A randomized controlled trial of the effect of supervised progressive cross-continuum strength training and protein supplementation in older medical patients: the STAND-Cph trial

Increased knee-extension strength and steps per day after a novel post-hospitalization rehabilitative program in older adults (65+): Secondary analyses of a randomized controlled single-blinded trial using an expanded sample size

INTRODUCTION

Older adults are at risk of developing new or worsened disability when hospitalized for acute medical illness. This study is a secondary analysis of the STAND-Cph trial on the effect of a simple strength training intervention initiated during hospitalization and continued after discharge. We investigated the between-group difference in change in functional performance outcomes, the characteristics of patients who experienced a relevant effect of the intervention, and the characteristics of those who were compliant with the intervention, using an expanded sample size as protocolized.

METHODS

The STAND-Cph was a randomized controlled trial conducted at a major Danish university hospital. Acutely admitted older adult patients (65+) from the Emergency Department were randomized to the intervention group receiving progressive strength training and a protein supplement during and after hospitalization (12 sessions over 4 weeks) or control group receiving usual care. The primary outcome was the de Morton Mobility Index assessed at baseline and 4 weeks after discharge. The secondary outcomes were 24-h mobility (assessed by ActivPAL accelerometers), isometric knee-extension strength, 30 s. sit-to-stand performance, and habitual gait speed.

RESULTS

Between September 2013 and September 2018, a total of 158 patients were included and randomized to either the intervention group (N = 80; mean age 79.9 ± 7.6 years) or the control group (N = 78; mean age 80.8 ± 7.4 years). We found no significant between-group difference in change in our primary outcome (p > 0.05). Both the intention-to-treat (difference in change 0.14 Nm/kg (95 % CI 0.03;0.24), p = 0.01) and the per protocol (difference in change 0.16 Nm/kg (95 % CI 0.04;0.29), p = 0.008) analyses showed that between baseline and 4 weeks, knee-extension strength increased significantly more in the intervention group than in the control group. Also, the per protocol analysis showed that the intervention group increased their daily number of steps significantly more than the control group (difference in change 1088 steps (95 % CI 44; 2132); p = 0.04). When examining subgroups of patients, we found no significant differences neither between those who experienced a clinically relevant improvement in the de Morton Mobility Index and those who did not, nor between those who were compliant and those who were not.

CONCLUSION

This exploratory analysis indicates that while simple progressive strength training and protein supplementation does not improve functional performance assessed by the de Morton Mobility Index, it can benefit specific facets of physical activity and muscle strength among geriatric patients.

Acute Sarcopenia: Mechanisms and Management

BACKGROUND

Acute sarcopenia refers to the swift decline in muscle function and mass following acute events such as illness, surgery, trauma, or burns that presents significant challenges in hospitalized older adults.

METHODS

narrative review to describe the mechanisms and management of acute sarcopenia.

RESULTS

The prevalence of acute sarcopenia ranges from 28% to 69%, likely underdiagnosed due to the absence of muscle mass and function assessments in most clinical settings. Systemic inflammation, immune-endocrine dysregulation, and anabolic resistance are identified as key pathophysiological factors. Interventions include early mobilization, resistance exercise, neuromuscular electrical stimulation, and nutritional strategies such as protein supplementation, leucine, β-hydroxy-β-methyl-butyrate, omega-3 fatty acids, and creatine monohydrate. Pharmaceuticals show variable efficacy.

CONCLUSIONS

Future research should prioritize serial monitoring of muscle parameters, identification of predictive biomarkers, and the involvement of multidisciplinary teams from hospital admission to address sarcopenia. Early and targeted interventions are crucial to improve outcomes and prevent long-term disability associated with acute sarcopenia.

Effectiveness of a multidisciplinary and transitional nutritional intervention compared with standard care on health-related quality of life among acutely admitted medical patients aged ≥65 years with malnutrition or risk of malnutrition: A randomized controlled trial

BACKGROUND & AIM

Malnutrition, risk of malnutrition, and risk factors for malnutrition are prevalent among acutely admitted medical patients aged ≥65 years and have significant health-related consequences. Consequently, we aimed to investigate the effectiveness of a multidisciplinary and transitional nutritional intervention on health-related quality of life compared with standard care.

METHODS

The study was a block randomized, observer-blinded clinical trial with two parallel arms. The Intervention Group was offered a multidisciplinary transitional nutritional intervention consisting of dietary counselling and six sub-interventions targeting individually assessed risk factors for malnutrition, while the Control Group received standard care. The inclusion criteria were a Mini Nutritional Assessment Short-Form score ≤11, age ≥65 years, and an acute admittance to the Emergency Department. Outcomes were assessed on admission and 8 and 16 weeks after hospital discharge. The primary outcome was the difference between groups in change in health-related quality of life (assessed by the EuroQol-5D-5L) from baseline to 16 weeks after discharge. The secondary outcomes were difference in intake of energy and protein, well-being, muscle strength, and body weight at all timepoints.

RESULTS

From October 2018 to April 2021, 130 participants were included. Sixteen weeks after discharge, 29% in the Intervention Group and 19% in the Control Group were lost to follow-up. Compliance varied between the sub-interventions targeting nutritional risk factors and was generally low after discharge, ranging from 0 to 61%. No difference was found between groups on change in health-related quality of life or on well-being, muscle strength, and body weight at any timepoint, neither using the intention-to-treat analysis nor the per-protocol analysis. The protein intake was higher in the Intervention Group during hospitalization (1.1 (Standard Deviation (SD) 0.4) vs 0.8 (SD 0.5) g/kg/day, p = 0.0092) and 8 weeks after discharge (1.2 (SD 0.5) vs 0.9 (0.4) g/kg/day, p = 0.0025). The percentual intake of calculated protein requirements (82% (SD 24) vs 61% (SD 32), p = 0.0021), but not of calculated energy requirements (89% (SD 23) vs 80% (SD 37), p = 0.2), was higher in the Intervention Group than in the Control Group during hospitalization. Additionally, the Intervention Group had a significantly higher percentual intake of calculated protein requirements (94% (SD 41) vs 74% (SD 30), p = 0.015) and calculated energy requirements (115% (SD 37) vs 94% (SD 31), p = 0.0070) 8 weeks after discharge. The intake of energy and protein was comparable between the groups 16 weeks after discharge.

CONCLUSION

We found no effect of a multidisciplinary and transitional nutritional intervention for acutely admitted medical patients aged ≥65 years with malnutrition or risk of malnutrition on our primary outcome, health-related quality of life 16 weeks after discharge. Nor did the intervention affect the secondary outcomes, well-being, muscle strength, and body weight from admission to 8 or 16 weeks after discharge. However, the intervention improved energy and protein intake during hospitalization and 8 weeks after discharge. Low compliance with the intervention after discharge may have compromised the effect of the intervention. The study is registered at ClinicalTrials.gov (identifier: NCT03741283).

Nutritional rehabilitation after acute illness among older patients: A systematic review and meta-analysis

BACKGROUND & AIMS

Acute illness can lead to disability and reduced quality of life in older patients. The aim of this systematic review was to evaluate the effect of nutritional rehabilitation provided during and after hospitalisation for an acute event on functional status, muscle mass, discharge destination and quality of life of older patients.

METHODS

The protocol for this systematic review was registered in PROSPERO (CRD42021264971). Articles were searched using Scopus, Medline, Google Scholar and Clinical.

TRIALS

gov. For studies included in the meta-analysis, Hedges'g standardized mean difference effect size was calculated and transformed in odds ratios.

RESULTS

We identified 7383 articles, of which 45 publications (41 trials, n = 8538 participants, mean age 80.35 ± 7.01 years.) were eligible for the systematic review. Patients were hospitalized for acute medical diseases (n = 6925) and fractures (n = 1063). The interventions included supplementation with a fixed amount of oral nutritional supplements (ONS, n = 17 trials), individualized diet plan (n = 3), combination of physical exercise with nutrition therapy (n = 14 trials), combination of anabolic agents with nutrition therapy (n = 5 trials). Overall nutritional rehabilitation improved functional status (Odds ratio 1.63 [1.15; 2.3], p = 0.003) and muscle mass (Odds ratio 2.61 [1.22; 5.5], p = 0.01), but not the quality of life or the discharge destination.

CONCLUSION

Nutritional rehabilitation was found to improve functional status and muscle mass. There is a need for larger studies involving older hospitalized patients.

Shared and distinct factors underlying in-hospital mobility of older adults in Israel and Denmark (97/100)

BACKGROUND

Low in-hospital mobility is widely acknowledged as a major risk factor in acquiring hospital-associated disabilities. Various predictors of in-hospital low mobility have been suggested, among them older age, disabling admission diagnosis, poor cognitive and physical functioning, and pre-hospitalization mobility. However, the universalism of the phenomena is not well studied, as similar risk factors to low in-hospital mobility have not been tested.

METHODS

The study was a secondary analysis of data on in-hospital mobility that investigated the relationship between in-hospital mobility and a set of similar risk factors in independently mobile prior to hospitalization older adults, hospitalized in acute care settings in Israel (N = 206) and Denmark (N = 113). In Israel, mobility was measured via ActiGraph GT9X and in Denmark by ActivPal3 for up to seven hospital days.

RESULTS

Parallel multivariate analyses revealed that a higher level of community mobility prior to hospitalization and higher mobility ability status on admission were common predictors of a higher number of in-hospital steps, whereas the longer length of hospital stay was significantly correlated with a lower number of steps in both samples. The risk of malnutrition on admission was associated with a lower number of steps, but only in the Israeli sample.

CONCLUSIONS

Despite different assessment methods, older adults' low in-hospital mobility has similar risk factors in Israel and Denmark. Pre-hospitalization and admission mobility ability are robust and constant risk factors across the two studies. This information can encourage the development of both international standard risk evaluations and tailored country-based approaches.

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.

Effectiveness of home-based exercise for improving physical activity, quality of life and function in older adults after hospitalisation: A systematic review and meta-analysis

OBJECTIVE

To determine if home-based exercise programmes for older adults after hospitalisation are effective at improving physical activity, quality of life, activities of daily living (ADL) and mobility compared to no intervention, standard care or centre-based exercise.

METHODS

Databases were searched from inception to March 2022. Randomised controlled trials which included home-based exercise in older adults recently discharged from hospital were included. The primary outcome was physical activity. Secondary outcomes were quality of life, ADL performance, mobility, adverse events and hospital readmissions. Two reviewers independently selected relevant studies and extracted data. Quantitative synthesis with meta-analyses using a random-effects model and qualitative synthesis were performed.

RESULTS

Ten trials (PEDro score 6-8) were included. Three trials reported on physical activity but meta-analysis was not possible due to heterogeneity. Home-based exercise was more effective than no intervention at improving ADL performance (SMD 0.60, 95% CI 0.03 to 1.17); and standard care at improving quality of life (SMD 0.30, 95% CI 0.11 to 0.49) and mobility (SMD 0.23, 95% CI 0.00 to 0.45). Few and minor adverse events were associated with home-based exercise.

CONCLUSION

Based on individual trials, home-based exercise has the potential to improve physical activity compared to no intervention or standard care. Meta-analyses indicate that home-based exercise is more effective than no intervention at improving activities of daily living performance, and standard care at improving mobility and quality of life. It is unclear if home-based exercise is more effective than centre-based exercise at improving these outcomes.

Feasibility and implementation fidelity of a co-designed intervention to promote in-hospital mobility among older medical patients-the WALK-Copenhagen project (WALK-Cph)

BACKGROUND

Mobility interventions can prevent functional decline among older patients, but implementation of such interventions may be complicated by barriers in the clinical setting. The WALK-Copenhagen project (WALK-Cph) is aimed at promoting a 24-h mobility among older medical patients during hospitalization. The WALK-Cph intervention was co-designed by researchers and stakeholders to tailor the intervention to the clinical context. The aim of this study was to investigate the feasibility and implementation fidelity of the WALK-Cph intervention before evaluating clinical effectiveness in a randomized controlled trial (ClinicalTrials.gov NCT03825497).

METHODS

The WALK-Cph intervention consisted of six components: a welcome folder explaining the importance of in-hospital activity, a WALK-plan prescribing up to three daily walking sessions during and after hospitalization, a WALK-path in the hallway that patients were motivated to use daily, exercise posters in the hallways and bedrooms, self-service on beverages and clothes, and discharge with a WALK-plan. The present study reports on phase 2 of WALK-Cph and consists of a feasibility and a fidelity component. The study was conducted at the two WALK-Cph intervention departments after the initiation of the WALK-Cph intervention. A cohort of older medical patients (+65) was recruited for the feasibility study to assess recruitment and data collection procedures and the method for assessment of activity. Simultaneously, implementation fidelity was assessed by observing clinical practice and intervention delivery at the intervention departments.

RESULTS

A feasibility cohort of 48 patients was included. Inclusion was considered feasible with recruitment rates between 62% and 70% of all eligible patients. Also, data collection was conducted without obstacles, and all patients accepted to wear activity monitors. The fidelity observations showed that three of the six intervention components were partially implemented as planned whereas three components were not implemented as planned.

CONCLUSION

The WALK-Cph intervention was found feasible, and although the intervention was not implemented with fidelity, the level of fidelity was considered sufficient to continue with further testing of the WALK-Cph intervention in a large-scale trial.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03825497 (retrospectively registered). Protocol PubMed ID (PMID): 29523569.

Variations in physical activity and sedentary behavior during and after hospitalization in acutely admitted older medical patients: a longitudinal study

BACKGROUND

Inactivity is frequent among older patients during hospitalization. It is unknown how patients' daily activity pattern (diurnal profile) vary between hospitalization and after discharge. This study aims to describe and compare the distribution of physical activity and sedentary behavior in acutely hospitalized older patients during hospitalization and after discharge.

METHODS

We included data on 80 patients (+65 years) admitted with acute medical illness from the STAND-Cph trial. Physical activity and sedentary behavior were measured as daily number of steps, uptime (walking/standing) and sedentary behavior (lying/sitting) with an activity monitor (activPAL3, PAL Technologies Ltd). The patients wore the monitor for three periods of one week: during hospitalization, after discharge, and four weeks after discharge.

RESULTS

The patients' median age was 80 years [IQR: 75;88], 68% were female and the median De Morton Mobility Index (DEMMI) was 57 [IQR: 48;67]. The daily median uptime was 1.7 h [IQR: 1;2.8] during hospitalization, 4.0 h [IQR: 2.7;5.4] after discharge and 4.0 h [IQR: 2.8;5.8] four weeks after discharge. The daily median number of steps was 728 [IQR: 176;2089], 2207 [IQR: 1433;3148], and 2622 [IQR: 1714;3865], respectively, and median daily sedentary behavior was 21.4 h (IQR: 20.7;22.4), 19.5 h (IQR: 18.1;21.0) and 19.6 h (IQR: 18.0;20.8), respectively. During hospitalization, a small activity peak was observed between 9-11 AM without any notable variation after. At discharge and four weeks after discharge, a peak in physical activity was seen between 9-12 AM and at 5 PM.

CONCLUSION

Older hospitalized patients spend most of their time being sedentary with their highest activity between 9-11 AM. Daily activity doubles after discharge with one extra peak in the afternoon. Daily routines might be disrupted, and older patients have the potential to be more physically active during hospitalization. Interventions that encourage physical activity during hospitalization are warranted.

Optimization of Nutrition And Medication (OptiNAM) for acutely admitted older patients: protocol for a randomized single-blinded controlled trial

BACKGROUND

Internationally, older patients (≥65 years) account for more than 40% of acute admissions. Older patients admitted to the emergency department (ED) are frequently malnourished and exposed to inappropriate medication prescribing, due in part to the inaccuracy of creatinine-based equations for estimated glomerular filtration rate (eGFR). The overall aims of this trial are to investigate: (1) the efficacy of a medication review (MED intervention) independent of nutritional status, (2) the accuracy of eGFR equations based on various biomarkers compared to measured GFR (mGFR) based on ^99mTechnetium-diethylenetriaminepentaacetic acid plasma clearance, and (3) the efficacy of an individualized multimodal and transitional nutritional intervention (MULTI-NUT-MED intervention) in older patients with or at risk of malnutrition in the ED.

METHODS

The trial is a single-center block randomized, controlled, observer-blinded, superiority and explorative trial with two parallel groups. The population consists of 200 older patients admitted to the ED: 70 patients without malnutrition or risk of malnutrition and 130 patients with or at risk of malnutrition defined as a Mini Nutritional Assessment-Short Form score ≤11. All patients without the risk of malnutrition receive the MED intervention, which consists of a medication review by a pharmacist and geriatrician in the ED. Patients with or at risk of malnutrition receive the MULTI-NUT-MED intervention, which consists of the MED intervention in addition to, dietary counseling and individualized interventions based on the results of screening tests for dysphagia, problems with activities of daily living, low muscle strength in the lower extremities, depression, and problems with oral health. Baseline data are collected upon study inclusion, and follow-up data are collected at 8 and 16 weeks after discharge. The primary outcomes are (1) change in medication appropriateness index (MAI) score from baseline to 8 weeks after discharge, (2) accuracy of different eGFR equations compared to mGFR, and (3) change in health-related quality of life (measured with EuroQol-5D-5L) from baseline to 16 weeks after discharge.

DISCUSSION

The trial will provide new information on strategies to optimize the treatment of malnutrition and inappropriate medication prescribing among older patients admitted to the ED.

TRAIL REGISTRATION

ClinicalTrials.gov NTC03741283 . Retrospectively registered on 14 November 2018.