As a geriatrician I have encountered innumerable distressed elderly women in hospitals and nursing homes slumped and sliding out of chairs and begging to be allowed to lie down. What is the evidence that elderly patients benefit from extended periods of sitting in chairs? How many patients need further investigation or palliative care rather than "mobilisation"? What about patients' rights to reject such "treatment"?
Surgeons introduced early "ambulation" after operations in the 1940s as an alternative to the time honoured tradition of nursing virtually all patients in bed. As curative surgery and other treatments became available, it was realised that prolonged inactivity not only did not help but might even retard recovery. An army of physiotherapists was recruited to help patients walk and become independent after treatment.
Prescribed bed rest is not the same as rest resulting from felt need
The most famous advocate of ambulation for elderly patients was Richard Asher, a humane iconoclast who liked to poke fun at the establishment. In a memorable paper, "The dangers of going to bed" (British Medical Journal 1947;ii: 967-8), he wrote: "Look at the patient lying in bed. What a pathetic picture he makes! The blood clotting in his veins, the lime draining from his bones, the scybala stacking up his colon, the flesh rotting from his seat, the urine leaking from his distended bladder and the spirit evaporating from his soul." However, few if any proponents of ambulation seem to have read Asher's next paragraph: "I have painted a gloomy and unfair picture: it is not as bad as all that. There is much comfort and healing in the bed, and rest is essential for the management of many illnesses. My object has been to disclose the evils of overdose."
Today Asher would be concerned about an overdose of nursing in chairs. He would also appreciate the difference between his patients and elderly patients today. The average age in his wards was around 73 years. Most patients were quite fit but unable to be discharged because they had nowhere else to go. They responded well to being got up and given physiotherapy and occupational therapy. Today's elderly hospital patients are generally 10 years older, have several illnesses, and are either newly injured or very sick. Their short admission is usually confined to the period when they are acutely ill.
One problem of evidence based medicine is that research in healthy young volunteers may not apply to sick or elderly patients. In one frequently quoted study of the adverse effects of bed rest, healthy young men were immobilised in plaster casts for six to eight weeks. The main findings were a negative nitrogen balance, calcium loss, diminished muscle strength, and orthostatic intolerance. However, similar adverse effects have been shown when young men are seated immobile in chairs, and few studies have looked at the effects of bed rest in old people.
Lying down increases blood flow in leg veins and in the liver, lungs, and brain. Improved renal perfusion increases insulin clearance. Vasodilatation increases blood flow to internal organs, muscles, and skin. Conversely, standing or sitting causes reflex vasoconstriction. Patients who try to sleep in chairs complain of cold feet. Excretion of water and electrolytes is reduced in the upright position, especially in old people, causing leg oedema and fluid overload during the day and nocturia and incontinence at night. Prolonged sitting on long flights is known to cause venous thrombosis. Blood flow velocity in the common femoral vein is 20 times less in the sitting than in the supine position.
The importance of the recumbent position for relaxation and sleep is scarcely mentioned in textbooks. Besides the obvious effects on performance and memory, lack of sleep raises serum cortisol and catecholamine concentrations, reduces thyroid stimulating hormone, and increases lipid intolerance and the likelihood of diabetes. Production of anabolic hormones is increased during sleep, allowing tissue renewal and healing. Crossover trials showed that elderly orthopaedic patients who had shorter rather than longer sessions of chair nursing had a lower incidence of pressure sores, fatigue, tachycardia, hypotension, leg oedema, and constipation. They were also more independently mobile and were able to be discharged sooner.
A 1999 review of trials that compared prescribed bed rest with ambulation concluded that in all cases activity was better than bed rest. However, prescribed bed rest is not the same as rest resulting from felt need. Exercising little and often and sitting out of bed for meals where practicable are obviously important, but so is the need for rest after exertion and after meals. Mobile patients can choose whether to sit or lie down. Less mobile and sick patients should be sat out of bed, if at all, for periods of not more than one to two hours.