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 Table of Contents  
Year : 2018  |  Volume : 5  |  Issue : 1  |  Page : 58-61

Impact of cognitive activity combined with physiotherapy in a bedridden elderly: A case study

1 Department of Physiotherapy, School of Medicine, College of Health Sciences and Ayder Comprehensive specialized Hospital, Mekelle University, Mek'ele, Ethiopia
2 Department of Physiotherapy, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
3 Department of Physiotherapy, Sree Balaji college of Physiotherapy, Chennai, India

Date of Web Publication27-Jun-2018

Correspondence Address:
Hariharasudhan Ravichandran
Department of Physiotherapy, School of Medicine, College of Health Sciences and Ayder Comprehensive Specialized Hospital, Mekelle University, Mek'ele
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jgmh.jgmh_11_17

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Rehabilitating hospitalized bedridden elderly patients is a challenging task for multidisciplinary team. The reasons for their hospital stay, their level of physical activity before hospitalization, and their disease prognosis interfere with the physiotherapist's intervention in mobilizing the patient out of bed. In this case study, Mr. S, a 66-year-old patient, hospitalized for hyponatremia and bounded to bed for 2 weeks due to his comorbid illness (hypertension and type II diabetes) and delirium was mobilized with cognitive activity, and the physiotherapy interventions have been discussed. This case study demonstrates the impact of cognitive therapy combined with physiotherapy interventions in mobilizing the elderly patient with delirium. In this case study, the patient was treated with cognitive therapy and physiotherapy for 7 days. Baseline and postintervention assessment of timed up and go test (TUG) and 6-min walk test (6MWT) was screened by a senior physiotherapist who is not aware of the interventions provided. Cognitive therapy and physiotherapy interventions are provided by a therapist who is not aware of the baseline and postintervention results. After 7 days, Mr. S was physically active and performed TUG in 12 s and achieved 245.4 m in 6MWT. Cognitive activity is essential among elderly patients expressing the state of delirium. Without sound cognition, it is not easy to rehabilitate elderly patients. In this case study, cognitive activity combined with physiotherapy is found to be effective.

Keywords: 6-min walk test, delirium, hyponatremia, timed up and go test

How to cite this article:
Ravichandran H, Janakiraman B, Sundaram S, Fisseha B, Gelaw AY. Impact of cognitive activity combined with physiotherapy in a bedridden elderly: A case study. J Geriatr Ment Health 2018;5:58-61

How to cite this URL:
Ravichandran H, Janakiraman B, Sundaram S, Fisseha B, Gelaw AY. Impact of cognitive activity combined with physiotherapy in a bedridden elderly: A case study. J Geriatr Ment Health [serial online] 2018 [cited 2019 May 24];5:58-61. Available from: http://www.jgmh.org/text.asp?2018/5/1/58/235359

  Introduction Top

The Indian elderly population is growing at a rapid pace because of improvement in the standard of general medical care.[1] According to United Nations, Department of Economic and Social Affairs 2008, it is projected that the proportion of Indians aged 60 and older will rise from 7.5% in 2010 to 11.1% in 2025. This is a small percentage point increase, but a remarkable figure in absolute terms.[2] The proportion of hospitalized adults who are elderly is only expected to increase as the population ages.[3] The current statistics of elderly in India gives a prelude to a new set of medical, social, and economic problems that could arise if a timely initiative in this direction is not taken in improving their quality of life.[4] In a hospital setup, a significant proportion of patients who experience delayed discharge are elderly;[5] this is because elderly populations have a different pattern of disease and different response to treatment than younger patients. In general, aging in elderly is associated with loss of muscle strength, muscle mass, motor units, aerobic capacity, hormonal reserve, and many other physiological changes. These factors result in a reduction in gait speed, difficulties or restriction to perform activities of daily living, and impaired mobility.[6] Immobilization of elderly people in hospitals following an illness or surgery leads to an increased risk of morbidity, disability, and a decline in muscle function, especially in frail elderly individuals.[7] The controversy that exists among family members or relatives of an elderly with illness is that physical mobility cannot be re-established in elderly after sustaining an illness. This is not true in all the conditions. Even though they might suffer from systemic illness, rehabilitating them through early mobilization out of bed will result in improving their quality of life.

Functional decline often starts around the time of admission and can progress quickly.[8] Functional decline is partially a result of hospitalization and not related to diagnostic or therapeutical interventions,[9] meaning that it is not entirely explained by the acute medical problem that led to hospitalization and may persist even after the medical problem is resolved.[10] According to the 10th revision of International Statistical Classification of Diseases and Related Health Problems, “Delirium is a condition which causes a confused mental state and changes in behaviour.” Delirium, a state of cognitive impairment different from dementia, exists among the hospitalized elderly. Symptoms of delirium include inattention, distractibility, drowsiness, befuddlement associated with hallucinations, and mood lability.[11] Recently, much attention has been given to the possibility of restoring the functional status by means of physiotherapy, as well as compensating for the loss of functions resulting from various diseases.[12] Working with elderly patients with delirium can present the physiotherapist with a set of challenges unparalleled in other areas of practice. Elderly patients admitted for musculoskeletal, neurological, or cardiovascular problems may have low mood, delirium, deconditioning, and poor quality of life, once they become bed bounded. These differences in presentation of disease, with unique pattern of aging and varying responses, demonstrate the complexity of challenge in inpatient rehabilitation.[13] The primary focus of hospital care is treating acute and chronic illnesses. Physiotherapy helps to prevent decline in physical functioning arising from immobility and prolonged bed rest. Over the years, several multidisciplinary and exercise interventions have been studied. In this case study, the effectiveness of mobilizing bedridden senior citizens with cognitive activity is investigated. Mr. S was started with the intervention (cognitive + physiotherapy) once the medical team approves he is stable and fit for mobilization.

  Methods Top

Research design

This case study describes the use of cognitive activities before exercises and mobilizing an elderly patient out of bed.

  Case Report Top


A 66-year-old gentleman was admitted to the general medicine department with complaints of altered sensorium, drowsiness, and inability to stand and walk for 2 days. He was a known case of chronic kidney disease and was on hemodialysis for past 2 years. He was diagnosed with hyponatremia and admitted for further management. The patient had no history of dementia or other neurological illness. He did not use an assistive device for ambulation before admission to the hospital. He was performing his activities of daily living and was home bounded due to his kidney disease. A review of the patient's medical history revealed the following comorbidities: hypertension for the past 7 years and on medications, type II diabetes and on oral hypoglycemic agents, and dyslipidemia. There was no history of previous surgeries. His electrolyte sodium level was gradually corrected by the treating physician and gradually became bounded to bed. His hospitalization was prolonged for 2 weeks due to his comorbidities and because he was on hemodialysis. He was referred to the physiotherapy department for mobilization. His physician discussed with us about his state and sought our referral for mobilizing the patient and plan for discharge.

On examination, he was moderately built, in a state of delirium, oriented to person and not oriented to place and timings, most of the time drowsy and sleepy, arousable, and able to respond for verbal commands. He was afebrile. There was no neurological illness. He speaks slow and had difficulty in cooperating with motor examination. He was sleepy and needs loud verbal commands to arouse him. His upper limb and lower limb had a muscle power of 3/5. Muscle power for grades 4 and 5 was not checked due to delirium state. To prevent postural hypotension, he was made to sit up in bed for 10 min and then transferred to chair. In the chair, he was given pegboard task followed by physiotherapy.


The patient received cognitive activity and exercise interventions for seven sessions. Each therapy session lasted approximately 45–60 min – cognitive activity for 15 min followed by exercise program for approximately 30 min. All outcome measures were assessed by a senior physiotherapist at baseline and after seven sessions of interventions. Therapy was provided by a physiotherapist who was not aware of the outcome measure scorings.


Treatment consisted of cognitive activity in addition to exercise program and gait training. Cognitive activities included pegboard activities, crosswords, puzzles, and simple problem-solving activities such as Sudoku. All these cognitive activities were interchanged every session. Physiotherapy program consisted of 10–15 repetitions per se t of ankle pumps, straight leg raises, pelvic bridges, sit to standing, and weight shifting in standing. Balance exercises and gait training was provided with manual support initially, and the patient progressed gradually to perform the tasks without support. Before and after therapy, the vitals of the patient were recorded by the duty medical officer.

Outcome measures

Performance-based tests – the timed up and go test (TUG) and the 6-min walk test (6MWT) – were utilized in this study as the outcome measures. The TUG assesses functional mobility and has been used to evaluate gait and balance disorders in the elderly. The TUG measures, in seconds, the time taken by an individual to stand up from a standard arm chair, walk a distance of 3 m, turn, walk back to the chair, and sit down. The patient performed one trial, after which the average of two trials was recorded as his score. TUG has good intertester and intratester reliability (intercorrelation coefficient [ICC] = 0.99). 6MWT assesses the functional exercise capacity and serves as an indicator of one's ability to perform daily activities. The 6MWT measures the distance an individual covers over a hard flat surface in 6 min. During the test, the patient is encouraged to walk as far as possible within 6 min, with permission provided to stop and rest as needed. Upon expiration of 6 min, the tester measures the distance covered in meters. The American Thoracic Society recommends the use of a straight 30-m corridor in which to conduct the test. 6MWT has a high test–retest reliability (ICC = 0.94–0.97).

  Results Top

Timed up and go test

The patient decreased his time on the TUG from 47 s at the first session to 12 s at the end of seven sessions – a reduction of 35 s approximately [Table 1]. Initially, TUG was performed with assistance from the therapist while getting up and walking. At posttest, the patient performed the task without any manual support from the therapist [Graph 1].
Table 1: Baseline and posttest scores of timed up and go test and 6-min walk test

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Six-minute walk test

By the last session, the patient improved the distance walked from 27.8 to 245.4 m [Table 1]. Initially, the patient had more rest frequently during the 6MWT and gradually improved to walk with minimal rest during the test [Graph 2].

  Discussion Top

There is a lack of consensus and a paucity of evidence-based research regarding the most effective mobilization program among the bedridden elderly, especially in the inpatient setting. Due to adverse effects of delirium among these populations, physical exercises alone will not provide adequate result. The aim of this case study is to evaluate the effect of cognitive activity in mobilizing the bedridden elderly population. Physical inactivity is more common among the hospitalized elderly. Physical inactivity has been identified as the fourth leading risk factor for global mortality, causing an estimated 3.2 million deaths globally.[14] A physically active elderly patient may become inactive once hospitalized or immobilized. Old age, presence of symptoms, duration of stay at the hospital, and intravenous lines are significantly associated with a low level of mobility during hospitalization.[15] Physiotherapy plays a major role in such circumstances. Physiotherapy interventions are targeted at preventing falls and reinforce the need to focus attention on maintaining balance in standing or walking.[16] Mobilizing elderly patients with delirium is challenging because their response differs from younger population. The ability to balance and maintain a posture in standing is directly related to their orientation, level of consciousness, and alertness.[17] In this case study, cognitive activities play a major role in improving the patient's level of alertness before participating in physical activity. This helps Mr. S to perform the exercises safely and be aware of the activity he is assigned.

A multidisciplinary coordinated team including primary care physician, physiatrist, nurse, physiotherapist, and occupational therapist should evaluate the hospitalized elderly persons. From the physiological point of view, walking is an integrated result of the functioning of musculoskeletal, cardiorespiratory, sensory, and neural systems. Two of the most immediate prerequisites for walking are lower extremity strength and postural balance. These are needed to generate movement and to maintain a balanced upright position while moving. Good cognitive function is an essential element in promoting physical activity. Limitations in this case study are that it needs a randomized controlled trial to prove the effectiveness of cognitive activity among larger samples.

  Conclusion Top

The admission of elderly patients to hospital, their treatment, and subsequent discharge can prove challenging. This hospital-based case study brings important evidence regarding the bedridden geriatric mobility program criteria. This case study concludes that cognitive activity combined with physiotherapy helps to recover elderly bedridden patients with delirium.

What is new from this study?

  • Lack of physical activity increases fragility and decreases physical strength
  • Geriatric population requires adequate cognitive activity and physical fitness to maintain independent activities of daily living and reduce their risk of age-related diseases.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Indrajeet SG, Sankha SC, Raj S, Dharam PS. Insomnia in the elderly – A hospital based study from North India. J Clin Gerontol Geriatr 2014;4:117-21.  Back to cited text no. 1
Subhojit D, Devaki N, Lakshmi JK, Kabir S, Srinath Reddy K. Health of the elderly in India: Challenges of access and affordability. Aging in Asia: Findings from New and Emerging Data Initiatives. India: The National Academic Press; 2012.  Back to cited text no. 2
Merck Manual of Geriatrics. Available from: http://www.merck.com/mrkshared/mmg/home.jsp. [Last accessed on 2006 Sep 20].  Back to cited text no. 3
Ingle GK, Nath A. Geriatric health in India: Concerns and solutions. Indian J Community Med 2008;33:214-8.  Back to cited text no. 4
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Ostir GV, Berges I, Kuo YF, Goodwin JS, Ottenbacher KJ, Guralnik JM, et al. Assessing gait speed in acutely ill older patients admitted to an acute care for elders hospital unit. Arch Intern Med 2012;172:353-8.  Back to cited text no. 8
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Janakiraman B, Rajasekaran VR. Impact of incidence of fall and stumbles on the level of physical activity in middle aged adults with obesity. Int J Curr Res Rev 2012;4:95-101.  Back to cited text no. 14
Senait D, Janakiraman B, Getahun AA, Eskeder A. In-hospital mobility and associated factors. Br J Med Med Res 2015;5:780-87. [DOI: 10.9734/BJMMR/2015/10787].  Back to cited text no. 15
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