netting. Discharge with the right equipment, a written exercise plan, a home care package and review at 2 to 6 weeks. Patients and carers are told to return for sudden weakness, new numbness, loss of bladder or bowel control, a fall with injury, calf swelling, chest pain or breathlessness, fever, or inability to get out of bed or chair.