Exercise Intervention and Hospital-Associated Disability: A Nonrandomized Controlled Clinical Trial.

Importance: Inpatient exercise interventions may prevent, at least partly, hospital-associated disability (HAD) in older adults, but whether they also confer clinical benefits in the months following discharge is unclear. Objective: To examine the association of exercise and health education with HAD incidence in hospitalized older adults receiving acute hospital care at discharge and 3 months later. Design, Setting, and Participants: This single-center open-label, nonrandomized controlled clinical trial included patients aged 75 years or older seen at an acute care for elders unit at a tertiary public hospital in Madrid, Spain, from May 1, 2018, to June 30, 2022. Interventions: Patients were allocated to an intervention or control group. Both groups received usual care, but the intervention group also performed a supervised multicomponent exercise program (daily strength, balance, and walking exercises along with inspiratory muscle training) during hospitalization and received health education on how to exercise at home and telephone counseling during follow-up. Main Outcomes and Measures: The primary outcome was HAD incidence (determined by the Katz Index of Independence in Activities of Daily Living [hereafter, Katz Index]) at discharge and after 3 months compared with baseline (ie, 2 weeks before admission). Secondary outcomes included HAD incidence determined by the Barthel Index for Activities of Daily Living, ambulatory capacity decline at discharge and follow-up, changes in physical performance at discharge, and incidence of falls, readmissions, and mortality during the follow-up period. Results: The study included 260 patients (134 women [51.5%]; mean [SD] age, 87.4 [4.9] years [range, 75-105 years]; median hospital length of stay, 7 days [IQR, 5-10 days]), of whom 130 received the intervention and 130 were in the control group. Differences in HAD incidence did not reach statistical significance at discharge (odds ratio [OR], 0.62; 95% CI, 0.37-1.05; P = .08) or follow-up (OR, 0.65; 95% CI, 0.36-1.17; P = .15) when using the Katz Index. A lower HAD incidence was observed in the intervention group at discharge (OR, 0.47; 95% CI, 0.27-0.81; P = .01) and at follow-up (OR, 0.36; 95% CI, 0.20-0.66; P = .001) when using the Barthel Index for Activities of Daily Living. The intervention was also associated with a lesser decline in ambulatory capacity (OR, 0.55; 95% CI, 0.32-0.96; P = .03) and improved physical performance at discharge (Cohen d, 0.39; 95% CI, 0.12-0.65; P = .004). No significant associations were observed for readmissions, falls, or mortality. Conclusions and Relevance: In this nonrandomized controlled clinical trial, an exercise and health education intervention was not significantly associated with reduced HAD incidence when measured by the Katz Index. However, the benefits found for several secondary outcomes might support the implementation of in-hospital exercise programs for older patients. Trial Registration: ClinicalTrials.gov Identifier: NCT03604640.

Exercise effects on functional capacity and quality of life in older patients with colorectal cancer: study protocol for the ECOOL randomized controlled trial.

BACKGROUND: Surgery and treatment for colorectal cancer (CRC) in the elderly patient increase the risk of developing post-operative complications, losing functional independence, and worsening health-related quality of life (HRQoL). There is a lack of high-quality randomized controlled trials evaluating the potential benefit of exercise as a countermeasure. The primary aim of this study is to evaluate the effectiveness of a home-based multicomponent exercise program for improving HRQoL and functional capacity in older adults undergoing CRC surgery and treatment. METHODS: This randomized, controlled, observer-blinded, single-center trial aims to randomize 250 patients (>74 years) to either an intervention or a control group (i.e., usual care). The intervention group will perform an individualized home-based multicomponent exercise program with weekly telephone supervision from diagnosis until three months post-surgery. The primary outcomes will be HRQoL (EORTC QLQ-C30; CR29; and ELD14) and functional capacity (Barthel Index and Short Physical Performance Battery), which will be assessed at diagnosis, at discharge, and one, three, and six months after surgery. Secondary outcomes will be frailty, physical fitness, physical activity, inspiratory muscle function, sarcopenia and cachexia, anxiety and depression, ambulation ability, surgical complications, and hospital length of stay, readmission and mortality. DISCUSSION: This study will examine the effects of an exercise program in older patients with CRC across a range of health-related outcomes. Expected findings are improvement in HRQoL and physical functioning. If proven effective, this simple exercise program may be applied in clinical practice to improve CRC care in older patients. TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT05448846.

Functional trajectories associated with acute illness and hospitalization in oldest old patients: Impact on mortality.

Background: The literature pays low attention to functional changes during acute illness in older patients. Our main objectives were to separately describe the different functional changes occurring before and after hospital admission in oldest old medical patients, to investigate their association with mortality, and identify predictors associated with in-hospital failure to recover function. Methods: Secondary analysis of data from a prospective cohort study conducted in a tertiary teaching hospital. The study followed the STROBE criteria. The sample included 604 consecutive patients aged 65 or older hospitalized for acute illness, discharged alive, and not fully dependent at baseline. Activities of daily living measured at baseline, admission, and discharge were used to classify patients into four functional trajectories depending on whether they decline or remain stable between baseline and admission (prehospital) and whether they decline, remain stable, or recover baseline function between admission and discharge (in-hospital). Multivariate models were used to test the association between functional trajectories with mortality, and predictors for in-hospital recovery. Results: Functional trajectories were: "stable-stable" (18%); "decline-recovery" (18%); "decline-no recovery" (53%); "in-hospital decline" (11%). Prehospital decline occurred in 75% and 64% were discharged with worse function than baseline. "In-hospital decline" and "decline-no recovery" trajectories were independently associated with higher 6- and 12-month mortality. Extent of prehospital decline and dementia were predictors of failure to in-hospital recovery. Conclusion: In acutely ill older people, differentiating between prehospital and in-hospital functional changes has prognostic implications. Lack of functional regain at discharge is associated with higher mortality at 6- and 12-months.

Recuperación funcional al alta y a tres meses tras una intervención multicomponente de ejercicio físico en ancianos hospitalizados en una unidad de agudos de geriatría / Functional recovery at discharge and at three months after a multicomponent physical exercise intervention in elderly subjects hospitalized in an Acute Geriatric Unit

Introducción: La hospitalización en ancianos, aún en estancias cortas, se asocia frecuentemente a un deterioro funcional. La evolución de este deterioro una vez revertida la enfermedad aguda que generó la hospitalización es muy variable, observándose que más de la mitad de los pacientes mantiene la discapacidad adquirida incluso un año después del ingreso. Dicha discapacidad se asocia con un mayor riesgo de institucionalización y muerte al alta y a los 30 días. Diversos estudios han demostrado que los programas interdisciplinares de ejercicio físico tienen el potencial de mejorar el estado funcional al alta y además pueden conseguir un descenso de la tasa de mortalidad, de la estancia media y una menor tasa de institucionalización.Diseño y objetivos: El objetivo de este estudio es evaluar la efectividad de un programa de ejercicios y educación sanitaria en la prevención del deterioro funcional durante la hospitalización y a los tres meses en mayores de 74 años, mediante un ensayo clínico aleatorizado en la Unidad de Agudos de Geriatría del Hospital General Universitario Gregorio Marañón. Se excluyeron pacientes con un Barthel basal (15 días antes del ingreso) menor a 20, con deterioro cognitivo severo o incapaces de caminar. La intervención consistió en un programa de ejercicio físico (sentadillas, equilibrio, estimulación de la marcha, bandas elásticas y entrenamiento de la musculatura inspiratoria) y educación sanitaria. El grupo control recibe el cuidado habitual. (AU)

Introduction: Hospitalization in the elderly, even in short stays, is associated with functional impairment. Once the acute illness is reversed, the evolution of this hospital-generated impairment can be variable, and a year after hospitalization more than half of the elderly patients remain impaired. This impairment is associated with a higher risk of institutionalization, of mortality at discharge and of 30-day mortality. Previous studies have shown how interdisciplinary physical exercise programs can improve functionality at discharge and decrease mortality rate, hospital stay and institutionalization.Study design and objectives: In the Acute Geriatric Unit of the Gregorio Marañon University hospital a randomized controlled trial was carried out to assess the effectiveness of an exercise and health education program to prevent functional decline during hospitalization and at three months after discharge in elderly subjects aged 74 years or older. Patients were excluded if at least one of the following exclusion criteria was met: baseline Barthel Index (15-days prior hospitalization) below 20, severe cognitive impairment or inability to walk. The intervention consisted on a physical exercise program (that included squats, balance, gait stimulation, elastic bands, and inspiratory muscle training) and health education program. The control group received usual care. (AU)

[Functional recovery at discharge and at three months after a multicomponent physical exercise intervention in elderly subjects hospitalized in an Acute Geriatric Unit]. / Recuperación funcional al alta y a tres meses tras una intervención multicomponente de ejercicio físico en ancianos hospitalizados en una unidad de agudos de geriatría.

INTRODUCTION: Hospitalization in the elderly, even in short stays, is associated with functional impairment. Once the acute illness is reversed, the evolution of this hospital-generated impairment can be variable, and a year after hospitalization more than half of the elderly patients remain impaired. This impairment is associated with a higher risk of institutionalization, of mortality at discharge and of 30-day mortality. Previous studies have shown how interdisciplinary physical exercise programs can improve functionality at discharge and decrease mortality rate, hospital stay and institutionalization. STUDY DESIGN AND OBJECTIVES: In the Acute Geriatric Unit of the Gregorio Marañon University hospital a randomized controlled trial was carried out to assess the effectiveness of an exercise and health education program to prevent functional decline during hospitalization and at three months after discharge in elderly subjects aged 74 years or older. Patients were excluded if at least one of the following exclusion criteria was met: baseline Barthel Index (15-days prior hospitalization) below 20, severe cognitive impairment or inability to walk. The intervention consisted on a physical exercise program (that included squats, balance, gait stimulation, elastic bands, and inspiratory muscle training) and health education program. The control group received usual care.

Individual Responsiveness to Physical Exercise Intervention in Acutely Hospitalized Older Adults.

We analyzed inter-individual variability in response to exercise among acutely hospitalized oldest-old adults. In this ancillary analysis of a randomized controlled trial, 268 patients (mean age 88 years) were assigned to a control (n = 125, usual care) or intervention group (n = 143, supervised exercise, i.e., walking and rising from a chair [1-3 sessions/day]). Intervention group patients were categorized as responders, non-responders, or adverse responders (improved, no change, or impaired function in activities of daily living [ADL, Katz index] from hospital admission to discharge, respectively). We analyzed the association between responsiveness to exercise and variables assessed at baseline (2 weeks pre-admission), admission, during hospitalization, at discharge, and during a subsequent 3-month follow-up. An impaired ADL function and worse nutritional status at admission were associated to a greater responsiveness, whereas a better ADL function at admission, longer hospitalization and lower comorbidity index were associated with a poorer response (p < 0.05). Adverse responders had worse outcomes at discharge and during the follow-up (e.g., impaired physical performance and greater fall number) (p < 0.05). Although exercise intervention helps to prevent ADL function decline in hospitalized oldest-old people, a number of them-particularly those with a better functional/health status at admission and longer hospitalization-are at higher risk of being adverse responders, which can have negative short/middle-term consequences.

Hip Fracture in Nonagenarians: Characteristics and Factors Related to 30-Day Mortality in 1177 Patients.

BACKGROUND: The number of nonagenarian patients with hip fracture is increasing. The goals of this study were to describe the characteristics and in-hospital course of a cohort of 1177 nonagenarians admitted for hip fracture compared with younger patients and to identify risk factors for 30-day mortality after admission. METHODS: This is a retrospective observational cohort study including patients aged 65 years or older admitted for hip fracture during various periods from February 1997 to December 2016. We defined 3 age groups: 65-79, 80-89, and 90 years and older. We included sociodemographic variables, baseline functional status, comorbidities, fracture and surgical characteristics, postoperative complications, length of stay, and in-hospital and 30-day mortality. Multiple logistic regression analysis was used to study risk factors for 30-day mortality in surgically treated nonagenarians. RESULTS: Nonagenarians were more likely to be women and to have dementia and heart disease. Some 72% walked independently before the fracture. The most relevant treatable risk factor for 30-day mortality in nonagenarians (in terms of higher odds ratio [OR]) was developing respiratory infection (OR: 4.56, 95% confidence interval [CI]: 2.73-7.63). Better prefracture functional status (higher Katz score; OR: 0.83, 95% CI: 0.74-0.92) and spinal anesthesia (OR: 0.19, 95% CI: 0.05-0.68) decreased risk of 30-day mortality. CONCLUSIONS: Nonagenarian patients with hip fracture differ significantly from younger patients concerning clinical characteristics, medical complications, and in-hospital and 30-day mortality rates. We identified several variables on which we could act to reduce 30-day mortality, such as respiratory infection, electrolyte disorders, polypharmacy, cardiac arrhythmia, and spinal anesthesia.

Effect of a Simple Exercise Program on Hospitalization-Associated Disability in Older Patients: A Randomized Controlled Trial.

OBJECTIVE: Hospitalization-associated disability [HAD, ie, the loss of ability to perform ≥1 basic activities of daily living (ADLs) independently at discharge] is a frequent condition among older patients. The present study assessed whether a simple inpatient exercise program decreases HAD incidence in acutely hospitalized very old patients. DESIGN: In this randomized controlled trial (Activity in Geriatric Acute Care) participants were assigned to a control or intervention group and were assessed at baseline, admission, discharge, and 3 months thereafter. SETTING AND PARTICIPANTS: In total, 268 patients (mean age 88 years, range 75-102) admitted to an acute care for older patients unit of a public hospital were randomized to a control (n = 125) or intervention (exercise) group (n = 143). METHODS: Both groups received usual care, and patients in the intervention group also performed simple supervised exercises (walking and rising from a chair, for a total duration of ∼20 minutes/day). We measured ADL function (Katz index) and incident HAD at discharge and after 3 months (primary outcome) and Short Physical Performance Battery, ambulatory capacity, number of falls, rehospitalization, and death during a 3-month follow-up (secondary outcomes). RESULTS: Median duration of hospitalization was 7 days (interquartile range 4 days). The intervention group had a lower risk of HAD with reference to both baseline [odds ratio (OR) 0.36; 95% confidence interval (CI) 0.17-0.76, P = .007] and admission (OR 0.29; 95% CI 0.10-0.89, P = .030). A trend toward an improved ADL function at discharge vs admission was found in the intervention group compared with controls (OR 0.32; 95% CI ‒0.04 to 0.68; P = .083). No between-group differences were noted for the other endpoints (all P > .05). CONCLUSION AND IMPLICATIONS: A simple inpatient exercise program decreases risk of HAD in acutely hospitalized, very old patients.

Revisión sobre el deterioro funcional en el anciano asociado al ingreso por enfermedad aguda / Review of functional impairment associated with acute illness in the elderly

El ingreso hospitalario supone un riesgo para el paciente mayor, con alta probabilidad de sufrir eventos adversos, entre los que destaca el deterioro funcional asociado, por su alta frecuencia y el grave impacto sobre la calidad de vida que produce. Los principales factores de riesgo del deterioro funcional asociado al ingreso hospitalario son la edad avanzada, la inmovilidad, las alteraciones cognitivas y la situación funcional previa al ingreso. Es preciso detectar a tiempo al paciente de riesgo para poner en marcha las medidas necesarias para evitar este deterioro, entre las que destacan el ejercicio físico y la atención geriátrica multidisciplinar (AU)

Hospitalization is a risk for elderly population, with a high probability of having adverse events. The most important one is functional impairment, due to its high prevalence and the serious impact it has on the quality of life. The main risk factors for functional decline associated with hospitalization are, age, immobility, cognitive impairment, and functional status prior to admission. It is necessary to detect patients at risk in order to implement the necessary actions to prevent this deterioration, with physical exercise and multidisciplinary geriatric care being the most important (AU)

[Review of functional impairment associated with acute illness in the elderly]. / Revisión sobre el deterioro funcional en el anciano asociado al ingreso por enfermedad aguda.

Hospitalization is a risk for elderly population, with a high probability of having adverse events. The most important one is functional impairment, due to its high prevalence and the serious impact it has on the quality of life. The main risk factors for functional decline associated with hospitalization are, age, immobility, cognitive impairment, and functional status prior to admission. It is necessary to detect patients at risk in order to implement the necessary actions to prevent this deterioration, with physical exercise and multidisciplinary geriatric care being the most important.

Implicaciones pronósticas del NT-proBNP en insuficiencia cardíaca con fracción de eyección preservada / Prognostic value of NT-proBNP in heart failure with preserved ejection fraction

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Pronóstico global en la insuficiencia cardíaca: hipertensión pulmonar y comorbilidad / Global prognosis in heart failure: pulmonary hypertension and comorbidity

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Reducción de ingresos hospitalarios tras la implantación de un programa multidisciplinario de insuficiencia cardíaca en medicina interna / Reduction of hospital admissions after the development of a multidisciplinary program for cardiac failure in the internal medicine depart

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Overall Asessment of the Response to Terrorist Bombings in Trains, Madrid, 11 March 2004.

OBJECTIVES: To provide an overall assessment of the response to the terrorist bombings in Madrid, 11 March 2004, which were considered the deadliest terrorist attack on European soil in modern times. MATERIALS AND METHODS: Overall data on the number of victims treated at the scenes and at primary care facilities and hospitals, as well as the logistics involved, were reported by the EMS and the Health Authority of the Comunidad de Madrid local government. Data were mainly obtained by retrospective chart review, and did not include casualties who had only emotional shock, superficial bruises or transient hearing loss from barotraumas without eardrum perforation. We defined as critical any casualty with an Injury Severity Score (ISS) >15. RESULTS: Over 70,000 personnel were mobilized in the care of the victims. EMS response and total evacuation times at the four blast scenes averaged 7 and 99 min, respectively. There were around 2,000 casualties, and a typical bimodal distribution of deaths, with 177 immediate fatalities and 14 subsequent in-hospital deaths. Almost 60% of casualties were taken to the two closest hospitals. Problems related to security, identification of casualties and record-keeping were encountered at the closest hospital. Closed doors increased the immediate fatality rate in the trains. Most survivors had noncritical injuries, but 14% of the 512 casualties assessed had an ISS >15. The critical mortality rate was 19.5%. The most frequently injured body regions were the head/neck and face. In all, 124 major surgical interventions were performed on 82 victims in the first 24 h, and orthopedic trauma procedures accounted for 50% of the case load. Most patients with lung injuries from the blasts required intubation and mechanical ventilation, and their survival rate was 88.3%. Also, 35% of laparotomies were either negative or nontherapeutic. CONCLUSION: There was a rapid EMS response and evacuation, but also overtriage, uneven distribution of casualties and difficulties in communication. The sizes and resources of the closest hospitals, as well as the early hour, were probably decisive in the adequacy of the overall response.