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Study Overview
Objective. To assess the effects of an individualized, multicomponent exercise intervention on the functional status of very elderly patients who were acutely hospitalized compared with those who received usual care.
Design. A single-center, single-blind randomized clinical trial comparing elderly (≥ 75 years old) hospitalized patients who received in-hospital exercise (ie, individualized low-intensity resistance, balance, and walking exercises) versus control (ie, usual care that included physical rehabilitation if needed) interventions. The exercise intervention was adapted from the multicomponent physical exercise program Vivifrail and was supervised and conducted by a fitness specialist in 2 daily (1 morning and 1 evening) sessions lasting 20 minutes for 5 to 7 consecutive days. The morning session consisted of supervised and individualized progressive resistance, balance, and walking exercises. The evening session consisted of functional unsupervised exercises including light weights, extension and flexion of knee and hip, and walking.
Setting and participants. The study was conducted in an acute care unit in a tertiary public hospital in Navarra, Spain, between 1 February 2015 and 30 August 2017. A total of 370 elderly patients undergoing acute care hospitalization were enrolled in the study and randomly assigned to receive in-hospital exercise or control intervention. Inclusion criteria were: age ≥ 75 years, Barthel Index score ≥ 60, and ambulatory with or without assistance.
Main outcome measures. The primary outcome was change in functional capacity from baseline (beginning of exercise or control intervention) to hospital discharge as assessed by the Barthel Index of independence and the Short Physical Performance Battery (SPPB). Secondary outcomes were changes in cognitive capacity (Mini-Mental State Examination [MMSE]) and mood status (Yesavage Geriatric Depression Scale [GDS]), quality of life (QoL; EuroQol-5D), handgrip strength (dominant hand), incident delirium (Confusion Assessment Method), length of stay (LOS), falls during hospitalization, transfer after discharge, and readmission rate and mortality at 3 months after discharge. Intention-to-treat analysis was conducted.
Main results. Of the 370 patients included in the study’s analyses, 209 (56.5%) were women, mean age was 87.3 ± 4.9 years (range, 75-101 years; 130 [35.1%] nonagenarians). The median LOS was 8 days in both groups (interquartile range [IQR], 4 and 4 days, respectively). The median duration of the intervention was 5 days (IQR, 0 days), with 5 ± 1 morning and 4 ± 1 evening sessions in the exercise group. Adherence to the exercise intervention was high (95.8% for morning sessions; 83.4% for evening sessions), and no adverse effects were observed with the intervention.
The in-hospital exercise intervention program yielded significant benefits over usual care in functional outcomes in elderly patients. The exercise group had an increased change in measures of functional capacity compared to the usual care group (ie, Barthel Index, 6.9 points; 95% confidence interval [CI], 4.4-9.5; SPPB score, 2.2 points; 95% CI, 1.7-2.6). Furthermore, acute hospitalization led to an impairment in functional capacity from baseline to discharge in the Barthel Index (−5.0 points; 95% CI, −6.8 to −3.2) in the usual care group. In contrast, exercise intervention reversed this decline and improved functional outcomes as assessed by Barthel Index (1.9 points; 95% CI, 0.2-3.7) and SPPB score (2.4 points; 95% CI, 2.1-2.7).
The beneficial effects of the in-hospital exercise intervention extended to secondary end points indicative of cognitive capacity (MMSE, 1.8 points; 95% CI, 1.3-2.3), mood status (GDS, −2.0 points; 95% CI, −2.5 to −1.6), QoL (EuroQol-5D, 13.2 points; 95% CI, 8.2-18.2), and handgrip strength (2.3 kg; 95% CI, 1.8-2.8) compared to those who received usual care. In contrast, no differences were observed between groups that received exercise intervention and usual care in incident delirium, LOS, falls during hospitalization, transfer after discharge, and 3-month hospital readmission rate and mortality.
Conclusion. An individualized, multicomponent physical exercise program that includes low-intensity resistance, balance, and walking exercises performed during the course of hospitalization (average of 5 days) can reverse functional decline associated with acute hospitalization in very elderly patients. Furthermore, this in-hospital exercise intervention is safe and has a high adherence rate, and thus represents an opportunity to improve quality of care in this vulnerable population.
Commentary
Frail elderly patients are highly susceptible to adverse outcomes of acute hospitalization, including functional decline, disability, nursing home placement, rehospitalization, and mortality.1 Mobility limitation, a major hazard of hospitalization, has been associated with poorer functional recovery and increased vulnerability to these major adverse events after hospital discharge.2-4 Interdisciplinary care models delivered during hospitalization (eg, Geriatric Evaluation Unit, Acute Care for Elders) that emphasize functional independence and provide protocols for exercise and rehabilitation have demonstrated reduced hospital LOS, discharge to nursing home, and mortality, and improved functional status in elderly patients.5-7 Despite this evidence, significant gaps in knowledge exist in understanding whether early implementation of an individualized, multicomponent exercise training program can benefit the oldest old patients who are acutely hospitalized.
This study reported by Martinez-Velilla and colleagues provides an important and timely investigation in examining the effects of an individualized, multicomponent (ie, low-intensity resistance, balance, and walking) in-hospital exercise intervention on functional outcomes of hospitalized octogenarians and nonagenarians. The authors reported that such an intervention, administered 2 sessions per day for 5 to 7 consecutive days, can be safely implemented and reverse functional decline (ie, improvement in Barthel Index and SPPB score over course of hospital stay) typically associated with acute hospitalization in these vulnerable individuals. These findings are particularly significant given the paucity of randomized controlled trials evaluating the impact of exercise intervention in preserving functional capacity of geriatric patients in the setting of acute hospitalization. While much more research is needed to facilitate future development of a consensus opinion in this regard, results from this study provide the rationale that implementation of an individualized multicomponent exercise program is feasible and safe and may attenuate functional decline in hospitalized older patients. Finally, the beneficial effects of in-hospital exercise intervention may extend to cognitive capacity, mood status, and QoL—domains that are essential to optimizing patient-centered care in the frailest elderly patients.
The study was well conceived with a number of strengths, including its randomized clinical trial design. In addition, the trial patients were advanced in age (35.1% were nonagenarians), which is particularly important because this is a vulnerable population that is frequently excluded from participation in trials of exercise interventions and because the evidence-base for physical activity guidelines is suboptimal. Moreover, the authors demonstrated that an individualized multicomponent exercise program could be successfully implemented in elderly patients in an acute setting via daily exercise sessions. This test of feasibility is significant in that clinical trials in exercise intervention in geriatrics are commonly performed in nonacute settings in the community, long-term care facilities, or subacute care. The major limitation in this study centers on the generalizability of its findings. It was noted that some patients were not assessed for changes from baseline to discharge on the Barthel Index (6.1%) and SPPB (2.3%) because of their poor condition. The exclusion of the most debilitated patients limits the application of the study’s key findings to the frailest elderly patients, who are most likely to require acute hospital care.
Applications for Clinical Pract
Functional decline is an exceedingly common adverse outcome associated with hospitalization in older patients. While more evidence is needed, early implementation of an individualized, multicomponent exercise regimen during hospitalization may help to prevent functional decline in vulnerable elderly patients.
—Fred Ko, MD, MS
1. Goldwater DS, Dharmarajan K, McEwan BS, Krumholz HM. Is posthospital syndrome a result of hospitalization-induced allostatic overload? J Hosp Med. 2018;13(5).doi:10.12788/jhm.2986.
2. Creditor MC. Hazards of hospitalization of the elderly. Ann Intern Med. 1993;118:219-223.
3. Minnick AF, Mion LC, Johnson ME, et al. Prevalence and variation of physical restraint use in acute care settings in the US. J Nurs Scholarsh. 2007;39:30-37.
4. Zisberg A, Shadmi E, Sinoff G et al. Low mobility during hospitalization and functional decline in older adults. J Am Geriatr Soc. 2011;59:266-273.
5. Rubenstein LZ, et al. Effectiveness of a geriatric evaluation unit. A randomized clinical trial. N Engl J Med. 1984;311:1664-1670.
6. Landefeld CS, Palmer RM, Kresevic DM, et al. A randomized trial of care in a hospital medical unit especially designed to improve the functional outcomes of acutely ill older patients. N Engl J Med. 1995;332:1338-1344.
7. de Morton NA, Keating JL, Jeffs K. Exercise for acutely hospitalised older medical patients. Cochrane Database Syst Rev. 2007;CD005955.
Study Overview
Objective. To assess the effects of an individualized, multicomponent exercise intervention on the functional status of very elderly patients who were acutely hospitalized compared with those who received usual care.
Design. A single-center, single-blind randomized clinical trial comparing elderly (≥ 75 years old) hospitalized patients who received in-hospital exercise (ie, individualized low-intensity resistance, balance, and walking exercises) versus control (ie, usual care that included physical rehabilitation if needed) interventions. The exercise intervention was adapted from the multicomponent physical exercise program Vivifrail and was supervised and conducted by a fitness specialist in 2 daily (1 morning and 1 evening) sessions lasting 20 minutes for 5 to 7 consecutive days. The morning session consisted of supervised and individualized progressive resistance, balance, and walking exercises. The evening session consisted of functional unsupervised exercises including light weights, extension and flexion of knee and hip, and walking.
Setting and participants. The study was conducted in an acute care unit in a tertiary public hospital in Navarra, Spain, between 1 February 2015 and 30 August 2017. A total of 370 elderly patients undergoing acute care hospitalization were enrolled in the study and randomly assigned to receive in-hospital exercise or control intervention. Inclusion criteria were: age ≥ 75 years, Barthel Index score ≥ 60, and ambulatory with or without assistance.
Main outcome measures. The primary outcome was change in functional capacity from baseline (beginning of exercise or control intervention) to hospital discharge as assessed by the Barthel Index of independence and the Short Physical Performance Battery (SPPB). Secondary outcomes were changes in cognitive capacity (Mini-Mental State Examination [MMSE]) and mood status (Yesavage Geriatric Depression Scale [GDS]), quality of life (QoL; EuroQol-5D), handgrip strength (dominant hand), incident delirium (Confusion Assessment Method), length of stay (LOS), falls during hospitalization, transfer after discharge, and readmission rate and mortality at 3 months after discharge. Intention-to-treat analysis was conducted.
Main results. Of the 370 patients included in the study’s analyses, 209 (56.5%) were women, mean age was 87.3 ± 4.9 years (range, 75-101 years; 130 [35.1%] nonagenarians). The median LOS was 8 days in both groups (interquartile range [IQR], 4 and 4 days, respectively). The median duration of the intervention was 5 days (IQR, 0 days), with 5 ± 1 morning and 4 ± 1 evening sessions in the exercise group. Adherence to the exercise intervention was high (95.8% for morning sessions; 83.4% for evening sessions), and no adverse effects were observed with the intervention.
The in-hospital exercise intervention program yielded significant benefits over usual care in functional outcomes in elderly patients. The exercise group had an increased change in measures of functional capacity compared to the usual care group (ie, Barthel Index, 6.9 points; 95% confidence interval [CI], 4.4-9.5; SPPB score, 2.2 points; 95% CI, 1.7-2.6). Furthermore, acute hospitalization led to an impairment in functional capacity from baseline to discharge in the Barthel Index (−5.0 points; 95% CI, −6.8 to −3.2) in the usual care group. In contrast, exercise intervention reversed this decline and improved functional outcomes as assessed by Barthel Index (1.9 points; 95% CI, 0.2-3.7) and SPPB score (2.4 points; 95% CI, 2.1-2.7).
The beneficial effects of the in-hospital exercise intervention extended to secondary end points indicative of cognitive capacity (MMSE, 1.8 points; 95% CI, 1.3-2.3), mood status (GDS, −2.0 points; 95% CI, −2.5 to −1.6), QoL (EuroQol-5D, 13.2 points; 95% CI, 8.2-18.2), and handgrip strength (2.3 kg; 95% CI, 1.8-2.8) compared to those who received usual care. In contrast, no differences were observed between groups that received exercise intervention and usual care in incident delirium, LOS, falls during hospitalization, transfer after discharge, and 3-month hospital readmission rate and mortality.
Conclusion. An individualized, multicomponent physical exercise program that includes low-intensity resistance, balance, and walking exercises performed during the course of hospitalization (average of 5 days) can reverse functional decline associated with acute hospitalization in very elderly patients. Furthermore, this in-hospital exercise intervention is safe and has a high adherence rate, and thus represents an opportunity to improve quality of care in this vulnerable population.
Commentary
Frail elderly patients are highly susceptible to adverse outcomes of acute hospitalization, including functional decline, disability, nursing home placement, rehospitalization, and mortality.1 Mobility limitation, a major hazard of hospitalization, has been associated with poorer functional recovery and increased vulnerability to these major adverse events after hospital discharge.2-4 Interdisciplinary care models delivered during hospitalization (eg, Geriatric Evaluation Unit, Acute Care for Elders) that emphasize functional independence and provide protocols for exercise and rehabilitation have demonstrated reduced hospital LOS, discharge to nursing home, and mortality, and improved functional status in elderly patients.5-7 Despite this evidence, significant gaps in knowledge exist in understanding whether early implementation of an individualized, multicomponent exercise training program can benefit the oldest old patients who are acutely hospitalized.
This study reported by Martinez-Velilla and colleagues provides an important and timely investigation in examining the effects of an individualized, multicomponent (ie, low-intensity resistance, balance, and walking) in-hospital exercise intervention on functional outcomes of hospitalized octogenarians and nonagenarians. The authors reported that such an intervention, administered 2 sessions per day for 5 to 7 consecutive days, can be safely implemented and reverse functional decline (ie, improvement in Barthel Index and SPPB score over course of hospital stay) typically associated with acute hospitalization in these vulnerable individuals. These findings are particularly significant given the paucity of randomized controlled trials evaluating the impact of exercise intervention in preserving functional capacity of geriatric patients in the setting of acute hospitalization. While much more research is needed to facilitate future development of a consensus opinion in this regard, results from this study provide the rationale that implementation of an individualized multicomponent exercise program is feasible and safe and may attenuate functional decline in hospitalized older patients. Finally, the beneficial effects of in-hospital exercise intervention may extend to cognitive capacity, mood status, and QoL—domains that are essential to optimizing patient-centered care in the frailest elderly patients.
The study was well conceived with a number of strengths, including its randomized clinical trial design. In addition, the trial patients were advanced in age (35.1% were nonagenarians), which is particularly important because this is a vulnerable population that is frequently excluded from participation in trials of exercise interventions and because the evidence-base for physical activity guidelines is suboptimal. Moreover, the authors demonstrated that an individualized multicomponent exercise program could be successfully implemented in elderly patients in an acute setting via daily exercise sessions. This test of feasibility is significant in that clinical trials in exercise intervention in geriatrics are commonly performed in nonacute settings in the community, long-term care facilities, or subacute care. The major limitation in this study centers on the generalizability of its findings. It was noted that some patients were not assessed for changes from baseline to discharge on the Barthel Index (6.1%) and SPPB (2.3%) because of their poor condition. The exclusion of the most debilitated patients limits the application of the study’s key findings to the frailest elderly patients, who are most likely to require acute hospital care.
Applications for Clinical Pract
Functional decline is an exceedingly common adverse outcome associated with hospitalization in older patients. While more evidence is needed, early implementation of an individualized, multicomponent exercise regimen during hospitalization may help to prevent functional decline in vulnerable elderly patients.
—Fred Ko, MD, MS
Study Overview
Objective. To assess the effects of an individualized, multicomponent exercise intervention on the functional status of very elderly patients who were acutely hospitalized compared with those who received usual care.
Design. A single-center, single-blind randomized clinical trial comparing elderly (≥ 75 years old) hospitalized patients who received in-hospital exercise (ie, individualized low-intensity resistance, balance, and walking exercises) versus control (ie, usual care that included physical rehabilitation if needed) interventions. The exercise intervention was adapted from the multicomponent physical exercise program Vivifrail and was supervised and conducted by a fitness specialist in 2 daily (1 morning and 1 evening) sessions lasting 20 minutes for 5 to 7 consecutive days. The morning session consisted of supervised and individualized progressive resistance, balance, and walking exercises. The evening session consisted of functional unsupervised exercises including light weights, extension and flexion of knee and hip, and walking.
Setting and participants. The study was conducted in an acute care unit in a tertiary public hospital in Navarra, Spain, between 1 February 2015 and 30 August 2017. A total of 370 elderly patients undergoing acute care hospitalization were enrolled in the study and randomly assigned to receive in-hospital exercise or control intervention. Inclusion criteria were: age ≥ 75 years, Barthel Index score ≥ 60, and ambulatory with or without assistance.
Main outcome measures. The primary outcome was change in functional capacity from baseline (beginning of exercise or control intervention) to hospital discharge as assessed by the Barthel Index of independence and the Short Physical Performance Battery (SPPB). Secondary outcomes were changes in cognitive capacity (Mini-Mental State Examination [MMSE]) and mood status (Yesavage Geriatric Depression Scale [GDS]), quality of life (QoL; EuroQol-5D), handgrip strength (dominant hand), incident delirium (Confusion Assessment Method), length of stay (LOS), falls during hospitalization, transfer after discharge, and readmission rate and mortality at 3 months after discharge. Intention-to-treat analysis was conducted.
Main results. Of the 370 patients included in the study’s analyses, 209 (56.5%) were women, mean age was 87.3 ± 4.9 years (range, 75-101 years; 130 [35.1%] nonagenarians). The median LOS was 8 days in both groups (interquartile range [IQR], 4 and 4 days, respectively). The median duration of the intervention was 5 days (IQR, 0 days), with 5 ± 1 morning and 4 ± 1 evening sessions in the exercise group. Adherence to the exercise intervention was high (95.8% for morning sessions; 83.4% for evening sessions), and no adverse effects were observed with the intervention.
The in-hospital exercise intervention program yielded significant benefits over usual care in functional outcomes in elderly patients. The exercise group had an increased change in measures of functional capacity compared to the usual care group (ie, Barthel Index, 6.9 points; 95% confidence interval [CI], 4.4-9.5; SPPB score, 2.2 points; 95% CI, 1.7-2.6). Furthermore, acute hospitalization led to an impairment in functional capacity from baseline to discharge in the Barthel Index (−5.0 points; 95% CI, −6.8 to −3.2) in the usual care group. In contrast, exercise intervention reversed this decline and improved functional outcomes as assessed by Barthel Index (1.9 points; 95% CI, 0.2-3.7) and SPPB score (2.4 points; 95% CI, 2.1-2.7).
The beneficial effects of the in-hospital exercise intervention extended to secondary end points indicative of cognitive capacity (MMSE, 1.8 points; 95% CI, 1.3-2.3), mood status (GDS, −2.0 points; 95% CI, −2.5 to −1.6), QoL (EuroQol-5D, 13.2 points; 95% CI, 8.2-18.2), and handgrip strength (2.3 kg; 95% CI, 1.8-2.8) compared to those who received usual care. In contrast, no differences were observed between groups that received exercise intervention and usual care in incident delirium, LOS, falls during hospitalization, transfer after discharge, and 3-month hospital readmission rate and mortality.
Conclusion. An individualized, multicomponent physical exercise program that includes low-intensity resistance, balance, and walking exercises performed during the course of hospitalization (average of 5 days) can reverse functional decline associated with acute hospitalization in very elderly patients. Furthermore, this in-hospital exercise intervention is safe and has a high adherence rate, and thus represents an opportunity to improve quality of care in this vulnerable population.
Commentary
Frail elderly patients are highly susceptible to adverse outcomes of acute hospitalization, including functional decline, disability, nursing home placement, rehospitalization, and mortality.1 Mobility limitation, a major hazard of hospitalization, has been associated with poorer functional recovery and increased vulnerability to these major adverse events after hospital discharge.2-4 Interdisciplinary care models delivered during hospitalization (eg, Geriatric Evaluation Unit, Acute Care for Elders) that emphasize functional independence and provide protocols for exercise and rehabilitation have demonstrated reduced hospital LOS, discharge to nursing home, and mortality, and improved functional status in elderly patients.5-7 Despite this evidence, significant gaps in knowledge exist in understanding whether early implementation of an individualized, multicomponent exercise training program can benefit the oldest old patients who are acutely hospitalized.
This study reported by Martinez-Velilla and colleagues provides an important and timely investigation in examining the effects of an individualized, multicomponent (ie, low-intensity resistance, balance, and walking) in-hospital exercise intervention on functional outcomes of hospitalized octogenarians and nonagenarians. The authors reported that such an intervention, administered 2 sessions per day for 5 to 7 consecutive days, can be safely implemented and reverse functional decline (ie, improvement in Barthel Index and SPPB score over course of hospital stay) typically associated with acute hospitalization in these vulnerable individuals. These findings are particularly significant given the paucity of randomized controlled trials evaluating the impact of exercise intervention in preserving functional capacity of geriatric patients in the setting of acute hospitalization. While much more research is needed to facilitate future development of a consensus opinion in this regard, results from this study provide the rationale that implementation of an individualized multicomponent exercise program is feasible and safe and may attenuate functional decline in hospitalized older patients. Finally, the beneficial effects of in-hospital exercise intervention may extend to cognitive capacity, mood status, and QoL—domains that are essential to optimizing patient-centered care in the frailest elderly patients.
The study was well conceived with a number of strengths, including its randomized clinical trial design. In addition, the trial patients were advanced in age (35.1% were nonagenarians), which is particularly important because this is a vulnerable population that is frequently excluded from participation in trials of exercise interventions and because the evidence-base for physical activity guidelines is suboptimal. Moreover, the authors demonstrated that an individualized multicomponent exercise program could be successfully implemented in elderly patients in an acute setting via daily exercise sessions. This test of feasibility is significant in that clinical trials in exercise intervention in geriatrics are commonly performed in nonacute settings in the community, long-term care facilities, or subacute care. The major limitation in this study centers on the generalizability of its findings. It was noted that some patients were not assessed for changes from baseline to discharge on the Barthel Index (6.1%) and SPPB (2.3%) because of their poor condition. The exclusion of the most debilitated patients limits the application of the study’s key findings to the frailest elderly patients, who are most likely to require acute hospital care.
Applications for Clinical Pract
Functional decline is an exceedingly common adverse outcome associated with hospitalization in older patients. While more evidence is needed, early implementation of an individualized, multicomponent exercise regimen during hospitalization may help to prevent functional decline in vulnerable elderly patients.
—Fred Ko, MD, MS
1. Goldwater DS, Dharmarajan K, McEwan BS, Krumholz HM. Is posthospital syndrome a result of hospitalization-induced allostatic overload? J Hosp Med. 2018;13(5).doi:10.12788/jhm.2986.
2. Creditor MC. Hazards of hospitalization of the elderly. Ann Intern Med. 1993;118:219-223.
3. Minnick AF, Mion LC, Johnson ME, et al. Prevalence and variation of physical restraint use in acute care settings in the US. J Nurs Scholarsh. 2007;39:30-37.
4. Zisberg A, Shadmi E, Sinoff G et al. Low mobility during hospitalization and functional decline in older adults. J Am Geriatr Soc. 2011;59:266-273.
5. Rubenstein LZ, et al. Effectiveness of a geriatric evaluation unit. A randomized clinical trial. N Engl J Med. 1984;311:1664-1670.
6. Landefeld CS, Palmer RM, Kresevic DM, et al. A randomized trial of care in a hospital medical unit especially designed to improve the functional outcomes of acutely ill older patients. N Engl J Med. 1995;332:1338-1344.
7. de Morton NA, Keating JL, Jeffs K. Exercise for acutely hospitalised older medical patients. Cochrane Database Syst Rev. 2007;CD005955.
1. Goldwater DS, Dharmarajan K, McEwan BS, Krumholz HM. Is posthospital syndrome a result of hospitalization-induced allostatic overload? J Hosp Med. 2018;13(5).doi:10.12788/jhm.2986.
2. Creditor MC. Hazards of hospitalization of the elderly. Ann Intern Med. 1993;118:219-223.
3. Minnick AF, Mion LC, Johnson ME, et al. Prevalence and variation of physical restraint use in acute care settings in the US. J Nurs Scholarsh. 2007;39:30-37.
4. Zisberg A, Shadmi E, Sinoff G et al. Low mobility during hospitalization and functional decline in older adults. J Am Geriatr Soc. 2011;59:266-273.
5. Rubenstein LZ, et al. Effectiveness of a geriatric evaluation unit. A randomized clinical trial. N Engl J Med. 1984;311:1664-1670.
6. Landefeld CS, Palmer RM, Kresevic DM, et al. A randomized trial of care in a hospital medical unit especially designed to improve the functional outcomes of acutely ill older patients. N Engl J Med. 1995;332:1338-1344.
7. de Morton NA, Keating JL, Jeffs K. Exercise for acutely hospitalised older medical patients. Cochrane Database Syst Rev. 2007;CD005955.