Domain 5 – Mobility
Having tackled the first 4 domains, things can often be easier after this. It is for this reason that I’ve been to some assessments where the assessor will start at the back & work forward or start at domain 5 and then do the first 4 at the end, as it can make the completion of the first 4 domains easier, as there will have been a lot of discussions by the end of the assessment that will be relevant to these domains. In this series of blogs I’m taking them in the order that they are written.
Mobility is about the person’s physical abilities to move and in particular to walk. So can they walk unaided? Do they need a stick / frame etc? These mobility tools can get in the way if they are not used properly and therefore can create a risk of falling.
If the person can walk sometimes, but not all the time, they may need a wheelchair for longer distances, then it is an issue about how well they can co-operate with the transfers. There are various pieces of mobility equipment, so of which require the assistance of the individual. The question is then, can they physically co-operate and can they cognitively co-operate? If the individual is severely cognitively impaired, they will probably not be able to follow the instructions to assist, which would mean that any movements are done for them. There is an issue about agreement to move, this is not physical co-operation.
Can they reposition themselves; if they slumped in their chair can they change position? Can they move in bed or in a chair? If they can’t then they will need to be moved and usually every few hours (as this will impact on the risks to their skin). The person’s weight becomes relevant here, as someone 8 stone is likely to be easier to move than someone 18 stone.
If they are cognitively impaired, it can feel unsteady to them being hoisted and they get nervous and start flailing or crying etc when hoisted. This is likely to impact on how easy it is to hoist them. They are also not likely to be co-operative in transferring.
Arthritis can be an issue, which creates pain on movement or there are other conditions that require careful positioning to make sure they are not in pain. It is not just pain that requires careful positioning, they need to be able to eat and breathe, so have to be positioned accordingly.
Once some kind of immobility sets in, this will lead to long term consequences, there will loss of muscle tone and contracture (clinically described as a “permanent bending or fixation”). There is no return from a contracture and that limb will always be awkward to deal with. It can lead to rubbing on parts of the body (which impact on skin integrity). I had a client who following a broken hip developed a contracture in one leg, which looked like she was in the lotus position with that leg and the other leg was out straight. The 2 legs therefore crossed over and needed to be supported to make sure that one didn’t rub the other one. Contractures mean that the person needs more care and puts their skin at risk and can put their bones as risk if the contracture is moved in the wrong way, especially if they have osteoporosis.
Risk of falls is a common issue for many individuals. The person can be mobile and not had any falls, but still at risk of falls. If a proper falls assessment has been undertaken and they score as high risk of falls, then they score high on the Decision Support Tool. I’ve had clients who have fallen weekly and clients that have fallen only very rarely, if at all and it is about the risk of falls, although someone who falls weekly would demonstrate evidence of their risk of falls. The results of a fall could be a small bruise or it could be fatal or anything in between. Falling is risky and the whole emphasis on the Decision Support Tool is around risk, the key message is that falls are risky.
Scoring severe on mobility is hard, the person has to not only be fairly immobile, but on top of that they have to have a physical health condition that puts them at serious risk. Pam Coughlan (who is the person who brought the Court case that looked at this issue) is a spinal break survivor, she needs to be position carefully so that she can breathe properly, without the ability to breathe properly, it is easy to see that this will have a big impact in a short space of time and could die fairly quickly. Someone with osteoporosis may break a bone if they were not moved carefully. There needs to be some kind of big risk related to their immobility and immobility alone will not be enough to score severe, there are not many people with these health issues.