Sustaining Mobility Through Enhanced Bed Egress

Affiliations:

¹Patient Safety Center of Inquiry, The Villages, FL

²Sport and Exercise Science, University of Central Florida, Orlando, FL

Abstract: Mobility is essential in preventing a deteriorating state of health and retaining a high quality of life and independence for older adults. This article focuses on the physical actions required to rise and get out of bed and discusses how these actions may present a challenge for older adults with reduced physical abilities. Solutions that facilitate the successful performance of the physical actions of bed egress are also discussed. To ensure the quality, function, and safety of long-term care living environments, it is important to consider the ergonomics of bed systems and other key furnishings.

Key words: ergonomics, loss of mobility, bed egress, maintaining mobility, independence.
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The ability to remain mobile is a critical determinant in the preservation of independence as adults age. The loss of mobility not only burdens the individual and those who provide care, but mobility loss can also place substantial financial strain on the healthcare system. Mobility is essential in preventing a deteriorating state of health and retaining a high quality of life for older adults. When mobility becomes impaired, the consequences can be both mentally and physically devastating.¹ The challenge of maintaining mobility can be approached from many angles. Approaches are often classified as intrinsic (eg, physical health) and extrinsic (eg, environmental design) factors and incorporate several measures of mobility, including ambulation and activities of daily living. This article focuses on one essential but often overlooked task for maintaining mobility and independence in older adults: the ability to rise up and get out of bed.

Difficulty in the ability to rise from a bed is a common problem in older adults, affecting at least 63% of adults over age 65 residing in nursing homes.² Difficulty in getting out of bed can further exacerbate declining health status due to the physical deconditioning that occurs with reduced mobility when individuals are confined to bed. Hence, strategies to assist older adults in getting out of bed may facilitate the preservation of mobility and maintained activity-associated health status. Sustained mobility enables greater independence in the aging population and hence reduced burden on the postacute healthcare system. Individuals who may benefit most from assistive strategies for bed egress include those residing in an institutional setting for long-term care who are concerned with maintaining mobility, those in a rehabilitation setting working towards regaining mobility and those residing independently in a home setting trying to retain a level of independence. This article examines the physical actions required to get up and rise out of bed and then discuss how those actions may present a challenge for an older adult with reduced physical abilities. Through analysis of the existing physical challenges to bed egress, solutions are presented that can be integrated into the design of healthcare bed systems. Solutions may facilitate the successful performance of the physical actions of bed egress to enable greater mobility in older adults. The task of bed egress can be broken down into two distinct actions where difficulty may be experienced: supine to sit, and sit to stand. Below, we review both of these actions in detail and describe ways of assisting elderly persons with these actions.

Supine to Sit

The first action of the bed egress task involves the supine to sit and rotate action, as previously described by Alexander and colleagues.² This bodily movement requires trunk flexion and rotation to position the body to assume the subsequent standing posture. Trunk flexion and rotation require adequate strength from several muscle groups. Musculature of the trunk, thoracic and spinal regions are recruited to perform trunk flexion and axial rotation.^4,5 Additionally, hip flexor muscles may assist trunk muscles in performing trunk flexion past 45 degrees.^3,6 In addition to muscle strength, motor coordination and balance are also important to successfully performing the supine-to-sit task.³ Prior analyses of supine-to-sit movement patterns suggest different motor coordination strategies are sometimes used to complete the task. Trunk and limb muscles may or may not move together during the task and usually show left-right alternating limb use throughout the rise. ⁷

With advancing age, trunk strength, coordination, and balance all decline, impairing the ability to perform the supine-to-sit action and altering the movement patterns.⁸ Compared with healthy young adults, older adults are more likely to laterally flex their trunks and use their elbow and hip to achieve a pivot while rising from supine to sitting.⁹ Older adults living in long-term care facilities also report greater difficulty in the leg movements used and in the coordination of trunk and pelvic motions to facilitate the action of rising compared to healthy older adults.^9,10 Thus, age-related muscle weakness and recruitment make the supine-to-sit task a challenge for older adults, particularly those residing in long-term care facilities.

Facilitating Supine-to-Sit Motion

Although improving trunk function through strength training is one strategy for the aging population to facilitate rising from the supine-to-sit position, it can be difficult to implement in frail or bedridden older adults.^11,12 Hence, a viable alternative strategy for facilitating older adult performance on bed mobility tasks, and specifically rising from supine to sitting, needs to look beyond improving trunk function and strength through only therapy.

One potential strategy might incorporate additional musculature to perform the task, such as the upper limbs to assist the weakened trunk muscles in trunk flexion.² The upper limbs can assist in the task of supine to sit through integrating features into bed system which allow for use of the upper limbs to assist in the ability to rise to a sitting position. The strategy of bed alterations that allow the upper limbs to assist in the sitting position enables more older adults to sit up independently as well as enhancing opportunities for therapy.² Further consideration of proper upper limb motion strategies and proper upper limb positioning during the rise, particularly when considering the deficits of the person, may present a realistic and viable solution to mobility enhancement. Currently, bed features such as trapeze systems and standard bed rails exist for this purpose. However, additional enhancements might go beyond the more common equipment, to include areas of stiffened mattress support and additional handholds that would optimize upper limb involvement for trunk flexion. Facilitation by the upper limbs might also differ depending upon different phases of the rise cycle, so that initial trunk elevation might require a different support system and rise strategy than that required to pivot and turn to a seated position at the edge of the bed.²

Figure 1 illustrates an assistive device providing a handhold, which can help with the turn and pivot movement from a flat surface. Assistance with the first phase of the rise can be achieved with an adjustable bed frame where the head of the bed can be elevated. This mechanism provides an assistive mechanism for those individuals who might have difficulty elevating their trunk in the supine to sit motion. Amount of assistance provided by the head of bed elevation can vary depending on the persons physical abilities allowing musculoskeletal conditioning to continue to maintain functional abilities.

Figure 1. Assistive device to rise supine to sit and pivot.

However, a bed design that allows about 65 degrees of bed elevation is recommended. Once the trunk of the body is elevated from a supine position, the person in bed should have easily accessible handholds, as shown in Figure 2, which will allow an easy turning motion for completion of the rise to a sitting position and for pivoting the legs over the edge of the bed and onto the floor. Handholds should consider ergonomics for optimum arm positioning and provide for easy grasping, which can allow the individual to involve the upper limbs to provide assistance as needed to complete the supine to sit action and pivot legs over the edge of the bed. The process of grasping and using handholds in addition to providing assistance, serve as a way for the individual to maintain function by continuing to use their own ability as much as possible in completing the supine to sit motion.

Figure 2. Head of bed elevation with two assistive devices to rise from supine to sit and then pivot.

Sit to Stand

The second action of bed egress requires standing from a seated position on the bed. The sit to stand movement is a complex task characterized by moving the body’s center of mass upward from a sitting position to a standing position without losing balance.¹³ The movement to the upright posture requires movement of the center of mass from a somewhat stable position while seated to a less stable position over extended lower extremities while standing.¹⁴ The sit-to-stand motion has been broken down into various phases to describe the required movements.^15,16,17 Generally the phases involve weight shifting, extension or lift, and stabilization.^16,18 Initially during the movement, momentum is generated by the upper body to perform the rise which is transferred to forward and upward momentum to enable extension. During extension, the body rises to its full upright position and then regains balance in the standing position.¹⁶ During the rise, the erector spinae, rectus femoris, and vastus medialis are sequentially recruited, followed by the biceps femoris, gluteus maximus, and rectus abdominis to complete the extension.¹⁸ Muscle weakness, especially of the leg extensor muscles, makes the sit-to-stand action a challenge for older adults.¹⁹ The challenge of the task results in functionally impaired older adults trying to implement a different strategy than young when attempting to rise from a seated position.²⁰ During the rise, functionally impaired older adults attempt to increase their momentum by increasing hip flexion velocity while also increasing their stability by taking more time to rise and shortening the distance between their center of mass/base of support at lift-off.²⁰

Facilitating Sit-to-Stand Motion

The biomechanics of the sit-to-stand task and the modified strategies attempted by older adults to complete the task should be considered in the design of furnishings for our healthcare facilities to enable bed egress.²¹ One important consideration is the height of the bed surface. When an older adult is attempting to stand from a seated position and rise from the bed surface, there is an optimum starting height, which facilitates the start of the sit to stand movement. The optimal height is equal to slightly more than the knee height of an individual. If a person is seated on a surface equal to a little more than knee height when attempting to stand the feet will be placed firmly on the floor and the knee angle will be at a little more than 90 degrees. A knee angle slightly above 90 degrees is most desirable if feet are able to comfortably and securely contact the floor surface since this joint angle provides a good positioning for effective muscle use.^20,22 With the bed surface at this optimum starting height an older adult can firmly and securely place their feet on the floor and rise from the bed surface making the best use of their own available capabilities. Additionally, knees should be positioned directly above the feet to optimize biomechanics during the motion. Achieving the optimal seat height can reduce the work required by the knee and hip joints by as much as 60%.²¹ When selecting an optimum bed surface height to enhance bed egress, the average knee height of the general population is an important consideration.

Adjustable height beds can allow optimal seat height to be achieved during bed egress to enable further independence and mobility and to allow for the caregiver to provide the proper level of assistance when needed. To provide additional assistance as required, for an independent or dependent person, using the bed surface height adjustment capabilities of the bed, and raising the bed surface level during the standing process can provide a powered standing aid. Having a means to easily achieve this optimum starting egress height is highly desirable on the bed frame. A simple and desirable bed system feature to consider would be to provide a one touch function on the bed control which would automatically position the bed at the optimum egress height for the general population. When required, minor bed surface height adjustments could be easily made as needed to accommodate smaller and larger individuals in the elderly population to customize optimum bed egress height.

Hand hold devices may provide additional solutions to facilitate the sit-to-stand action. Studies have demonstrated that when an older adult is able to use hands and arms in the process of standing the ease and ability to stand is greatly improved.^2,23 Using the upper body can reduce the work required by the hip joint by as much as 50%.²¹ A well designed and well placed handhold device as shown in Figure 3 allows easy grasp for residents providing for use of hands and arms in the process of standing. This device may further facilitate the standing task contributing to maintaining independence and improving safety by reducing fall risks during the bed egress process. Additionally, mattress surface material may provide some additional assistance in the sit to stand task. Mattress surfaces should be constructed to have a firmer perimeter to facilitate the process of standing. Mattresses that lack perimeter firmness may make the sit to stand task more difficult by reducing knee angle and absorbing some of the momentum generated to perform the task.^11,24,25,26

Figure 3. Assistive devices with proper bed height for sit to stand. Bed surface elevation can be used for further assistance.

Conclusion

Solutions to sustain mobility in older adults are essential to maintaining independence, physical and psychological health and well-being. Moreover, independence is an important contributor to a person’s dignity. As we design environments for our aging population we must consider the key furnishings and how these furnishing contribute to the quality, function, and safety of the environment. Bed systems are the essential and primary furnishing in the environment of care in today’s healthcare environment and will become more important as our aging population grows. Providing the best possible bed system should be a major objective for all healthcare providers and there is evidence available to guide and support necessary considerations when choosing bed systems. Providers should make an effort to stay educated and seek out knowledge which will allow them to make the best choices when selecting bed systems. It is our hope and intention to advise providers on some of the important considerations required for selecting bed systems. Armed with this knowledge and the mission of providing high quality care, providers can effectively help our aging population maintain their dignity, independence, and mobility.

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Disclosures: The authors report no relevant financial relationships.

Address correspondence to: Guy Fragala, PhD, Senior Advisor for Ergonomics, Patient Safety Center of Inquiry, 1475 Salley Avenue, The Villages, FL, 32162; guyfragala@comcast.net