Abstract

Background: Several studies have suggested the complications of prolonged immobilization cause many adverse outcomes, including increased morbidity and mortality, prolonged hospitalization, increased hospitalization costs, and lead to a global burden of disease. The issue of elderly immobilization remains a challenge in the practice of geriatric medicine and health.

Methods: This research is a cross-sectional analytic study using medical record data. The population is immobilized elderly patients who were hospitalized at Wahidin Sudirohusodo Hospital from November 2024 to April 2025. The statistical test was chi-square test.

Results: Data analysis was carried out on 80 immobilized elderly patients. The main finding of this study is that the longer the level of immobilization, the higher the risk of DVT in elderly patients. The findings of the study were confirmed by the results of mild immobilization which had a DVT risk of low risk and moderate risk of 75% and 25% respectively; moderate immobilization had a DVT risk of low risk, moderate risk, and severe risk of 19.4%, 74.2%, and 6.5% respectively; while severe immobilization had a DVT risk of low risk, moderate risk, and severe risk of 11.3%, 32.5%, and 56.3% respectively. The risk of severe DVT was most dominant in the second week of immobilization (≥ 8 days). (p-value=0.000).

Conclusion: There is a significant correlation between the severity of immobilization and the risk of DVT in elderly patients, where it is found that the longer the level of immobilization of elderly patients, the higher the risk of DVT obtained.

Keywords:Immobilization; Elderly; DVT

Introduction

According to Law No. 13 of 1998, an elderly person is some­one who has reached the age of 60 years and above. According to the United Nation World Population Prospects 2019, more than 700 million people in the world are over the age of 65. This num­ber is expected to double to 1.5 billion people by 2050 due to ad­vances in science and medicine, meaning that one in six people are over 65 years old [1,2].

Age related changes and the aging process can lead to changes towards thrombosis and bleeding. Endothelial dysfunction is an important cardiovascular phenomenon that increases with aging. In advanced age, muscle fiber atrophy occurs in the vessel wall and valves thicken, altering the anatomy of the venous vessels [1].

Endothelial thromboresistance at the valve decreases with age, shifting towards a decrease in anticoagulant properties. In addition, immobilization in the elderly can cause DVT, where im­mobilization conditions can cause changes in blood flow such as static and turbulence, especially behind the venous valve bag [3].

Age is a risk factor for thrombosis and aging can also cause thrombophilia. Mechanisms underlying this relationship include hypercoagulation, endothelial damage, and venous stasis along with increased chronic inflammation. Additional factors including comorbidities that are common in elderly patients such as cancer, chronic heart failure, and stroke can significantly contribute to the prothrombotic tendency in elderly patients [4].

Physiological hemostasis is regulated by multiple factors that work harmoniously in maintaining a balance between inhibitors and stimulators of thrombus formation. Aging is associated with comorbidities in most elderly patients, thus increasing age has become a cause associated with basic pathophysiologic mecha­nisms involving: (1) endothelial injury, (2) hypercoagulobility, (3) venous stasis [4].

Hemostasis involves a complex series of procoagulant, and fi­brinolytic processes controlled by inhibitory and feedback mech­anisms. With aging, changes in the balance of hemostasis tend to lead to thrombophilia and an increased risk of thromboembolic events [1].

Immobilization is associated with decreased venous blood flow, occurring in venous sacs and valves which can lead to in­flammation and hypercoagulation. Immobilization or decreased independent mobility is an important and prevalent risk factor for DVT (deep vein thrombosis) in hospitalized patients. Prolonged periods of immobilization will lead to vascular stasis, which is one of the cornerstones of Virchow triage in thrombosis pathology [5,6].

Several studies have suggested the complications of pro­longed immobilization cause many adverse outcomes, including increased morbidity and mortality, prolonged hospitalization, in­creased hospitalization costs, and cause a global burden of disease [7,8].

The reason for choosing this study is because the problem of elderly immobilization remains a challenge in the practice of geri­atric medicine and health. This challenge is in the form of the risk of physical complications that many elderly people face.

Materials and Methods

Approval for the research protocol was obtained from the Hasanuddin University Research Ethics Committee, under the leadership of Prof. Dr. Muh Nasrum Massi, PhD, SpMK, Sub­sp.Bakt[K]. The protocol was assigned the unique identifier UH24100822, signifying adherence to established ethical stan­dards and procedures. The ethical clearance was granted on No­vember 4, 2024, following a thorough review process to ensure compliance with ethical guidelines and principles.

This research design is a cross-sectional analytic study us­ing medical record data. The research was conducted at Wahidin Sudirohusodo Hospital Makassar. The study was conducted from November 2024 to April 20, 2025. The population of this study was mobilized elderly patients who were hospitalized at Wahidin Sudirohusodo Hospital since November 2024 until the sample size was met (80 subjects). The research sample was taken from the population who met the research criteria.

Inclusion criteria

Male and Female aged ≥ 60 years

Elderly patients immobilized ≥ 3 days

Patient is tested for platelet level, PT, APTT, D-dimers

Patients are assessed using the wells score

Complete medical record data

Exclusion criteria

Subjects were not examined for platelet levels, D-dimers, PT, Aptt

Subjects are not assessed using the wells score

Subjects who use anticoagulant drugs

Incomplete medical record data

The analysis method consists of analytical methods and sta­tistical tests. The statistical test used was the chi-square test. Sta­tistical test results were considered significant if the test p-value was < s0.05. The results obtained will be displayed in the form of a narrative supplemented by tables.

Result

Table 1 This study was conducted on elderly patients who were immobilized. The subjects of this study were elderly pa­tients who were immobilized at Wahidin Sudirohusodo Hospital with the level of immobilization divided into mild (3 days), mod­erate (4-7 Days), severe (≥ 8 days). Elderly patients are divided into young elderly (60 - 69 years), middle elderly (70-79 years), and old elderly (≥80 years). The sample size was 80 people. The distribution of research variables can be seen in table 1, which consists of 35 men (43.8%) and 45 women (56.3%). Based on ad­vanced age divided into young elderly 48 people (68%), middle elderly 25 people (31.3%), old elderly 7 people (8.8%). Based on the length of immobilization divided into mild immobilization 4 people (5%), moderate immobilization 31 people (38.8%), severe immobilization 45 people (56.3%).

In Table 2 The relationship between the length of immobiliza­tion with the risk of DVT, it is found that the chi square value is less than 0.05 (p < 0.05), which means that there is a significant differ­ence between the length of immobilization with the risk of DVT.

In Table 3 Changes in coagulation factors in immobilized pa­tients, the results of normal platelets were obtained with 63.75% and abnormal 36.25%. In prothrombin time (PT), 81.25% normal results were obtained, and 18.75% abnormal. In Activated Partial Thromboplastin Time (APTT), the normal results were 76.25% and abnormal 23.75% while in d-dimer the normal results were 5% and abnormal 95%.

Chi square test (P = 0,000).

In Table 4 Comorbidities of immobilization patients where malignancy is 47.5%, hypertension 27.5%, sepsis 20%, diabetes mellitus 18.8%, stroke 17.5%, heart failure 11.3%, postoperative 8.8%, and trauma 3.8%.

Discussion

In this study, we found an association between the duration of immobilization and the risk of DVT in elderly patients, where there was a significant result where the P value was <0.05. The main finding of this study is that the longer the level of immobili­zation, the higher the risk of DVT in elderly patients. The findings of the study have been confirmed with the results in mild immo­bilization having a risk of DVT, namely low risk and moderate risk of 75% and 25% respectively; in moderate immobilization having a risk of DVT, namely low risk, moderate risk, and severe risk of 19.4%, 74.2%, and 6.5% respectively; while in severe immobili­zation having a risk of DVT, namely low risk, moderate risk, and severe risk of 11.3%, 32.5%, and 56.3% respectively. The risk of severe DVT was most dominant in the second week of immobili­zation (≥ 8 days).

The findings of this study have a correlation with previously conducted studies, among others:

In the research of M J Engbers, J W Blom, M Cushman, F R Rosendaal, A Van Hylckama Vlieg with the research title “The Con­tribution of Immobility Risk Factors to the Incidence of Venous Thrombosis in an Older Population” the results showed that im­mobilization factors, especially long duration of immobilization, contributed significantly to the increased incidence of venous thrombosis in the elderly population [9].

Pottier, J.B. Hardouin, et al. with the research title Im­mobilization and the Risk of Venous Thromboembolism: A Me­ta-Analysis on Epidemiological Study. The results showed that patients who lay for more than 3 days had a higher risk of VTE compared to those who only experienced immobilization for a short time. This risk was higher in patients who were immobi­lized for longer periods, and the risk increased with the duration of immobilization [10].

Marissa J Engbers, et al with the research title “Function­al Impairment and Risk of Venous Thrombosis in Older Adults”. The results showed that the elderly who experienced prolonged immobilization (more than 3-5 days) had a higher incidence of DVT compared to those who remained active. In addition to func­tional impairment, comorbidities such as diabetes, hypertension, and heart disease were found to exacerbate the risk of thrombosis in the elderly group with functional impairment [11].

Sebastien Weill-Engerer, MD, Sylvie Meaume, MD, et al with the research title “Risk Factors for Deep Vein Thrombosis in Inpatients Aged 65 and Older: A Case-Control Multicenter Study”. The results showed that long duration of immobilization was a very significant risk factor. Patients who were laid up for a long time (more than 3-5 days) had a greater chance of DVT develop­ment. Patients with a history of heart disease, diabetes, or cancer had a higher risk of DVT [12].

Jing Kao et al with the research title “Risk factors associ­ated with deep venous thrombosis in patients with different bed rest durations: A Multi Institutional case-control study”. The re­sults of their study stated that at least 4 weeks of bed rest signifi­cantly increased the risk of DVT [13].

Piazza G, Seddighzadeh A, Goldhaber SZ with the re­search title “Deep-Vein Thrombosis in the Elderly. Clinical and Applied Thrombosis / Hemostasis”. The results of the study were that 50.5% of patients with DVT were immobilized within 30 days before diagnosis due to neurological disorders such as stroke, par­kinson’s, and alzheimer’s. showed that patients with neurological disorders are more susceptible to deep vein thrombosis [14].

Park YU, Kim HN, Cho JH, Kim T, Kang G, Seo YW. “Inci­dence and Risk Factors of Deep Vein Thrombosis after Foot and Ankle Surgery”. The results of the study were patients who experi­enced immobilization for 10-14 days had an increased risk of DVT up to 35% [15].

Zixuan L, Chen W, Li Y, Wang X, Zhang W, Zhu Y, Zhang F. “Incidence of deep venous thrombosis (DVT) of the lower ex­tremity in patients undergoing surgeries for ankle fractures.” The results of the study were 2.6% of elderly patients affected by DVT with an average length of immobilization of 7 days [16].

Immobilization is considered a risk factor for DVT, not only due to static blood flow but also due to muscle atrophy and weak­ness. Secondary complications of immobilization will eventually lead to edema and thrombus formation [17].

Immobilization can cause degeneration processes that occur in almost all organ systems as a result of changes in gravitational pressure and decreased motor function. Some effects of immo­bilization on the cardiopulmonary and vascular systems include hypercoagulation, increased resting pulse, decreased myocardi­al perfusion, orthostatic intolerance, decreased maximal oxygen uptake, decreased plasma volume, decreased pulmonary function tests, pulmonary atelectasis, pneumonia, increased venous stasis, increased platelet aggregation [18,19].

The biological hallmarks of aging are chronic diseases and proinflammatory conditions as evidenced by elevated serum lev­els of proinflammatory cytokines such as interleukin 6 (IL-6) and tumor necrosis factor alpha (TNF α). These biomarkers are strong independent predictors of health impacts that can lead to various chronic diseases, disability, length of hospitalization, and mortali­ty. The biology of aging has elucidated the mechanisms underlying the proinflammatory state of aging. One of the key features of ag­ing is the aging-associated secretory phenotype characterized by the secretion of proinflammatory mediators, including IL-6 and IL-1 that will lead to the proinflammatory state of aging. Increas­ing age is a risk factor for thrombosis and aging can also lead to thrombophilia. Mechanisms underlying this relationship include hypercoagulation, endothelial damage, and venous stasis along with increased chronic inflammation. Additional factors including comorbidities that are common in elderly patients such as cancer, chronic heart failure, and stroke can significantly contribute to the prothrombotic tendency in elderly patients [4,20].

Conclusion

There is a significant correlation between the severity of im­mobilization and the risk of DVT in elderly patients, where it is found that the longer the level of immobilization of elderly pa­tients, the higher the risk of DVT obtained.

Acknowledgement

The authors acknowledge the Department of Internal Medi­cine, Faculty of Medicine, Hasanuddin University, Makassar, South Sulawesi, Indonesia for the support on this study.

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