14.4 Deconditioning, Get Up Get Dressed Get Moving & Discharge Planning
Key Takeaways
- RCSI lists Deconditioning as a topic heading citing signs, symptoms and solutions and the HSE description of deconditioning as patient harm hidden in plain sight, and separately lists the HSE Get Up, Get Dressed, Get Moving programme.
- Bed rest causes rapid loss of muscle mass and strength, with the greatest proportional losses in the antigravity muscles of the legs and trunk, and older adults lose more and recover more slowly.
- Deconditioning is multisystem: it affects muscle, bone, the cardiovascular system, respiration, skin, bowel and bladder function, cognition and mood, and every one of those harms is preventable.
- Get Up, Get Dressed, Get Moving asks that patients be out of bed, in their own day clothes and moving as their condition allows, because the pyjamas and the bed are themselves interventions with side effects.
- RCSI lists the multidisciplinary team roles in discharge planning under older person care, and discharge planning starts on admission rather than on the day of discharge.
Deconditioning, Get Up Get Dressed Get Moving & Discharge Planning
RCSI lists Deconditioning as a topic heading in its own right, citing material on its signs, symptoms and solutions and the HSE's framing of deconditioning as "patient harm hidden in plain sight". It separately lists the HSE Get Up, Get Dressed, Get Moving programme, and names deconditioning as a current example for the older person care OSCE station. Under the same heading it lists the roles of the multidisciplinary team in discharge planning from hospital.
The unifying idea is uncomfortable and worth stating plainly: the bed is not neutral. Prolonged bed rest is an intervention with dose-dependent harms, and in many hospital admissions it causes more lasting disability than the illness that prompted the admission.
What Deconditioning Is
Deconditioning is the multisystem loss of physiological reserve and functional capacity that results from inactivity. It begins within days, accelerates with age, and is often irreversible in a frail older adult.
Muscle is lost fastest in the antigravity muscles - the quadriceps, glutei, calf and trunk muscles that keep a person upright. These are precisely the muscles needed to stand from a chair, climb a stair and recover a stumble. A person can therefore lose the ability to get out of a chair without losing much overall body weight.
The Multisystem Picture
| System | Effect of prolonged bed rest |
|---|---|
| Musculoskeletal | Rapid loss of muscle mass and strength, especially in the legs and trunk; joint stiffness and contracture; accelerated bone loss and fracture risk |
| Cardiovascular | Reduced stroke volume and plasma volume; orthostatic hypotension - the person becomes dizzy on standing, which makes the first attempt at mobilising frightening and reinforces the immobility; venous stasis and VTE risk |
| Respiratory | Reduced lung volumes, basal atelectasis, retained secretions, weaker cough, pneumonia |
| Skin | Sustained pressure and shear over the sacrum and heels; pressure injury |
| Gastrointestinal | Slowed transit, constipation, reduced appetite |
| Urinary | Difficulty voiding supine, incomplete emptying, retention, urinary tract infection, incontinence and consequent skin damage |
| Metabolic | Insulin resistance; negative nitrogen balance; loss of lean mass compounded by poor intake |
| Neurological and psychological | Sensory deprivation, disturbed sleep-wake cycle, delirium, low mood, anxiety about falling, loss of confidence |
| Social | Loss of independence, inability to return home, new or increased care needs, admission to long-term care |
Recognising It
- Needing more help to transfer or walk than on admission.
- Dizziness or unsteadiness on first standing.
- Sitting out only for meals, or not at all.
- Wearing a hospital gown or pyjamas at midday.
- Using a urinal or commode at the bedside when the person could walk to the toilet.
- A documented fall in confidence - "I'd be afraid to try on my own now."
- Reduced oral intake, because people eat less lying down and in bed.
Measure it rather than sensing it: record what the person could do on admission - transfers, walking distance, aid used, stairs - and compare daily. Functional decline that is documented gets acted on.
Get Up, Get Dressed, Get Moving
The HSE Get Up, Get Dressed, Get Moving programme reframes ordinary daily routine as clinical treatment. The three elements are exactly what they say.
Get Up
- Sit out of bed for meals at a minimum, and for longer periods as tolerated.
- Sit upright in a chair, not slumped in bed - it improves respiratory function, swallow safety and appetite.
- Mobilise to the toilet with assistance rather than defaulting to a bedpan or commode, unless clinically contraindicated.
- Challenge bed rest orders that have outlived their reason. Ask the question: why is this person still in bed?
Get Dressed
- The person's own day clothes, not a gown. Clothing supports dignity, orientation to time of day, self-image and the expectation of activity.
- Properly fitting footwear with a back to it - not backless slippers, which are a recognised falls hazard.
- Glasses on, hearing aids in, dentures in, hair brushed. These are not cosmetic; they are functional and cognitive interventions.
- Ask families at admission to bring in clothes and footwear. This is a nursing action on day one, not a discharge task.
Get Moving
- Any movement counts: sitting on the edge of the bed, standing, marching on the spot, walking to the door, walking the corridor.
- Little and often beats one long session.
- Use the physiotherapy plan and reinforce it between sessions - physiotherapy twice a day is not a mobility programme by itself; the nursing team delivers most of the movement.
- Involve family visitors in walking with the person.
- Manage the barriers rather than accepting them: treat the pain first, empty the bladder first, check the blood pressure sitting and standing if dizziness is the obstacle, and make sure the person has something to walk in.
The Common Objections
| Objection | Response |
|---|---|
| "They're too unwell." | Then sit them up, sit them on the edge of the bed, and do passive or active-assisted exercises. Being unwell increases the harm from immobility, it does not remove it |
| "They might fall." | Assess falls risk and mobilise safely with assistance. Preventing falls by preventing mobility guarantees deconditioning and produces a person who will fall at home instead |
| "We don't have time." | Walking a patient to the toilet takes less nursing time than managing incontinence, a pressure injury and a delayed discharge |
| "They have a drip and a catheter." | Review whether both are still needed. Lines and catheters tether people to beds and are frequently retained past their indication |
Discharge Planning from Day One
RCSI lists the roles of the multidisciplinary team in discharge planning under older person care, so expect to be able to name who does what.
| Discipline | Contribution to discharge |
|---|---|
| Nursing | Functional baseline and current ability, continence, skin, nutrition, medicines education, wound and device care, the referral that starts everything |
| Medical team | Diagnosis, treatment plan, medication review and deprescribing, fitness for discharge, follow-up |
| Physiotherapy | Mobility, gait and balance, strength, stairs assessment, walking aids, exercise programme |
| Occupational therapy | Activities of daily living, home assessment, equipment - rails, raised toilet seat, perching stool - cognitive and functional assessment |
| Speech and language therapy | Swallow assessment, texture-modified diet and fluids, communication support |
| Dietetics | Nutritional assessment, fortification, supplements, enteral feeding plans |
| Medical social work | Home support packages, long-term care applications, financial and benefits advice, safeguarding concerns, carer support, family meetings |
| Pharmacy | Medicines reconciliation, interaction and adherence review, compliance aids, counselling |
| Public health nurse | Continuing nursing care at home - wounds, catheters, monitoring - and the key community link |
| Community services | Home support workers, day centres, meals services, community intervention teams, voluntary organisations |
Principles
- Start at admission. Ask on day one where the person lives, who is at home, what supports exist, how many stairs there are, and what they could do a fortnight ago.
- Estimate a discharge date early so that referrals, equipment and home supports run in parallel rather than in sequence.
- Refer early. Occupational therapy equipment, home support packages and community services all have lead times.
- Involve the person and their family or carer throughout, and check the carer's own capacity honestly rather than assuming it.
- Hold a family meeting where needs are complex, and document what was agreed.
- Communicate at transfer. A discharge letter for the GP and public health nurse, a clear medication list with changes explained, wound or device care instructions, follow-up appointments, and written information the person can actually read.
- Use teach-back. Ask the person to explain their new medicines and warning signs in their own words before they leave.
- Plan for readmission risk: what to do if things go wrong, who to call, and when to seek help.
A person who has been kept moving, dressed and eating throughout their admission is a person who can go home. That is why deconditioning is a discharge-planning issue and not only a mobility issue.
An 80-year-old woman who walked independently at home has been in bed for five days with pneumonia. She is now clinically improving but is dizzy when she stands and says she is afraid to walk. What is the most appropriate nursing response?
Which of the following best captures the rationale for the HSE Get Up, Get Dressed, Get Moving programme?
A frail patient is likely to need a raised toilet seat, grab rails and a home support package on discharge. When should these be arranged?