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Insight Into the Movement Behaviors of Nursing Home Residents Living With Obesity: A Report of Two Cases

Case Report

Insight Into the Movement Behaviors of Nursing Home Residents Living With Obesity: A Report of Two Cases

Index: Wound Management & Prevention 2020;66(5):18–29

Abstract

Obesity (body mass index [BMI] ≥30 kg/m2) can have a profound influence on the likelihood of developing a pressure injury (PrI); little is known about the movement behaviors (movement frequency, body position frequency, and position duration) of obese individuals. PURPOSE: This report examines 2 cases of obese nursing home residents and their movement behaviors in relation to their potential influence on overall PrI risk. METHODS: Resident movements were monitored 24 hours/day using a wearable sensor, and repositioning events were observed as part of a larger study examining repositioning intervals. Braden Pressure Ulcer Risk Assessment was conducted weekly. RESULTS: Both residents (BMI 39 kg/m2 and 50 kg/m2) had limitations in movement with prolonged periods spent in a single body position. Each resident addressed movement challenges unique to their desire to remain mobile and level of dependency on nursing staff. CONCLUSION: Presence of obesity is a factor affecting resident movement and creates environmental and psychosocial barriers to health. Nurses can play a key role in PrI prevention by addressing these barriers and encouraging positive, long-term behavior changes that mitigate risk. Future research should guide tailored PrI prevention protocols and national/ international guidelines for obese residents.

Introduction

Obesity challenges an individual’s ability to remain mobile and can lead to difficulty participating in common activities of daily living (ADL) that require movement,1-5 predisposing individuals living with obesity (LWO) to remain more sedentary for extended periods1,2 and increasingly reliant on caregiver assistance.2-4 The increased size and weight from excess adipose tissue can structurally and functionally limit physical movement,5,6 cause pain in the weight-bearing joints and back,7-10 and can alter the center of gravity (or balance),11,12 increasing fall risk and fear of falling.11 Obesity not only increases the likelihood of nursing home (NH) admission, but it also markedly compounds the demands of nursing care.2,4,13 Cai et al14 evaluated the growing obesity epidemic in NHs from the Minimum Data Set (1999–2009) and found that obesity-related limitations in mobility was considered a risk factor for pressure injury (PrI) development.14  PrI occurs when skin tissue is exposed to unrelieved high levels of constant pressure that reduces blood flow, which prevents tissue reperfusion, and thus increases the risk of tissue necrosis.15-19 Kraemer-Aguiar et al20 studied skin microcirculatory dysfunction in individuals with metabolic syndrome. They found that tissue reperfusion took longer to achieve in obese participants (due to smaller capillary diameters, lower functional capillary density, fewer capillaries per square millimeter, and less red blood cell velocity) compared to lean and overweight controls without metabolic syndrome. They concluded that, despite a normoglycemic environment, obese individuals may be more susceptible to weight-based PrI.20 

Whether independent or assisted, movement is the cornerstone for PrI prevention.15 The effects of obesity on movement behaviors (ie, movement frequency, body position frequency, position duration) among NH residents is unknown.

Obesity as a PrI risk factor. Obesity (body mass index [BMI] ≥30 kg/m2), now considered a disease,21 exacerbates age-related decline in physical function, impairs quality of life, and requires the delivery of complex care.22-27 Obesity is differentiated by subcategories28: Class 1 includes persons with a BMI 30 to <35 kg/m2, Class 2 includes persons with a BMI 35 to <40 kg/m2, and Class 3 includes persons with a BMI 40+ kg/m2. The prevalence of obesity among individuals >60 years of age in the United States in 2014 was 35.4% (range 31.3% –39.6%)29; among these individuals, 14.0% (range 11.1–17.6) had a BMI ≥35 (Classes 2 and 3).17 Obesity impacts care across clinical settings and has been shown to increase the risk of NH admission.2,3,30,31 

Being overweight,15 like being underweight (BMI ≤18.5 kg/m2),15,32,33 contributes to PrI development. Obesity is a relatively new phenomenon among older NH residents, increasing from 16.9% of residents in 2000 to 30.7% in 2013, with the odds of developing a PrI higher among individuals LWO.14 The etiology of PrI (ie, localized damage to skin and underlying soft tissue, usually over a bony prominence), depends on the intensity and duration of pressure on the tissues and is associated with an increased risk of medical complications, infections, length of stay, and health care costs.15 The increase in pressure from weighted adipose tissue (ie, pendulous breasts, abdominal pannus),15,17,34-38 coupled with lack of movement, impedes adequate tissue reperfusion and increases the risk for PrI development.2,15,17 

The underlying pathophysiologic processes of obesity include a progressive adipocyte hypertrophy that can alter blood supply, lead to tissue hypoxia, and, if unresolved, stimulate a cascade of inflammatory responses including macrophage infiltration into adipose tissue and an ongoing release of pro-inflammatory mediators, such as tumor necrosis factor-alpha and  interleukin-6.39-42 This chronic inflammation and oxidative stress negatively affect the microenvironment, capillary density, and blood flow to the tissues of the skin,43 ultimately placing individuals LWO at increased risk for PrI development.

Prevention of PrI includes the targeted repositioning of an individual at regular intervals—typically every 2 hours — which is thought to reduce the intensity and duration of pressure on tissues. However, because the actual movement of NH residents LWO is undercharacterized, this current one-size-fits-all, every-2-hours approach to repositioning may need to be tailored to the needs and movement behaviors of the obese resident. 

Movement challenges of residents LWO. Movement—that is, the active or passive change in physical location or position of the body or body part—minimizes the duration of pressure exposure that is essential to effective PrI prevention among vulnerable populations.15 Increased body weight and physical size can complicate even the simplest ADL. Unlike acute care settings,44,45 NHs do not have federal regulations requiring them to accommodate the special care needs of obese persons. Thus, NHs tend not to be as well-prepared to handle assistance with ADLs among residents LWO.

Equipment and staffing needs are more specialized and intensive for residents LWO. Movements often require both bariatric-proportioned beds and chairs and special bariatric lift devices that can accommodate the residents’ increased size and weight. Equipment typically in use in NHs includes standard-sized beds, wheelchairs, and recliners, any of which can restrict a resident’s movement and inhibit successful turning in bed or shifting weight in a chair. Also, the care burden for residents LWO is greater compared to those who are not, and there is an increased need for repositioning assistance from caregivers trained to operate specialized, heavy-duty lift equipment devices; these and other care and mobility-related tasks require additional time.2,3,14 Repositioning events can trigger fear and pain and potentially compromise the safety of both the resident and nurse/caregiver,7-9,26,46,47 outcomes that are accentuated for residents in Class 2 and 3 subcategories of obesity.17,34 

Movement among obese individuals is thought to be highly variable, but little is known about the actual movement behaviors of obese older adults who reside in NHs. To date, risk assessment for all NH residents is based on checklists, such as the Braden Scale for Predicting Pressure Sore Risk (hereafter “Braden”),48 and observation by staff. This case study contributed a digital record in real time on the movement behaviors of 2 NH residents with higher levels of obesity over 10 days. Gaining better insight and understanding of obese resident movement behaviors is foundational to tailoring PrI prevention clinical practice guidelines for an increasingly heavy, often caregiver-
dependent, population. 

Methods

Design and sample. This case study used a prospective, observational design study (R01NR016001; ClinicalTrials.gov: NCT02996331) that determined differences in the incidence of new PrIs in NH residents at low, moderate, and high risk, repositioned at 2-, 3-, or 4-hour frequencies, in 9 randomly assigned NHs. NH residents eligible for the clinical trial used viscoelastic, high-density foam support surfaces; had a Braden score ≥10; were free from adhesive allergy and existing PrI; and were fitted with a triaxial accelerometer sensor worn on the chest to monitor movement 24 hours a day throughout a 4-week monitoring period. Wireless antennas placed throughout the NH permitted monitoring in all resident areas. Sensor data provided real-time movement trends; visual notification cues for resident repositioning needs were provided at the point-of-care (ie, the affixed sensor flashed red, yellow, or green when lightly tapped) and remotely on computer monitors at the nurses’ station and hallways. All NHs provided ample linens and a lift device in each clinical unit and 5 pillows per participating resident. Two (2) residents LWO were selected purposively from a single NH where the standard of care was every 2-hour repositioning. Residents with a BMI ≥30 were identified from electronic medical record data, and 1 resident member was selected from Class 2 and 1 from Class 3. Repositioning events were observed by the first and third author during standard repositioning events 4 times within a 48-hour period. The parent study was approved by the Duke University Institutional Review Board as meeting ethics requirements for human subject research.

Measures. Movement and position were assessed using the Leaf Patient Monitoring System (Leaf Healthcare),49 a  wearable triaxial accelerometer sensor technology and accompanying software that reliably measures and combines movement data on turn frequency, turn angle, and position frequency and duration into an integrated position index. Based on a preset threshold, changes in position were recorded in real time. When residents were recumbent, the lateral roll angle threshold was set at ±20˚ to detect either a left or right position change. For seated positions, the tilt angle threshold was set at ±10˚ to detect leaning to the left or right, and a head elevation ±30˚ was set for an upright position in bed or chair. Roll/tilt angles may range from -100˚ to +100˚: positive degrees (0˚ to 100+˚) are on the left side; negative degrees (-100˚ to 0˚) are on the right side. Role/Tilt movement is operationalized as the total time spent in 6 positions: left, left-upright, back, back-upright, right, right-upright. 

Turn protocol compliance was calculated as the total time a resident was in compliance with the every-2-hour turn protocol divided by the total time monitored. Once the minimum turn angle is achieved and sustained, the monitoring system resets the time clock and gives another 2-hour interval before repositioning is due again. The period of time the resident remained in the same position past the scheduled repositioning due time was overdue time. Nursing staff recorded the rationale for each episode of overdue time. 

Self- and nurse-assisted repositioning events for each resident were observed 1) for the ability to move around in and out of bed (or chair), including mealtimes and toileting; 2) during physical therapy; and 3) for fear of falling. An investigator-developed observation checklist was completed during 2 separate staff-assisted repositioning events to record the resident’s and nurse(s)’ physical and verbal behaviors during repositioning. The observation checklist was developed based on an extensive literature review of the evidence to include a comprehensive inventory of possible resident and nursing behaviors encountered before, during, and after repositioning events; the checklist included NH resident body position before, during, and after repositioning events. 

Demographic and clinical variables for each resident were extracted from electronic medical records and included baseline age, gender, race, ethnicity, height and weight, medical diagnoses, Braden score, and incidence of PrI over the 4-week period. BMI was calculated before case selection. 

Analyses. Roll/tilt angles (left to right) and movement (position and duration) were plotted by graph for each resident over 10 days. Turn protocol compliance percentages were calculated based on the overdue time and total monitored time for each resident, and frequency measures for each rationale for nonadherence were compiled. The 10-day average time in each of 6 positions was calculated for each resident. 

Results

Case 1. Resident A was a 71-year old African American woman with a calculated BMI of 39 (Class 2). She was bedbound, and her medical history was significant for fatigue, type 2 diabetes mellitus, dysphagia, moderate protein-calorie malnutrition, generalized muscle weakness, difficulty walking, and frequent urinary tract infections. Before her NH admission, Resident A had been hospitalized for an acute pulmonary embolism, respiratory failure, and a deep vein thrombosis of her lower extremity that required long-term use of anticoagulants. There was no documented history of dementia, depression, or anxiety. Her baseline Braden score was 16 (mild risk); subscale scores were 4 (sensory), 2 (moisture), 2 (activity), 3 (mobility), 3 (nutrition), and 2 (friction-shear).

Resident A required minimal to moderate assistance to turn on her side while in bed and was not observed out of bed during this study. Before and after repositioning events, she rested quietly in her bed with her eyes closed; although she appeared to be sleeping, her feet were purposefully moving, with rhythmic dorsiflexion and plantar-flexion movements that allowed her heels and lateral/medial surfaces of her feet to rub gently against the mattress linens. During repositioning events, she opened her eyes, engaged in conversation, and was cooperative with the nursing staff. She was generally agreeable to movement requests and participated by reaching for the opposite bed rail and helping hold herself on her side while the nurse folded and placed pillows to support a new pressure-relieving position. She reported still feeling uncomfortable post-positioning. Nursing staff reported that Resident A rarely watched television or left her room, and she ate all of her meals and performed all of her ADLs with assistance while in bed. Toileting was managed by a diaper and occasionally a bedpan. 

During a conversation, Resident A reported no ambulation since the fall that precipitated the NH admission. Having lost weight since the fall, she commented that it was “a lot easier for me to move around in bed. I don’t mind it. I like being in my room and my bed.” She refused physical therapy (PT) and reported, “I could walk again if I wanted to, just not today…. I’m just scared I will fall and hurt myself, [and] I don’t want to go to the hospital again.” She liked being in her room for meals and didn’t mind using the bedpan. 

Resident A had 675 hours of total monitored time, with a 46% turn-protocol compliance rate. She was not repositioned on time 82% of the time. A total of 114 nursing staff documentations occurred with their rationale for why a repositioning event did not occur on time during the study: resident refusal (35 occasions, 31%), inability to reach an adequate turn angle (26 occasions, 23%), implementation of delirium/sleep protocol (16 occasions, 14%), priority given to a procedure (16 occasions, 14%) such as exam or imaging, and “other reason” or preference for another activity (19 occasions, 17%). Repositioning did not occur 2 times (1%) as indicated because “additional assistance was needed.”

Figure 1 and Figure 2 provide movement data for Resident A from an exemplar week of the intervention period. Figure 1 demonstrates her roll/tilt angles; she did not have a notable side preference. The period of time she remained in the same position past the scheduled repositioning due time ranged from 1.0 hour to 5.3 hours, with the longest overdue time occurring once during the evening (8:30 pm). Figure 2 demonstrates time on a side, with a range of 3 to 14 hours when repositioning went beyond protocol recommendations. Resident A spent 86.8% of her day lying flat on her back and less than 2% of her day in an upright (or sitting) position. She did not develop a PrI during the 4-week clinical trial. 

Case 2. Resident B was a 76-year old white woman with a calculated BMI of 51 (Class 3). Her admission to the NH was initiated after a series of falls at home resulted in frequent emergency department visits. Past medical history was significant for fatigue, major depressive disorder, anxiety, frequent falls (vertebrobasilar artery syndrome), essential hypertension, atherosclerotic heart disease (without angina pectoris), heart failure, type 2 diabetes mellitus, hyperlipidemia, polyneuropathy, osteoarthritis of the knees, spinal stenosis, generalized muscle weakness, difficulty walking (abnormalities of gait/mobility), chronic kidney disease (Stage 2, mild), cystitis, and frequent urinary tract infections. Although Resident B preferred to eat her meals in her room, she was otherwise observed to be very social with both the nursing staff and other NH residents. Her baseline Braden score was 19 (no risk); subscale scores were 4 (sensory), 4 (moisture), 2 (activity), 4 (mobility), 3 (nutrition), and 2 (friction-shear). 

Resident B was independently mobile in a bariatric-sized wheelchair, with sufficient strength and mobility to propel herself throughout the facility without assistance. With minimal cueing needed by the nursing staff, she self-initiated and independently repositioned herself in either a seated or lying position. Her independence with ADLs was limited by the width of the bariatric wheelchair, which presented challenges in her semi-private room and shared bathroom, all with standard door frames. The wheelchair had a (nonstandard) seat pillow and a slack back support, which allowed her to fit within the frame of the chair. Although Resident B was able to lock her wheelchair, stand, and walk short distances, she preferred the safety of her wheelchair for mobility due to her history of frequent falls. Accordingly, she was observed to spend a substantial amount of time in a seated position during the day. She was observed in bed only once in the late afternoon to take a nap, where she had independently repositioned herself.

During a conversation, Resident B reported, “[using] the wheelchair to get around the building because I fall so much. I can walk around, but my blood pressure drops, so it’s safer for me to use my wheelchair.” She complained that the back of the wheelchair was “slack and uncomfortable” and made her back ache, and 2 recent falls resulted in uncomfortable bruising along her shoulder, arm, hip, and leg. “[My wheelchair is] so wide I cannot get through the door frame of my bathroom! I have to either stand and walk or have one of the nurses help me get to the sink or toilet. There are lot of places in this building that my wheelchair doesn’t fit through. I either don’t go there, or I try and walk.” Her bed is “so wide that I have to stick to one side because, if I were to lie in the middle, I wouldn’t be able to reach either bedrail! Fortunately, I am not as heavy as I used to be, and I can move around pretty good.” She refused PT because the exercises “didn’t work for me—I keep falling! So why do them?” She feared both falling and getting a “bed sore [from not moving] every few hours” and made herself turn in bed even though it hurt. She preferred to eat alone in her room and complained repeatedly of safety-related restrictions on her cooking or baking for herself. 

Resident B had 675 hours of monitored time, but with a 95% turn protocol compliance rate. Nursing staff documented the rationale for 4.7 hours of noncompliant time; 59% was attributed to Resident B’s refusal to reposition. Figure 3 and Figure 4 provide movement data for Resident B from an exemplar week of the intervention period. Figure 3 demonstrates no notable side preference to either left or right side. Nine (9) overdue sensor cues were captured, ranging from 1.0 to 4.2 hours, with the longest overdue time occurring once during the afternoon (3:10 pm). Figure 4 demonstrates time on 1 side; time over the 2-hour mark in the same position beyond protocol recommendations ranged from 3 to 4 hours, with a one-time event at 6 hours overdue for repositioning. Resident B spent 55.8% of her day lying flat on her back and 30.2% upright (sitting). She did not develop a PrI during the 4-week clinical trial. 

Discussion

Obesity and PrIs are significant concerns in aging populations, but older persons LWO in nursing homes are an undercharacterized group with respect to the antecedent risk factors for PrIs. To the best of the authors’ knowledge, this case study was the first to use real-time data to describe everyday positions for NH residents LWO, enabling researchers to measure the durations of time spent in the upright versus recumbent position and the right, left, and back positions. Because the incidence of PrIs is up to 18% higher in obese than nonobese NH residents,50 objectively measuring time spent in recumbent positions is particularly important among this vulnerable, growing segment of the NH population because physical activity is associated with progressive functional decline and directly influences risk for PrI.14                                                                       

The 2 residents studied differed by obesity class, Braden score, functional ability, and some psychosocial behaviors, but wearable sensor data suggested that the they shared behaviors of lying flat in bed for long periods, avoiding communal meals, and reasons for nonadherence with repositioning protocols. These differences and similarities suggest both are avenues for further investigation regarding barriers to movement compliance and also are key elements of the nursing role in support of care of older persons LWO. 

Environmental and clinical barriers to movement compliance. While the digital data for these 2 residents with obesity suggested that both were sometimes able to achieve basic roll/tilt angle and movement, the multiple pauses in the repositioning schedule suggested that obesity may be exacerbated by both environmental and clinical-related barriers to care. Environmental barriers included the inconsistent availability of staff, linens, pillows, wedges, and heavy-duty lift equipment. Inconsistency of resources not only delays timely opportunities for movement and increases PrI risk, but it also creates work-related dissatisfaction and weight-bias towards individuals LWO.51,52 NH staffing levels and environments of care are often ill-equipped for the size and weight of heavier residents, and insurers may not reimburse for specialized bariatric equipment (eg, beds, wheelchairs, commodes, lifts) needed by nursing staff to do their job.2 Although supply/demand issues could be unique to this NH facility, it is important to stress the universal importance of environmental factors in PrI prevention. Nursing staff must advocate for residents by communicating care-related resource needs; in turn, nursing administration must be responsive in supporting environments of care necessary for PrI prevention. 

A bariatric-sized wheelchair helped facilitate movement for Resident B, but it remained challenging for her to maneuver its wider frame through standard door frames and narrow living areas. Self-propulsion of her bariatric wheelchair also may have potentially increased the pressure, friction, and shear forces within her weighted, overlapping skin folds and abdominal pannus.  Thus, it is important for nurses to consider not only BMI but also actual body size and measurements (eg, abdominal girth) as risk factors that require appropriate equipment. For example, standard wheelchairs have a seat depth of 18 inches and typically can neither support weight greater than 250 to 300 lb nor accommodate the physical size of larger individuals.2 Providing bariatric-sized beds, chairs, commodes, and other care-related equipment for NH residents LWO may facilitate pressure redistribution and reduce some of the challenges of PrI prevention. In addition, use of equipment such as a bariatric-sized commode, rather than a bedpan, for Resident A may have provided another opportunity for movement.

Clinical-related barriers to achieving and maintaining adequate roll/tilt angles and movements included pain and excessive adiposity for Resident B, who had sustained 2 falls within the same month of the study period. Although she did not sustain significant injury or require hospitalization, she did complain of discomfort that challenged her independent movement and side preference. This, coupled with her past medical history of spinal stenosis, osteoarthritis, and frequent falls, placed her at risk for functional decline. Hills et al5 note that insufficient lower limb strength to move excess body mass upright against gravity to rise from a seated position may encourage sedentary behavior (ie, to remain seated) for prolonged periods, which magnifies PrI risk. Notably, while neither resident had a history of pulmonary disease, some individuals LWO may have associated breathing difficulties such as obstructive sleep apnea53 and, subsequently, limited repositioning options to achieve adequate roll/tilt angles and movement (ie, they are unable to tolerate lying flat, supine, or prone), further increasing risk for PrI development.54        

In this case series, the heavier resident (Resident B) was the more functional of the 2 NH residents studied, reinforcing the importance of avoiding assumptions about mobility based on weight/BMI. Resident A, living with obesity Class 2, was neither motivated nor mobile until cued by NH nursing staff. Everything was done in her room in her bed. In an acute care hospital environment, this would likely not be allowed to occur, because she would be checked more regularly for vitals/monitoring and prompted to move, to get out of bed to the chair, to work with PT, to travel to diagnostic tests/imaging, and so on. Resident B, living with obesity Class 3, was motivated to move but hindered by her bed, her wheelchair, and the facility within which she maneuvered: mobility within the bed was impeded by its width, she had no trapeze, and many of the door frames were too narrow for her wheelchair. In this NH environment, each resident encountered movement challenges unique to her level of obesity and desire to remain mobile.

Psychosocial barriers to movement compliance. Although Resident A was not officially diagnosed with anxiety or depression, she spent a considerable amount of time lying flat in her bed, alone in her room, and was therefore, at risk for social isolation, loneliness, cognitive decline, and depression.55-57 In contrast, Resident B was frequently observed to engage in formal and informal activities that required regular movement, including self-propulsion of her bariatric wheelchair. Despite this outwardly, active engagement with the nursing staff and other NH residents, Resident B was diagnosed as having anxiety and depression; she spent considerable time alone in her room, either sitting in her bariatric wheelchair or lying in her extra wide bed.

Social relationships are central to human well-being and maintenance of health.56 The observations from this case study suggest missed opportunities for increased movement within their social group. For example, neither Resident A nor Resident B attended any of the meals served in the dining room, opting instead to eat in their respective rooms. Increased social engagement during regularly scheduled events (eg, dining, worship, crafts, music) not only builds and maintains social connections but also concurrently encourages physical movement necessary for PrI prevention. Notwithstanding the benefits of muscle mass preservation and strength, regular physical movement also favorably affects physical and cognitive function, improves quality of life, and performance (either independently or with assistance) of ADLs.24,57 Harris et al3 quantified the additional time that was required for ADL care and bathing for NH residents with a BMI >50kg/m2 compared to normal weight residents as 9 minutes and 60 minutes longer, respectively). Thus, inadequate staffing may exacerbate psychosocial barriers to movement and increase risk of PrI.

Digital monitoring of movement compliance. Systematic sensor data on trends over time, such as those presented in this case study, provide nursing staff with information on patterns of behavior that may suggest interventions to lower specific barriers to repositioning. For example, both Resident A and Resident B spent a considerable amount of time flat on their backs. Compared to Resident B, who gave very few reasons that on-time repositioning did not occur, Resident A provided extensive rationales, nearly a third of which were attributed to “resident refusal” (although the rationales for refusal were not specified) and nearly a quarter to the “inability to reach adequate turn angle.” Although all residents have the right to refuse care, any data trend of persistent refusal should trigger additional investigation by nursing staff and be integrated into daily care plans. Furthermore, while Resident A could assist with rolling side-to-side in her bed, sensor data documenting inability to achieve adequate turn angle could have been due either to environmental factors and resource deficits or to increased adiposity and body size, which would limit body movement and ability to turn or lean adequately in standard-sized beds or chairs. Measurement of abdominal girth is critical for providing a bed or chair with adequate width to move within the frame appropriately. 

Without the sensors used in this case study, these NH residents LWO would be at greater risk for PrI development because there is no monitoring (cueing) system in place to assess decreased activity overall, let alone to document movement compliance. Repositioning compliance is then based on memory/charting, which has been shown for decades to be insufficient for PrI prevention.58,59 Sensors assist the nursing staff to keep an eye on residents’ real-time movement patterns and to compare them over time with past trends (ie, decreased frequency of movement, repositioning side preference, insufficient turn angle). Changes in movement patterns can be subtle or dramatic; sensor data helps identify changes and trends so that interventions can be tailored to that individual. For example, the frequent pauses in repositioning for Resident A were concerning with regard to PrI risk. Although she was perfectly able to assist in her repositioning, she never left her room and was observed being assisted for everything in her bed, without movement unless someone cued/assisted her. This was confirmed in her graphed sensor data, which might lead one to suspect her movement was even less before the sensor was applied. On the other hand, Resident B was independently mobile and required minimal cueing. An important observation in these 2 cases is the substantial variability in movement among those who are obese, just as there is great variability among those of normal weight.  

Nursing’s role in movement compliance.

Safety. Among residents LWO and who are limited in functional mobility, such as the persons in the 2 cases presented, any injury or illness could further limit movement and exacerbate current mobility challenges. Resident B in particular had a history of falls, and bruising made it difficult for her to reposition comfortably in her bed or wheelchair. She complained that her side hurt, but she knew she should move, so she did. This was an ideal response but cannot be expected for persons with comparable or worse injuries/illnesses. Appropriate nursing responses to obesity-related behaviors include acceptance of refusal to reposition, increased medication administration to control symptoms such as pain, soliciting more staff to help reposition, or use of lift equipment. All nursing interventions aimed at PrI prevention strategies should be enacted within the context of safety—that is, using heavy-duty lifts and other bariatric equipment that are recommended for lifting/moving weight >35 pounds (16 kg).60-62 While this weight recommendation is not a strict policy, it provides guidance on safe patient handling and mobility to help prevent caregiver musculoskeletal injury.

Change and variability. Nursing assessment of obesity-related physical behaviors and verbal responses could include any change in sedentary behavior/refusal to reposition, exhaustion/fatigue, comorbidities exacerbation (pain, shortness of breath, chest pain), irritable or withdrawn mood, evidence of sadness/tearfulness/depressive symptoms, decreased socialization or increased social isolation, uncooperativeness or disengagement, and arguments, complaints, whining, or demands. The digital data from these 2 cases demonstrated movement variability not only between days, but also within the same day. In other words, residents may be able to perform behaviors (either partially or independently) at some but not other times of the day depending on a variety of factors. Blair et al63 found that it was better to combine behavior management and mutual goal setting with NH residents because too much assistance, or an inappropriate type of assistance, can increase dependency, and discrepancies between what individuals are able to do and what they actually perform are common in all care settings. In following general restorative care recommendations,64 rather than automatically assisting resident movement (or by allowing residents to accept assistance passively), a PrI prevention intervention may include an ongoing nursing assessment of each resident’s fluctuating functional abilities throughout the day, evaluating the possible underlying causes, and communicating these data to all care staff. This approach allows residents the opportunity to move across moments in time according to their individual ability.

Braden score. Swanson et al65 found in hospitalized obese patients (mean age 60.4 years old) that high-risk total Braden score and the mobility and friction-shear subscale scores were more strongly associated with PrI occurrence. Residents A and B had similarities to hospitalized patients with regard to the movement of weighted, intertriginous skin folds and their influence on friction and shear forces. In the home health care setting, Bergquist and Frantz66 found that progressive moisture, mobility, and friction-shear Braden Risk subscale scores were identified as predictors for PrI development among older adults (>60 years of age); the summative score, however, was found to be most strongly related to PrI development. In this case study, Resident A had a higher risk score for the moisture and mobility subscales compared to Resident B, but they were both at mild or no risk according to the total Braden score, and neither developed a PrI during the study. 

Implications for future research and clinical practice. Results from the case study will inform future implications for research and practice change. As it was observed that both residents spent considerable time alone in their rooms,  research could be directed at ways that nursing staff may be incentivized to preserve resident physical function and seek creative ways to motivate and encourage residents LWO to move more and spend less time in their rooms sitting or lying down. Wearable technology that cues nursing staff may be a feasible and long-term strategy for PrI prevention among this at-risk group of residents. Although recommendations to increase movement among NH residents is intended to promote health and wellness, measurable changes in physical activity levels (and their associated benefits) will remain elusive until real-time movement behaviors are captured and documented on a larger scale. Depending on future studies, this technology may have the potential to serve as an early warning system for changes in resident movement behaviors, such as subclinical illness or deterioration leading to lethargy or agitation, thus triggering the nurse to reevaluate the resident’s clinical condition and update the Braden assessment and subsequent care plan. Future research can guide prevention protocols and national/international clinical practice guidelines tailored to this unique but growing at-risk population. For safe-patient handling and mobility in a NH setting, recommendations for adequate staffing, regular training, and availability of bariatric-sized equipment for various care-related tasks and transfers should be included as key strategies for PrI prevention.

Limitations

Limitations of this case study include the inherent exclusiveness of a case study, associated bias, and lack of generalizability. The movement data examined in this study were accurate for these residents with implementation of the standard every 2-hour repositioning schedule using a visual cue to remind nursing staff. However, the movement data may not be generalizable to other residents or repositioning schedules when technology is not available to cue nursing staff. 

Conclusion

This was a case study of prospective, real-time movement and repositioning behaviors of 2 NH residents who are members of the heavier BMI subcategories (Classes 2 and 3) and theoretically at greatest risk for PrI development. The demonstrated functional variability between these 2 residents suggests that proactive use of wireless, wearable sensors to monitor actual function may be a better predictor for initial and ongoing PrI risk assessment than BMI alone. Environmental, clinical, and psychosocial barriers to movement among these 2 NH residents were suggested by digital data, staff observation, and patient reports. The nursing role includes targeted assessment, intervention, and advocacy on behalf of individual residents LWO. 

Affiliations

Dr. Sabol is a professor and division chair, Healthcare in Adult Populations, Duke University, Durham, NC. Dr. Kennerly is a professor, East Carolina University College of Nursing, Greenville, NC. Dr. Alderden is an assistant professor, University of Utah College of Nursing, Salt Lake City, UT. Dr. Horn is an adjunct professor, University of Utah School of Medicine.  Dr. Yap is an associate professor, Duke University School of Nursing. Please address correspondence to: Valerie K. Sabol, PhD, ACNP, GNP, CNE, ANEF, FAANP, FAAN, Department of Medicine, Division of Endocrinology, Metabolism and Nutrition, Duke University Medical Center,307 Trent Drive, DUMC #3322, Durham, NC 27710;  email: valerie.sabol@duke.edu.

Acknowledgments

The authors thank Judith C. Hays, PhD, who assisted in writing, preparing, and critically reviewing this manuscript.

Potential Conflicts of Interest

This study was funded by the National Institutes of Health, National Institute of Nursing, Award Number: R01NR016001, ClinicalTrials.gov: NCT02996331 [Recipient: Tracey L. Yap, PhD, RN, CNE, WCC, FGSA, FAAN]