Effects of exercise interventions on the functional status of acutely hospitalised older adults: A systematic review and meta-analysis

https://doi.org/10.1016/j.arr.2020.101076Get rights and content

Highlights

  • Acute hospitalisation has some potential negative health consequences in older adults, notably loss of functional independence and physical performance.

  • In-hospital supervised exercise interventions are safe and effective to improve––or attenuate the decline of––functional independence and physical performance in acutely hospitalised older adults.

  • No clear benefits of in-hospital supervised exercise interventions are found for other clinical endpoints including the length of stay or the incidence of readmission or mortality.

  • These results support the routine implementation of exercise interventions (15–30 minutes per session, 5–7 days per week) during the acute hospitalisation of older patients.

Abstract

Background

Acute hospitalisation can have adverse effects in older adults, notably functional decline. We aimed to summarize evidence on the effects of exercise interventions in acutely hospitalised older adults.

Methods

Relevant articles were systematically searched (PubMed, Web of Science, Rehabilitation & Sports Medicine Source, and EMBASE) until 19th March 2020. Randomized controlled trials (RCTs) of in-hospital exercise interventions versus usual care conducted in older adults (>60yrs) hospitalised for an acute medical condition were included. Methodological quality of the studies was assessed with the PEDro scale. Primary outcomes included functional independence and physical performance. Intervention effects were also assessed for other major outcomes (length of hospital stay, incidence of readmission, and mortality). A meta-analysis was conducted when ≥3 studies analysed the same outcome.

Results

Fifteen studies from 12 RCTs (n = 1748) were included. Methodological quality of the studies was overall high. None of the studies reported any adverse event related to the intervention. Exercise interventions improved functional independence at discharge (standardized mean difference [SMD] = 0.64, 95% confidence interval = 0.19–1.08) and 1–3 months post-discharge (SMD = 0.29, 95%CI = 0.13–0.43), as well as physical performance (SMD = 0.57, 95%CI = 0.18–0.95). No between-group differences were found for length of hospital stay or risk of readmission or mortality (all p > 0.05).

Conclusions

In-hospital supervised exercise interventions seem overall safe and effective for improving – or attenuating the decline of – functional independence and physical performance in acutely hospitalised older adults. The clinical relevance of these findings remains to be confirmed in future research.

Introduction

Periods of hospitalisation as a consequence of acute medical illness are associated with several negative health consequences in older adults, even when the illness that necessitated the hospitalisation is successfully treated. Indeed, approximately one-third of older adults experience the so-called hospital-associated functional decline (HAFD) or hospitalisation-associated disability (defined as the loss of the ability to perform one or more basic activities of daily living [ADL]) (Loyd et al., 2019), which is associated with an increased risk of disability, institutionalisation and mortality (Boyd et al., 2008; Fortinsky et al., 1999; Inouye et al., 1998). Hospitalisation periods are also associated with an increased risk of cognitive decline and dementia (Ehlenbach et al., 2010). Thus, the development of strategies aiming at reducing the adverse effects of acute hospitalisation in older patients should be a priority (Covinsky et al., 2011).

The generally low levels of physical activity performed by hospitalised older adults seem to play a major role in the negative health consequences associated with hospitalization (Agmon et al., 2017; Pavon et al., 2019; Zisberg et al., 2011). Hospitalised older adults spend most of the time in bed even if they are able to walk independently (Brown et al., 2009), and nearly 75% of them do not walk at all during hospitalisation (Callen et al., 2004). It has been proposed that exercise interventions might be a safe and effective strategy to enhance functional status in hospitalised older patients (e.g., rehabilitation programs in medically stable geriatric patients) (Bachmann et al., 2010; Heldmann et al., 2019; Kosse et al., 2013; Martínez-Velilla et al., 2016). For instance, meta-analytical evidence supports the benefits of exercise interventions on the functional status of medically stable patients (i.e., in the post-acute or rehabilitation setting) and on other clinical outcomes such as risk of nursing home admission and mortality (Bachmann et al., 2010; McKelvie et al., 2018). There is also evidence of a benefit of exercise interventions on functional independence and physical performance in older adults admitted for an acute medical condition (Martínez-Velilla et al., 2019; Ortiz-Alonso et al., 2020; Sáez de Asteasu et al., 2019a) and some qualitative reviews have summarized these findings (Kanach et al., 2018; Martínez-Velilla et al., 2016). However, to our knowledge there is no meta-analytic evidence supporting the effectiveness of in-hospital exercise interventions for the improvement of functional status in this patient population, or for their effect on other major outcomes such as length of hospital stay, incidence of readmission, or mortality.

The present systematic review and meta-analysis of randomized controlled trials (RCTs) aimed to summarize evidence on the effects of exercise interventions in acutely hospitalised older adults compared with usual care, with a particular focus on functional independence and physical performance, as well as on other clinical outcomes including length of hospital stay, incidence of readmission, and mortality.

Section snippets

Methods

The conduct and reporting of the present systematic review and meta-analysis conform to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA).

Studies’ selection

From the retrieved articles, 15 studies from 12 RCTs including 2618 patients were included in the systematic review (Fig. 1) (Blanc-Bisson et al., 2008; Braun et al., 2019; Brown et al., 2016; Hu et al., 2020; Jones et al., 2006; Killey and Watt, 2006; Martínez-Velilla et al., 2019; McCullagh et al., 2020; Ortiz-Alonso et al., 2020; Sáez de Asteasu et al., 2019b, 2019a, 2020; Siebens et al., 2000; Torres-Sánchez et al., 2017; Troosters et al., 2010). The characteristics of the included studies

Discussion

In this systematic review and meta-analysis of RCTs, in-hospital supervised exercise interventions appeared to be safe – as reflected by the lack of adverse events and of between-group differences in the incidence of falls – and effective for improving patients’ functional independence and physical performance compared to usual care. In turn, no differences were observed between groups for quality of life at discharge, the length of hospital stay, or for the risk of readmission or mortality. Of

Conclusions

In-hospital supervised exercise interventions appear to be safe and effective for improving – or attenuating the decline of – functional independence and physical performance in older adults hospitalised for an acute medical condition (Fig. 4). However, no differences were observed compared with usual care for other major outcomes such as the length of stay, risk of readmission, or mortality. Although preliminary, these results are of potential major relevance, particularly in light of the

Funding source

PLV is supported by a predoctoral contract granted by University of Alcalá (FPI2016). JSM is supported by a predoctoral contract granted by Spanish Ministry of Education, Culture and Sport (FPU14/03435). MI is supported by Spanish Ministry of Economy and Competitiveness and Fondos FEDER (PI17/01814). Research by AL is supported by Spanish Ministry of Economy and Competitiveness and Fondos FEDER (PI15/00558 and PI18/00139). Funders had no role in the study design; in the collection, analysis,

Declaration of Competing Interest

The authors declare no conflicts of interest.

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