Effectiveness of a simplified reablement program to minimize functional decline in hospitalized older patients

Optimal dose and type of physical activity to improve functional capacity and minimise adverse events in acutely hospitalised older adults: a systematic review with dose-response network meta-analysis of randomised controlled trials

OBJECTIVE

To identify the optimal dose and type of physical activity to improve functional capacity and reduce adverse events in acutely hospitalised older adults.

DESIGN

Systematic review and Bayesian model-based network meta-analysis.

DATA SOURCES

Four databases were searched from inception to 20 June 2022.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Randomised controlled trials that assessed the effectiveness of a physical activity-based intervention on at least one functional outcome in people aged ≥50 years hospitalised due to an acute medical condition were included. Pooled effect estimates (ie, standardised mean differences for functional capacity and the ratio of means for adverse events) were calculated using random treatment effects network meta-analysis models.

RESULTS

Nineteen studies (3842 participants) met the inclusion criteria. Approximately 100 Metabolic Equivalents of Task per day (METs-min/day) (~40 min/day of light effort or ~25 min/day of moderate effort activities) was the minimal dose to improve the functional capacity of acute hospitalised older adults (standardised mean difference (SMD)=0.28, 95% credible interval (CrI) 0.01 to 0.55). The optimal dose was estimated at 159 METs-min/day (~70 min/day of light effort or ~40 min/day of moderate effort activities; SMD=0.41, 95% CrI 0.08 to 0.72). Ambulation was deemed the most efficient intervention, and the optimal dose was reached at 143 METs-min/day (~50 min/day of slow-paced walking; SMD=0.76, 95% CrI 0.35 to 1.16), showing a high evidential power (87.68%). The minimal effective ambulation dose was estimated at 74 METs-min/day (~25 min/day of slow-paced walking; SMD=0.25, 95% CrI 0.01 to 0.41). Physical activity interventions resulted in a decrease in the rate of adverse events compared with usual care at discharge (ratio of means=0.96, 95% CrI 0.95 to 0.97; median time 7 days).

CONCLUSIONS

This meta-analysis yielded low to moderate evidence supporting the use of in-hospital supervised physical activity programmes in acutely hospitalised older adults. As little as ~25 min/day of slow-paced walking is sufficient to improve functional capacity and minimise adverse events in this population.

TRIAL REGISTRATION NUMBER

PROSPERO CRD42021271999.

Publication Trends in Reablement - A Scoping Review

Background

Reablement is a holistic and multidisciplinary intervention that can facilitate achievement of service users' goals related to their independence in everyday activities. Reablement has been the subject of increasing scientific activity in recent years. Currently, no review has provided a broad overview of the extent and breadth of international publications in reablement.

Objective

The objectives were 1) to map the volume of reablement publications, how the publications had increased over time, and their geographical distribution, 2) to identify the publication types and designs, 3) to identify publication trends, and 4) to identify knowledge gaps in the current peer-reviewed literature.

Methods

The scoping review approach designed by Arksey and O'Malley was used to identify peer-reviewed articles on reablement. Information was obtained on scientific activity on reablement over a period of more than two decades from five electronic databases and without language restrictions. Data was extracted from the eligible articles and both descriptive analysis and thematic analysis of the data was performed.

Results

A total of 198 articles published from 1999 to August 2022 from 14 countries were identified. There is a continuous interest in the field from countries where reablement has been implemented. An international and historical overview among countries with peer-reviewed publications on reablement is presented, which also partly reflects the countries that have implemented reablement. Most of the research derives from Western countries, in particular from Norway. Varied approaches to publications in reablement were noted with the majority being empirical and quantitative in nature.

Conclusion

The scoping review confirms the continued expansion of the breadth of reablement-focused publications in terms of originating countries, target populations, and research designs. In addition, the scoping review contributes to the knowledge base regarding reablement's research front.

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.

Moderated-mediation analysis of multimorbidity and health-related quality of life among the Chinese elderly: The role of functional status and cognitive function

OBJECTIVES

To investigate the relationship between multimorbidity and health-related quality of life (HRQoL), and explore the effects of functional status and cognitive function on Chinses elderly behind this relationship.

METHODS

The Multivariate logistic regression and Tobit regression models were used to determine the influence of multimorbidity on HRQoL. Bootstrap analysis was used to probe the mediating effects of functional status and the moderating role of cognition on multimorbidity and HRQoL.

RESULTS

Results of the 2,887 participants age  ≥ 60  years included in the analysis, 51.69% had chronic diseases. Stroke (β = -0.190; 95% confidence interval [CI], -0.232, -0.149; p < 0.001) and the combination of hypertension and stroke (β = -0.210; 95% CI, -0.259, -0.160; p < 0.001) had the greatest influence on HRQoL. Functional status partially mediated the relationship between the number of non-communicable diseases (No. of NCDs) and HRQoL, while cognitive function had a moderating effect not only in the A-path (No. of NCDs to functional status, β = 0.143; t = 7.18; p < 0.001) and but also in the C-path (No. of NCDs to HRQoL, β = 0.007; t = 6.08; p < 0.001).

CONCLUSION

Functional status partially mediated the relationship between multimorbidity and HRQoL in older adults. And cognitive function, if declined, may strengthen this relationship. These findings suggested that improving cognitive function and functional status in those who developed multimorbidity could be a viable prevention or treatment strategy to improve HRQoL in elderly patients.

Effect of early progressive mobilization on intensive care unit-acquired weakness in mechanically ventilated patients: An observational study

Early progressive mobilization is usually considered as an effective method for intensive care unit-acquired weakness (ICU-AW), but the controversies on this topic remain debatable, especially in initiation time, safety profile, and other implementation details. So, more studies should be performed to solve these disputes. A set of critically ill patients underwent mechanical ventilation in intensive care unit (ICU) of our hospital from March 2018 to September 2020 were included as study object. Patients received early progressive mobilization were included into the intervention group (n = 160), and another patients matched with the intervention group by gender, age, and APACHE II score, and these patients received routine intervention were included into the control group (n = 160). Then, indexes involving muscle strength, Barthel index, functional independence, incidence rates of ICU-AW and other complications were comparatively analyzed between the 2 groups. The Medical Research Council score and Barthel index score in the intervention group were significantly higher than those in the control group (all P < .05). The percentages of patients who were able to complete taking a shower, wearing clothes, eating, grooming, moving from bed to chair and using the toilet by alone in the intervention group were significantly higher than those in the control group (69.38% vs 49.38%, 73.13% vs 51.88%, 81.25% vs 55.63%, 74.38% vs 48.75%, 82.50% vs 65.63%, 78.13% vs 63.13%, respectively, all P < .05). The incidence rate of ICU-AW and overall incidence rate of complications in the intervention group were significantly lower than those in the control group (6.88% vs 28.13% and 23.13% vs 48.13%, both P < .05). Early progressive mobilization can effectively increase muscle strength and daily basic motion ability, improve functional status, and decrease risk of ICU-AW in critically ill patients underwent mechanical ventilation, and it has an attractive application value in clinic.

A qualitative study exploring the lived experiences of deconditioning in hospital in Ontario, Canada

Background

Older adults, especially those with physical and social complexities are at risk of hospital-associated deconditioning. Hospital-associated deconditioning is linked to increased length of stay in hospital, stress, and readmission rates. To date, there is a paucity of research on the experiences and implications of deconditioning in hospital from different perspectives. Therefore, the objectives of this exploratory, descriptive qualitative study were to explore hospital-associated deconditioning from the views of different stakeholders and to develop an understanding of deconditioning from physical, social, and cognitive perspectives.

Methods

Between August 2018 and July 2019, in-depth, semi-structured interviews were conducted with patients 50 years or older, who had a hip fracture or delay in discharge, as well as caregivers, providers, and decision-makers who provided support or impacted care processes for these patients. Participants were recruited from one urban and one rural health region located in Ontario, Canada. All interviews were audio-recorded, transcribed, and analyzed using a constant comparison approach.

Results

A total of 80 individuals participated in this study. Participants described insufficient activities in hospital leading to boredom and mental and physical deconditioning. Patients were frustrated with experiencing deconditioning and their decline in function seemed to impact their sense of self and identity. Deconditioning had substantive impacts on patients’ ability to leave hospital to their next point of care. Providers and decision-makers understood the potential for deconditioning but felt constrained by factors beyond their control. Factors that appeared to impact deconditioning included the hospital’s built environment and social capital resources (e.g., family, roommates, volunteers, staff).

Conclusions

Participants described a substantial lack of physical, cognitive, and social activities, which led to deconditioning. Recommendations to address deconditioning include: (1) measuring physical/psychological function and well-being throughout hospitalization; (2) redesigning hospital environments (e.g., create social spaces); and (3) increasing access to rehabilitation during acute hospital stays, while patients wait for the next point-of-care.

Effects of a Tailored Exercise Intervention in Acutely Hospitalized Oldest Old Diabetic Adults: An Ancillary Analysis

OBJECTIVE

To analyze the effects of a tailored exercise intervention in acutely hospitalized elderly diabetic patients.

RESEARCH DESIGN AND METHODS

This is an ancillary analysis of a randomized controlled trial (RCT). A total of 103 acutely hospitalized elderly adults (mean age ~87 years) with type II diabetes were randomized to an intervention (exercise, n = 54) or control group (usual care, n = 49). The primary endpoint was change in functional status from baseline to hospital discharge as assessed with the Barthel Index and the Short Physical Performance Battery (SPPB). Secondary endpoints comprised cognitive function and mood status, quality of life (QoL), incidence of delirium, and handgrip strength. Exercise-related side effects, length of hospital stay, and incidence of falls during hospitalization were also assessed, as well as transfer to nursing homes, hospital readmission, and mortality during a 3-month follow-up.

RESULTS

The median length of stay was 8 days (interquartile range, 4) for both groups. The intervention was safe and provided significant benefits over usual care on SPPB (2.7 [95% confidence interval (CI) 1.8, 3.5]) and Barthel Index (8.5 [95% CI: 3.9, 13.1]), as well as on other secondary endpoints such as cognitive status, depression, QoL, and handgrip strength (all P < 0.05). No significant between-group differences were found for the remainder of secondary endpoints.

CONCLUSIONS

An in-hospital individualized multicomponent exercise intervention was safe and effective for the prevention of functional and cognitive decline in acutely hospitalized elderly diabetic patients, although it had no influence on other endpoints assessed during hospitalization or at the 3-month follow-up after discharge.

Enabling and constraining successful reablement: Individual and neighbourhood factors

Using multilevel logistic regression to analyse management data of reablement episodes collected by Essex County Council, a UK local authority, this article identifies constraining and enabling factors for successful reablement. Overall, 59.5% of reablement clients were classed as able to care for themselves when assessed after 13 weeks following the reablement intervention (N = 8,118). Several age-related, disability, referral, and social factors were found to constrain reablement, but some of the largest constraining effects were neighbourhood deprivation as measured through the Index of Multiple Deprivation and, particularly, unfavourable geodemographic profiles as measured through Experian Mosaic consumer classifications. The results suggest that in order to optimise reablement, programmes should consider broader social and environmental influences on reablement rather than only individual and organisational aspects. Reablement might also be better tailored and intensified for client groups with particular underlying disabilities and for those displaying specific geodemographic characteristics.