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.