Exercise Program Prevents Decline Among Older Inpatients

Norra MacReady

November 14, 2018

A moderately challenging exercise program may help elderly patients avoid some of the deterioration associated with acute hospitalization, the authors of a new study write.

In a randomized clinical trial of patients ranging in age from 75 to 101 years, an individualized, multicomponent program consisting of resistance, balance, walking, and gait retraining exercises was associated with significant improvements in functional and cognitive status, compared with usual care, Nicolás Martinez-Velilla, MD, PhD, and colleagues explain in an article published online November 12 in JAMA Internal Medicine.

The traditional model of hospital care for elderly patients, which emphasizes bed rest, is often associated with significant functional decline even after the initial clinical problem has resolved. "More than half of all older adults do not recover to their preadmission functional levels 1 year after discharge, with high rates of nursing home placement and death," Martinez-Velilla, of the Geriatric Department, Complejo Hospitalario de Navarra, Pamplona, Spain, and colleagues write.

"Our study shows that an individualized, multicomponent exercise intervention including low-intensity resistance training exercises performed during a short period (mean, 5 days) provides a significant benefit over usual care and can help to reverse the functional decline associated with acute hospitalization in older adults," they write.

Instead of a disease-focused approach to the management of these patients, clinicians might consider functional status "as a clinical vital sign that can be impaired by traditional (bed rest–based) hospitalization but effectively reversed with specific in-hospital exercises," they explain.

There were no adverse effects associated with the intervention.

For their study, Martinez-Velilla and colleagues recruited 209 women and 161 men who had been admitted to a tertiary public hospital in Pamplona, Spain, between February 1, 2015, and August 30, 2017. The patients ranged in age from 75 to 101 years (mean age, 87.3 years; standard deviation, 4.9 years), including 130 (35.1%) nonagenarians. Exclusion criteria included very severe cognitive impairment, expected length of hospital stay less than 6 days, terminal illness, and other severe medical conditions, such as acute pulmonary embolism, recent major surgery, or a bone fracture incurred in the previous 3 months.

The patients were randomly assigned to either the control group, which received usual care, including physical rehabilitation when necessary, or the intervention group, which received twice-daily 20-minute exercise sessions for 5 to 7 consecutive days. The intervention exercises consisted of individualized progressive resistance, balance, and walking training exercises, as well as functional unsupervised exercises with light weights. Each group comprised 185 patients.

The authors assessed change in functional capacity from the beginning of the intervention (baseline) to hospital discharge using the Short Physical Performance Battery (SPPB), which combines balance, gait velocity, and leg strength as a single score on a 0 (worst) to 12 (best) scale. To evaluate patients' functional independence, they used the Barthel Index of Activities of Daily Living, which measures the extent to which an individual can independently perform basic activities such as bathing, feeding, and grooming, on a scale from 0 to 100, with higher scores reflecting greater ability.

In addition, the authors used standard, validated instruments such as the Mini–Mental State Examination to evaluate changes in patients' cognitive capacity, mood status, quality of life, and delirium. They also compared length of hospital stay, falls during hospitalization, transfer after discharge, and readmission rate and mortality at 3 months after discharge between the two groups.

For patients in both groups, the median length of stay was 8 days (interquartile range [IQR], 4 days for both groups), including a mean of 5.3 intervention days (IQR, 0 days).

In an intention-to-treat analysis, the mean change on the SPPB scale between baseline and discharge was 0.2 points in the control group (95% confidence interval [CI], -0.1 to 0.5) vs 2.4 points in the intervention group (95% CI, 2.1 - 2.7; P < .001). Similarly, the mean change in the Barthel Index was -5.0 for the control group (95% CI, -6.8 to -3.2) vs 1.9 for the intervention group (95% CI, 0.2 - 3.7; P < .001).

Significant differences favoring the intervention group were seen on measures of cognitive capacity, depression, quality of life, and handgrip strength. There were no adverse effects associated with the intervention.

However, there were no significant differences between the groups in incident delirium (P > .10), proportion of patients experiencing at least one fall while hospitalized, 3-month hospital readmission rate/mortality, or patient transfer.

Currently, "there is no consensus as to the most effective exercise interventions to attenuate functional decline" among acutely hospitalized elderly patients, William J. Hall, MD, writes in an invited commentary. Although the benefits of exercise have been documented for elderly people living in the community, less is known about its role in preventing or minimizing the declines associated with acute hospitalization in these individuals.

The study "has a number of findings that are important and relevant to internal medicine practice," writes Hall, professor of medicine at Highland Hospital Center for Health Aging, University of Rochester School of Medicine and Dentistry, Rochester, New York. One noteworthy feature is the large number of older people it enrolled, including 130 nonagenarians. As this population increases, "[n]ovel strategies that maintain health and well-being in these age groups are needed," he writes.

In addition, the use of inexpensive exercise equipment readily available in any sporting goods store and the inclusion of cognitive and functional assessments as well as physiologic measures "set this study apart from many others," he states.

Study limitations include the lack of information about the patients' cognitive and functional status prior to their hospital admission, as well as the inability to measure changes in certain patients from baseline to discharge due to their poor clinical condition, the authors write.

Nevertheless, the exercise intervention provided "significant benefits over usual care," they conclude. Overall, "our results indicate that, despite its short duration, a multicomponent exercise approach is effective in improving the functional status (measured by SPPB scale, Barthel Index) of very old adults."

The study authors and Dr Hall have disclosed no relevant financial relationships.

JAMA Intern Med. Published online November 12, 2018. Full text, Commentary

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