Exercise for acutely hospitalised older medical patients.

BACKGROUND: Approximately 30% of hospitalised older adults experience hospital-associated functional decline. Exercise interventions that promote in-hospital activity may prevent deconditioning and thereby maintain physical function during hospitalisation. This is an update of a Cochrane Review first published in 2007. OBJECTIVES: To evaluate the benefits and harms of exercise interventions for acutely hospitalised older medical inpatients on functional ability, quality of life (QoL), participant global assessment of success and adverse events compared to usual care or a sham-control intervention. SEARCH METHODS: We used standard, extensive Cochrane search methods. The latest search date was May 2021. SELECTION CRITERIA: We included randomised or quasi-randomised controlled trials evaluating an in-hospital exercise intervention in people aged 65 years or older admitted to hospital with a general medical condition. We excluded people admitted for elective reasons or surgery. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Our major outcomes were 1. independence with activities of daily living; 2. functional mobility; 3. new incidence of delirium during hospitalisation; 4. QoL; 5. number of falls during hospitalisation; 6. medical deterioration during hospitalisation and 7. participant global assessment of success. Our minor outcomes were 8. death during hospitalisation; 9. musculoskeletal injuries during hospitalisation; 10. hospital length of stay; 11. new institutionalisation at hospital discharge; 12. hospital readmission and 13. walking performance. We used GRADE to assess certainty of evidence for each major outcome. We categorised exercise interventions as: rehabilitation-related activities (interventions designed to increase physical activity or functional recovery, but did not follow a specified exercise protocol); structured exercise (interventions that included an exercise intervention protocol but did not include progressive resistance training); and progressive resistance exercise (interventions that included an element of progressive resistance training). MAIN RESULTS: We included 24 studies (nine rehabilitation-related activity interventions, six structured exercise interventions and nine progressive resistance exercise interventions) with 7511 participants. All studies compared exercise interventions to usual care; two studies, in addition to usual care, used sham interventions. Mean ages ranged from 73 to 88 years, and 58% of participants were women. Several studies were at high risk of bias. The most common domain assessed at high risk of bias was measurement of the outcome, and five studies (21%) were at high risk of bias arising from the randomisation process. Exercise may have no clinically important effect on independence in activities of daily living at discharge from hospital compared to controls (16 studies, 5174 participants; low-certainty evidence). Five studies used the Barthel Index (scale: 0 to 100, higher scores representing greater independence). Mean scores at discharge in the control groups ranged from 42 to 96 points, and independence in activities of daily living was 1.8 points better (0.43 worse to 4.12 better) with exercise compared to controls. The minimally clinical important difference (MCID) is estimated to be 11 points. We are uncertain regarding the effect of exercise on functional mobility at discharge from the hospital compared to controls (8 studies, 2369 participants; very low-certainty evidence). Three studies used the Short Physical Performance Battery (SPPB) (scale: 0 to 12, higher scores representing better function) to measure functional mobility. Mean scores at discharge in the control groups ranged from 3.7 to 4.9 points on the SPPB, and the estimated effect of the exercise interventions was 0.78 points better (0.02 worse to 1.57 better). A change of 1 point on the SPPB represents an MCID. We are uncertain regarding the effect of exercise on the incidence of delirium during hospitalisation compared to controls (7 trials, 2088 participants; very low-certainty evidence). The incidence of delirium during hospitalisation was 88/1091 (81 per 1000) in the control group compared with 70/997 (73 per 1000; range 47 to 114) in the exercise group (RR 0.90, 95% CI 0.58 to 1.41). Exercise interventions may result in a small clinically unimportant improvement in QoL at discharge from the hospital compared to controls (4 studies, 875 participants; low-certainty evidence). Mean QoL on the EuroQol 5 Dimensions (EQ-5D) visual analogue scale (VAS) (scale: 0 to 100, higher scores representing better QoL) ranged between 48.9 and 64.7 in the control group at discharge from the hospital, and QoL was 6.04 points better (0.9 better to 11.18 better) with exercise. A change of 10 points on the EQ-5D VAS represents an MCID. No studies measured participant global assessment of success. Exercise interventions did not affect the risk of falls during hospitalisation (moderate-certainty evidence). The incidence of falls was 31/899 (34 per 1000) in the control group compared with 31/888 (34 per 1000; range 20 to 57) in the exercise group (RR 0.99, 95% CI 0.59 to 1.65). We are uncertain regarding the effect of exercise on the incidence of medical deterioration during hospitalisation (very low-certainty evidence). The incidence of medical deterioration in the control group was 101/1417 (71 per 1000) compared with 96/1313 (73 per 1000; range 44 to 120) in the exercise group (RR 1.02, 95% CI 0.62 to 1.68). Subgroup analyses by different intervention categories and by the use of a sham intervention were not meaningfully different from the main analyses. AUTHORS' CONCLUSIONS: Exercise may make little difference to independence in activities of daily living or QoL, but probably does not result in more falls in older medical inpatients. We are uncertain about the effect of exercise on functional mobility, incidence of delirium and medical deterioration. Certainty of evidence was limited by risk of bias and inconsistency. Future primary research on the effect of exercise on acute hospitalisation could focus on more consistent and uniform reporting of participant's characteristics including their baseline level of functional ability, as well as exercise dose, intensity and adherence that may provide an insight into the reasons for the observed inconsistencies in findings.

Acceptability of physical activity monitoring in older adults undergoing inpatient rehabilitation.

BACKGROUND: There is little research into interventions to increase activity levels of hospitalised older adults. AIMS: To assess the feasibility of using a physical activity monitor (PAL2) in hospitalized older adults and the effect of group exercise on activity levels. METHODS: Participants were hospitalized, ambulant adults ≥ 65 years randomized to individual physical therapy alone or combined with a high intensity exercise group and wore the PAL2 for five consecutive days. RESULTS: Only 33% of eligible participants agreed to participate with 19/30 (63%) complete data sets obtained; physical activity levels were low regardless of intervention. CONCLUSION: Acceptability of physical activity monitoring in hospitalized older adults was low and physical activity levels of those monitored was low across groups. To improve monitor compliance, future studies may consider excluding patients with specific comorbidities that impact on wear time, or selection of an alternative monitor.

The effects of a high-intensity functional exercise group on clinical outcomes in hospitalised older adults: an assessor-blinded, randomised-controlled trial.

Objective: to investigate a high-intensity functional exercise (HIFE) group in hospitalised older adults. Design: assessor-blinded, randomised-controlled trial. Setting: sub-acute wards at a metropolitan rehabilitation hospital. Participants: older adults ≥65 years (n = 468) able to stand with minimum assistance or less from a chair and follow instructions. Intervention: 'group' participants were offered a standing HIFE group three times a week and individual physiotherapy sessions twice a week. Control participants were offered daily individual physiotherapy sessions. Main outcome measures: the primary outcome measure was the Elderly Mobility Scale (EMS). Secondary measures included the Berg Balance Scale, gait speed, Timed Up and Go Test, falls, length of stay and discharge destination. Results: participants' mean age was 84.3 (7.1) years and 61% were female. There was no difference between groups for the improvement in EMS from admission to discharge (effect size -0.07, 95% confidence interval: -0.26 to 0.11, P = 0.446) and no difference in discharge destination, P = 0.904. Therapists saved 31-205 min/week treating group participants compared with control participants. Conclusion: the results suggest that a HIFE group programme combined with individual physiotherapy may improve mobility to a similar extent to individual physiotherapy alone in hospitalised older adults. Providing physiotherapy in a group setting resulted in increased therapist efficiency. A high-intensity exercise group with individual physiotherapy may be an effective and efficient method to provide care to older inpatients.

Systematic review of high-intensity progressive resistance strength training of the lower limb compared with other intensities of strength training in older adults.

OBJECTIVE: To examine the effect of high-intensity progressive resistance strength training (HIPRST) on strength, function, mood, quality of life, and adverse events compared with other intensities in older adults. DATA SOURCES: Online databases were searched from their inception to July 2012. STUDY SELECTION: Randomized controlled trials of HIPRST of the lower limb compared with other intensities of progressive resistance strength training (PRST) in older adults (mean age ≥ 65y) were identified. DATA EXTRACTION: Two reviewers independently completed quality assessment using the Physiotherapy Evidence Database (PEDro) scale and data extraction using a prepared checklist. DATA SYNTHESIS: Twenty-one trials were included. Study quality was fair to moderate (PEDro scale range, 3-7). Studies had small sample sizes (18-84), and participants were generally healthy. Meta-analyses revealed HIPRST improved lower-limb strength greater than moderate- and low-intensity PRST (standardized mean difference [SMD]=.79; 95% confidence interval [CI], .40 to 1.17 and SMD=.83; 95% CI, -.02 to 1.68, respectively). Studies where groups performed equivalent training volumes resulted in similar improvements in leg strength, regardless of training intensity. Similar improvements were found across intensities for functional performance and disability. The effect of intensity of PRST on mood was inconsistent across studies. Adverse events were poorly reported, however, no correlation was found between training intensity and severity of adverse events. CONCLUSIONS: HIPRST improves lower-limb strength more than lesser training intensities, although it may not be required to improve functional performance. Training volume is also an important variable. HIPRST appears to be a safe mode of exercise in older adults. Further research into its effects on older adults with chronic health conditions across the care continuum is required.

Experiences of older adults in a group physiotherapy program at a rehabilitation hospital: A qualitative study.

Physiotherapy delivered in a group setting has been shown to be effective in a variety of populations. However, little is known about the attitudes of older adults toward participating in group physiotherapy. The objectives of this study were to explore older inpatients' perceptions and experiences of group physiotherapy using qualitative methods. Twelve hospitalized adults aged ≥65 years who were involved in a larger randomized controlled trial undertook individual semistructured interviews regarding their experiences in group physiotherapy. Interviews were transcribed verbatim, and line by line, iterative thematic analysis was undertaken. Descriptive codes were developed, compared, and grouped together to create themes. Analysis revealed 6 major themes and 10 subthemes. All participants reported feeling happy to attend group sessions, a satisfactory alternative to individual physiotherapy. Participants described physical benefits that increased their motivation, and comparisons with their peers either motivated them or made them feel gratitude for their own health. Perceived attentiveness of group instructors contributed to participants reporting that treatment was individualized and similar to individual physiotherapy. Motivation and camaraderie with peers contributed to their enjoyment of group physiotherapy. Hospitalized older adults enjoyed exercising with their peers and valued the physical and social benefits of group physiotherapy. Journal of Hospital Medicine 2016;11:358-362. © 2016 Society of Hospital Medicine.

An enhanced exercise and cognitive programme does not appear to reduce incident delirium in hospitalised patients: a randomised controlled trial.

OBJECTIVE: To determine if a programme of progressive resistance exercise, mobilisation and orientation, in addition to usual care, was superior to usual care alone in the prevention of incident delirium in older hospitalised patients. DESIGN: A randomised controlled trial. SETTING: The study was performed at a secondary referral hospital in Melbourne, Australia between May 2005 and December 2007. PARTICIPANTS: 648 consecutive medical inpatients aged 65 years or older who had been in hospital for less than 48 h and who did not have delirium. INTERVENTION: Participants were randomly allocated to a twice-daily programme of progressive resistance exercise tailored to individual ability, mobilisation and orientation in addition to usual care or to usual care alone. MEASUREMENTS: Delirium was measured using the Confusion Assessment Method at baseline and every 48 h until discharge. Secondary outcome measures were severity and duration of delirium, discharge destination and length of stay. RESULTS: Delirium occurred in 4.9% (95% CI 2.3% to 7.3%) of the intervention group (15/305) and in 5.9% (20/339; 95% CI 3.8% to 9.2%) of the group receiving usual care. No difference was observed between groups (χ(2); p=0.5). The intervention had no effect on delirium duration, severity, discharge destination or length of stay. CONCLUSION: A programme of progressive resistance exercise and orientation was not effective in reducing incident delirium in hospitalised elderly patients.

The effect of a post acute respiratory outreach service for patients with chronic obstructive pulmonary disease on hospital readmission rates.

OBJECTIVE: The aim of this study was to investigate the effect of a Post Acute Respiratory Outreach Service (PAROS) for patients with chronic obstructive pulmonary disease (COPD), on hospital utilization. METHODS: A retrospective cohort of patients was examined, using a nested comparison, to test the hypothesis that PAROS would affect hospital utilization in the 12 months following the intervention. Patients admitted with COPD and subsequently enrolled in PAROS were compared with age, sex and diagnosis-matched controls admitted with COPD, who did not receive PAROS. RESULTS: Of 216 patients admitted with COPD during the 1-year study period, 28 were referred to PAROS. A total of 25 suitable controls were identified. Three cases that could not be matched were excluded from the analysis. There were no significant differences in lung function or prior hospitalization between the two groups at baseline. A significant increase in hospital bed days, in the 12 months following the index admission, was observed in the PAROS group (P = 0.046). There was no difference in the number of admissions or emergency department presentations between the groups. CONCLUSIONS: The PAROS program did not lead to a reduction in hospital utilization. This study supports previous findings that respiratory outreach services delivered immediately post discharge increase hospital utilization.