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Effectiveness and feasibility of early physical rehabilitation programs for geriatric hospitalized patients: a systematic review

Effectiveness and feasibility of early physical rehabilitation programs for geriatric... Background: Old adults admitted to the hospital are at severe risk of functional loss during hospitalization. Early in-hospital physical rehabilitation programs appear to prevent functional loss in geriatric patients. The first aim of this review was to investigate the effect of early physical rehabilitation programs on physical functioning among geriatric patients acutely admitted to the hospital. The second aim was to evaluate the feasibility of early physical rehabilitation programs. Methods: Two searches, one for physical functioning and one for feasibility, were conducted in PubMed, CINAHL, and EMBASE. Additional studies were identified through reference and citation tracking. To be included articles had to report on in-hospital early physical rehabilitation of patients aged 65 years and older with an outcome measure of physical functioning. Studies were excluded when the treatment was performed on specialized units other than geriatric units. Randomized controlled trials were included to examine the effect of early physical rehabilitation on physical functioning, length of stay and discharge destination. To investigate feasibility also non randomized controlled trials were added. Results: Fifteen articles, reporting on 13 studies, described the effect on physical functioning. The early physical rehabilitation programs were classified in multidisciplinary programs with an exercise component and usual care with an exercise component. Multidisciplinary programs focussed more on facilitating discharge home and independent ADL, whereas exercise programs aimed at improving functional outcomes. At time of discharge patients who had participated in a multidisciplinary program or exercise program improved more on physical functional tests and were less likely to be discharged to a nursing home compared to patients receiving only usual care. In addition, multidisciplinary programs reduced the length of hospital stay significantly. Follow-up interventions improved physical functioning after discharge. The feasibility search yielded four articles. The feasibility results showed that early physical rehabilitation for acutely hospitalized old adults was safe. Adherence rates differed between studies and the recruitment of patients was sometimes challenging. Conclusions: Early physical rehabilitation care for acutely hospitalized old adults leads to functional benefits and can be safely executed. Further research is needed to specifically quantify the physical component in early physical rehabilitation programs. Keywords: Acute care, Rehabilitation, Hospital, Aged, Functional outcomes, Feasibility, ADL, Physical performance * Correspondence: n.m.kosse@umcg.nl University of Groningen, University Medical Center Groningen, Center for Human Movement Sciences, Groningen, The Netherlands Full list of author information is available at the end of the article © 2013 Kosse et al.; licensee BioMed Central Ltd. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Kosse et al. BMC Geriatrics 2013, 13:107 Page 2 of 16 http://www.biomedcentral.com/1471-2318/13/107 Background knowledge of which patient population benefit from the The rapidly growing population of old adults in Western program is required. Furthermore, it is important to know countries has become a major concern for health care if there will be adverse events during early physical re- systems. Due to a poorer health status, old adults con- habilitation programs in terms of falls or other injuries sume a disproportionate amount of medical care. In and what the adherence rate of the patients will be during some European countries, more than 40% of patients ad- the treatment sessions. Therefore, the first aim of this re- mitted to the hospital for an overnight stay are aged view is to evaluate the effects of early physical rehabilita- 65 years and older, while their total share of the popula- tion programs on physical functioning of geriatric patients tion is less than 20% [1]. acutely admitted to a hospital. In this review early physical Unfortunately, old adults admitted to the hospital are rehabilitation in acutely ill patients refers to physical ther- at severe risk of functional decline, both during hospi- apy, occupational therapy, and physical exercises initiated talization and after discharge [2,3]. A number of studies immediately upon achieving physiologic stability and con- found that approximately 33% of the patients have se- tinued throughout the hospital stay. Such activities start vere functional deterioration at time of discharge com- within 1 or 2 days after hospitalization. The second aim of pared to their status before hospital admission [3-5]. For the present review is to evaluate the feasibility of early patients 90 years or older this number even increases to physical rehabilitation programs in the hospitalized geriat- 63% [4]. Functional decline during and after hospital stay ric patients. has shown to be an important risk factor for nursing home placement [6,7]. Method The decline in functional capacity seems to be partly Search strategy the result of the hospitalization itself, unrelated to diag- A systematic literature search was conducted in three nostic or therapeutic interventions. Older patients have electronic databases, PubMed, CINAHL, and EMBASE in decreased physiological and functional reserves that August 2013. Keywords used to perform the search were: make them more vulnerable to the effects of bed rest “aged” or “elderly” or “geriatric”, “hospital” or “hospital- and decrease in dietary intake, which both are highly ized”, “exercise” or “rehabilitation”, “ADL” or “physical prevalent during hospitalization. Due to immobilisation, functioning” or “mobility” or “physical performance”,and muscle strength and aerobic capacity tend to decline “acute” or “acutely”. The articles included were random- rapidly. After only ten days of bed rest healthy old adults ized controlled trials (RCT), written in English, including lose 12-14% of both their VO and lower extremity participants aged 65 years or older who were acutely ad- 2max muscle strength [8]. Without any voluntary muscle con- mitted to the hospital. The interventions investigated in tractions muscle strength can even decrease by 5% per thearticles needed to includeaphysicalexercise part with day [2]. a physical functioning measure as outcome. Studies were Altogether, functional decline is a common problem excluded if the included patients required treatment on a that is significantly associated with negative outcomes specialized unit other than an acute geriatric unit or when such as institutionalization, re-hospitalization and subse- the evaluated intervention aimed at a specific disorder or quent mortality [3]. The primary focus of hospital care is surgical process. Articles about the feasibility of early treating acute and chronic illnesses. A physical rehabili- physical rehabilitation of inpatients were retrieved by tation intervention that may preserve physical function adding the keywords “feasibility” or “feasible” or “adher- is often not part of the treatment. To preclude a rapid ence rate” or “safety” to the keywords mentioned above. decline in physical function it is important that hospital The articles about feasibility had the same in and exclu- programs are also directed explicitly towards activating sion criteria as the articles addressing physical functioning the older patient early after hospital admission. Early with the exception that also non randomized controlled physical rehabilitation might help to prevent decline in trials were included. For the inclusion process title and ab- physical functioning arising from immobility and pro- stract were examined and when necessary the full article longed bed rest [9]. was obtained and read. Additional studies were identified Over the years, several multidisciplinary and exercise through reference and citation tracking. Two reviewers types of early rehabilitation interventions have been stud- independently screened title, abstract and full text. Dis- ied. Previous studies showed that early rehabilitation pro- agreement about inclusion of articles was resolved by dis- grams improved both patient (e.g. physical functioning) cussion and consensus between the two reviewers. and hospital outcomes (e.g. reducing costs) for acute ill geriatric patients [10,11]. However, an important issue not Data extraction and analysis yet addressed in the current literature is the feasibility of Data were extracted against pre-defined categories by in-hospital early exercise programs for acute geriatric pa- two researchers. The data compiled from the studies in- tients. To start an early physical rehabilitation program, cluded information on: study design, characteristics of Kosse et al. BMC Geriatrics 2013, 13:107 Page 3 of 16 http://www.biomedcentral.com/1471-2318/13/107 participants and setting, the intervention and control for the feasibility assessment. The article of Laver et al. group treatment, time of assessment, ADL, physical per- [14] was included in both the physical functioning and the formance, length of stay and discharge destination. Fur- feasibility section. PRISMA guidelines were followed in thermore, the feasibility outcomes were the ability to this systematic review [15]. enrol patients into the rehabilitation program, and the adherence rate and safety of the patients during the ther- Methodological quality apy sessions. The information extracted from the articles In Table 1 the quality scores on the Delphi Scale for the was organized into tables and systematically compared. different RCT studies are reported. Total quality scores ranged from 3 to 7 with a median score of 5. The meth- Methodological quality odological quality was moderate for most studies. The methodological quality of the included RCTs was Randomization methods and eligibility criteria were assessed using the Delphi scale [12]. The Delphi scale is clearly defined in all 13 studies. The studies scored par- a quality assessment tool for RCTs and has shown to be ticularly low on blinding the assessor, the care provider valid and reliable [13]. It consists of 9 different criteria and the participant. The Delphi scores were good for the which can be scored positive, negative, or unclear (“yes”, concealed treatment allocation, the similarity of the “no”,and “don’t know”). One point was given for each intervention and control groups at baseline and the clar- “yes” and zero points for each “no” or “don’t know”, the ity of the specified eligibility criteria. total quality sore ranged from 0 (low quality) to 9 (high quality). Inclusion criteria and patient characteristics Table 2 summarizes the characteristics of patients, study Results settings, early physical rehabilitation programs and out- Selected studies comes of the included RCT studies in this review. The The literature search for physical functioning yielded a mean age for patients admitted to acute care in the hos- total of 772 papers (Figure 1). After removing 765 arti- pital for a general medical condition varied between 78 cles based on title and abstract, 9 articles were qualified and 86 years old. The most common reasons for admis- for full text reading. Four articles were removed after full sion were cardiac problems, respiratory problems, text reading and ten articles were added after reference gastrointestinal problems, neurological problems, infec- checking. The remaining 15 articles, describing 13 stud- tions and injuries caused by a fall. The living situation of ies, were included to this review. The search for feasibil- the patients before they were admitted to the hospital ity studies yielded 50 papers. After removing 47 articles varied, patients came from nursing homes and other by title, abstract and full text reading and adding one art- types of institutionalised care or from the community icle after reference checking, four studies were included where they lived alone or with family. However, the Physical Functioning Feasibility Records identified through Records identified through Additional records identified Additional records identified database searching (n =57) database searching (n = 859) through other sources (n = 10) through other sources (n = 1) Records after duplicates removed Records after duplicates removed (n =51) (n = 782) Records screened Records screened Records excluded (n =773) Records excluded (n =46) (n = 782) (n =51) Full-text articles assessed Full-text articles excluded (n =1) Full-text articles assessed Full-text articles excluded (n =4) for eligibility (n = 5) Reasons: for eligibility (n = 19) Reasons: No acute care =1 No exercise part =2 No RCT =2 Studies included in Studies included in synthesis (n = 15) synthesis (n =4) Figure 1 Flowcharts of search results. Included Eligibility Screening Identification Included Eligibility Screening Identification Kosse et al. BMC Geriatrics 2013, 13:107 Page 4 of 16 http://www.biomedcentral.com/1471-2318/13/107 Table 1 Methodological quality scores on the Delphi scale for each RCT study Study Randomized Treatment Groups Eligibility Outcome Care Patient Variability Intention-to-treat Total allocation similar at criteria assessor provider blinded measures analysis (max 9) concealed baseline specified blinded blinded Abizanda [16]1 1 0 1 1 1 1 1 0 7 Asplund [17]1 1 1 1 0 0 0 0 0 4 Blanc-Bisson [18]1 0 1 1 0 0 0 1 1 5 Counsell [19]1 1 1 1 0 0 0 1 1 6 Courtney [20,21]1 1 1 1 1 0 0 1 1 7 De Morton [22]1 0 0 1 0 0 1 1 1 5 Jones [23]1 1 0 1 0 0 0 1 1 5 Landefeld [24]1 0 1 1 0 0 0 0 0 3 Laver [14]1 1 1 1 1 0 0 1 1 7 Nikolaus [25]1 1 1 1 1 0 0 1 0 6 Saltvedt [26,27]1 1 1 1 0 0 0 1 0 5 Siebens [28]1 1 1 1 0 0 0 0 1 5 Slaets [29]1 1 1 1 0 0 0 0 0 4 studies did not include all patients in the intervention, The aim of the exercise programs was predominantly to reasons for exclusion were medical instability [18,22,23], improving functional outcomes by training strength, mo- need for specialized care [17,19,22,24], living in nursing bility, and balance. Strength exercises were progressed homes [19,20,22,23,25,26,28], small survival chance or by increasing the number of sets and repetitions and need for palliative care [18,22,23,25,28], and being diag- walking exercises were progressed in intensity (from nosed with an illness causing functional impairment slow to moderate pace) or duration (from 5 to 30 mi- [18,23,28]. Overall, there was a great heterogeneity nutes). In one study an interactive video gaming pro- among the participants between the different studies. gram was used to exercise. A Nintendo Wii fit group trained 25 min/day, 5 days/week under supervision of a Setting and intervention physical therapist [14]. Some exercise programs sup- Table 2 gives an overview of the settings and interven- ported participants to continue exercise after discharge tions of each included randomized controlled trial. The [20,25,28]. This was achieved by educational materials, studies were performed on acute geriatric units, geriatric by (two or more regular) encouraging phone calls and units and medical units of university hospitals, city hos- home visits [20,28], or by a follow-up treatment, twice a pitals and acute care hospitals. Early physical rehabilita- week up to twice a day, including physical and occupa- tion programs could be divided into two categories, (1) tional therapy [25]. The control groups of the studies multidisciplinary programs with an exercise component generally received usual care according to the general and (2) usual care with an additional exercise program. routines of the hospital they were admitted to. In the review we refer to these categories as multidiscip- linary programs and exercise programs, respectively. The Physical functioning main aim of the multidisciplinary programs was to All included studies provided at least one outcome maintain or obtain independent ADL and encourage measure related to physical functioning. Most studies returning home. Multidisciplinary intervention teams used measures of activities of daily living (ADL) and usually consisted of a geriatrician, (geriatric) nurses, so- physical performance to describe physical functioning. cial workers, physical therapists and occupational thera- Additional information about length of stay and dis- pists [17,19,24,26,29]. The specific exercise component charge destination were also documented. of the multidisciplinary intervention studies is hardly de- scribed, and information on intensity, duration, and fre- Activities of daily living quency of exercises is often lacking. Usual care with an The included studies gained information on patient’s additional exercise program was provided in eight stud- ADL by conducting interviews and (self-administered) ies [14,16,18,20,22,23,25,28]. The patients in the exercise questionnaires. Table 3 gives on overview of the used in- programs were supervised by allied health assistants, a struments to measure (I)ADL. Eleven of the thirteen physiotherapist or an occupational therapist. Patients studies reported the effects of their intervention on performed exercises five times a week up to twice daily. (I)ADL at time of hospital discharge [14,16-19,21-25,29]. Kosse et al. BMC Geriatrics 2013, 13:107 Page 5 of 16 http://www.biomedcentral.com/1471-2318/13/107 Table 2 Setting and study characteristics physical functioning Study Population & Setting Intervention Time of assessment (I)ADL Physical Mortality LOS Discharge Performance (%) (days) ICF (%) Multidisciplinary care with an exercise component Asplund 2000 [17] Intervention (n=190) Multidisciplinary team, with physical and occupational T0 Admission BI ≥ 19 points NA T1 4.2 5.9 T1 11.6 therapy. Discharge planning and early rehabilitation. Mean age 80.9 years T1 Discharge T0 52% T2 11.1 T2 11.6 58% female, AGU, UH T2 3 months post-discharge T2 44% Control (n=223) General medical unit care BI ≥ 19 points T1 2.7 7.3 T1 19.3 Mean age 81.0 years T0 44% T2 7.6 T2 18.4 63% female, MU, UH T2 43% Counsell 2000 [19] Intervention (n=767) † Multidisciplinary team, with daily assessment of T0 2 weeks pre-admission ADL decline PPME score T1 2.7 6.1 T1 12.9 physical functioning and protocols to improve Mean age 80 years T1 Discharge T1 30% T1 5.6 T2 9.0 T2 10.3 self-care and mobility. Early discharge planning. 60% female, CH T2 1 months post-discharge T2 27% T3 15.9 T3 8.9 T3 3 months post-discharge T3 26% T4 22.6 T4 7.5 T4 6 months post-discharge T4 22% T5 31.4 T5 6.7 T5 1 year post-discharge T5 25% Control (n=764) † Usual physician and nursing staff care ADL decline PPME score T1 3.7 6.3 T1 15.6 Mean age 79 years T1 34% T1 5.0 T2 11.3 T2 10.1 61% female, CH T2 29% T3 26% T3 17.4 T3 7.2 T4 30% T5 30% T4 22.5 T4 8.0 T5 29.2 T5 7.3 Landefeld 1995 [24] Intervention (n=327) Multidisciplinary program, with daily assessment T0 Admission ADL score: NA T1 7.3 7.3 T1 5.8 of physical functioning and protocols to improve Mean age 80.2 years T1 Discharge T0 3.0 T2 20.8 T2 13.1 self-care and mobility 68% female, MU, CH T2 3 months post-discharge T1 3.6 T2 4.0 IADL score: T0 2.8 T1 3.3 T2 3.9 Kosse et al. BMC Geriatrics 2013, 13:107 Page 6 of 16 http://www.biomedcentral.com/1471-2318/13/107 Table 2 Setting and study characteristics physical functioning (Continued) Control (n=324) Usual care services provided by ADL score: T1 7.4 8.3 T1 11.7 physicians and nurses Mean age 80.1 years T0 3.0 T2 19.8 T2 18.8 65% female, MU, CH T2 3.8 IADL score: T0 2.8 T2 3.8 * * Saltvedt 2002 [26,27] Intervention (n=127) † Interdisciplinary program to prevent T0 Admission ADL dependence NA T1 11.8 15 NA complications, with early mobilization, Mean age 81.8 years T1 3 months post-discharge T1 21% T3 26.8 rehabilitation and discharge planning 81% female, GU, UH T2 6 months post-discharge T2 13% T3 1 year post-discharge T3 25% IADL dependence T1 46% T2 44% T3 45% * * Control (n=127) † Usual care ADL dependence T1 27.6 7 Mean age 82.4 years T1 12% T2 33.9 84% female, MU, UH T2 13% T3 23% IADL dependence T1 39% T2 40% T3 44% * * Slaets 1997 [29] Intervention Multidisciplinary program added to the T0 Admission Improved ADL Improved NA 19.7 T2 18 (n=140) usual care. Geriatrician, physiotherapist mobility and liaison nurse obtained optimal ADL * * Mean age 82.5 years T1 Discharge T1 61% T1 48% and mobility in 2 hours training a day. 67% female , MU, CH T2 1 year post-discharge * * Control (n=97) Usual care: services provided by physicians Improved ADL Improved 24.8 T2 27 and nurses. mobility * * Mean age 83.2 years T1 46% T1 44% 75% female, MU, CH Kosse et al. BMC Geriatrics 2013, 13:107 Page 7 of 16 http://www.biomedcentral.com/1471-2318/13/107 Table 2 Setting and study characteristics physical functioning (Continued) Usual care programs with an exercise intervention Abinzanda 2011 [16] Intervention (n=198) Conventional treatment plus occupational T0 Admission 55.6% improved NA T1 7.6 9.1 NA therapy: 5 days per week, 30 - 45 min a day ≥ 10 BI points Mean age 83.7 years T1 Discharge 56.6% female, AGU, UH Control (n=202) Conventional treatment: medical treatment, 36.7% improved T1 11.9 8.7 nursing care, physical therapy, and social ≥ 10 BI points Mean age 83.3 years assistance according with the usual practice of the unit. 56.9% female, AGU, UH Blanc-Bisson 2008 [18] Intervention (n=38) Usual care plus early intensive physical therapy T0 Admission Mean Katz index NA T1 5.3 T1 NA program: start day 1-2, strength training twice 12.6 Mean age 85.5 years T1 Clinical stability T0 6.7 T2 7.9 a day half an hour, 5 days a week until T1 66% female, AGU, UH T2 1 month after clinical T1 5.3 stability T2 4.5 Control (n=38) Usual care: transferred to arm-chair asap. Start Mean Katz index T1 5.3 T1 day 3-6 walking 3 times a week with human 12.6 Mean age 85.4 years T0 6.0 T1 5.3 help or without assistance. Physical therapy at home for 1 month 79% female, AGU, UH T1 4.7 T2 3.0 Courtney 2009 [20,21] Intervention (n=64) † Individual exercise program and nursing T0 Admission ADL: Mean score WIQ distance T1 1.6 4.6 NA visits, performed daily or several times a Mean age 78.1 years T1 4 weeks post-discharge index of ADL T0 23.54 T2 3.1 week. The intervention continued at home with home visits and regular telephone 62% female, MU, CH T2 12 weeks post-discharge T0 0.36 T1 53.62 T3 3.1 follow-up by a nurse. T3 24 weeks post-discharge T1 0.07 T2 54.83 T2 0.18 T3 62.89 T3 0.16 WIQ speed IADL: Mean T0 16.21 IADL scale T0 2.16 T1 41.30 T1 1.47 T2 44.62 T2 1.27 T3 48.56 T3 1.13 WIQ stairs T0 27.70 T1 46.73 T2 51.23 T3 57.20 Kosse et al. BMC Geriatrics 2013, 13:107 Page 8 of 16 http://www.biomedcentral.com/1471-2318/13/107 Table 2 Setting and study characteristics physical functioning (Continued) Control (n=64) † Routine care, discharge planning and ADL: Mean score WIQ distance T1 4.7 4.7 rehabilitation advice. If necessary, index of ADL in-home follow-up. Mean age 79.4 years T0 0.35 T0 20.22 T2 4.7 63% female, MU, CH T1 0.69 T1 28.90 T3 4.7 T2 0.75 T2 21.59 T3 1.27 T3 19.93 IADL: Mean WIQ speed IADL scale T0 2.62 T0 14.43 T1 3.29 T1 22.09 T2 3.56 T2 17.89 T3 4.33 T3 16.58 WIQ stairs T0 24.12 T1 26.06 T2 24.40 T3 22.18 De Morton 2007 [22] Intervention (n=110) † Usual care plus an individual exercise T0 Admission Mean BI: Mean TUG (s): T1 1.8 5.0 T1 18.2 program. Twice daily, 5 days a week, Mean age 78 years T1 Discharge T0 66 T0 35 for 20-30 minutes. 54% female, MU, ACH T1 79 T1 36 Mean FAC: T0 4.0 T1 4.8 Control (n=126) † Usual care: daily medical assessment, 24 hour Mean BI: Mean TUG (s): T1 1.6 6.0 T1 20.6 nursing assistance, and allied health service Mean age 80 years T0 68 T0 30 on referral from medical, nursing or other allied health staff. 56% female, MU, ACH T1 75 T1 26 Mean FAC: T0 3.9 T1 4.7 Kosse et al. BMC Geriatrics 2013, 13:107 Page 9 of 16 http://www.biomedcentral.com/1471-2318/13/107 Table 2 Setting and study characteristics physical functioning (Continued) Jones 2006 [23] Intervention (n=80) † Usual care plus an individual exercise T0 Admission T1 Discharge Mean change Mean change T1 5.0 9 T1 32.5 program Twice daily for approximately mBI: 11 points TUG: 5.4 sec Mean age 81.9 years 30 minutes. 54% female, MU, ACH Control (n=80) † Usual care: medical, nursing and allied health Mean change Mean change T1 2.5 11 T1 51.3 intervention and discharge planning consistent mBI: 9 points TUG: 1.2 sec Mean age 82.9 years with the patient’s diagnosis and resources available on the acute general medical wards. 61% female, MU, ACH Laver 2012 [14] Intervention (n=22) Individual interactive video game program T0 Admission IADL TUG T1 0 12.3 NA (Wii Fit) 25 min/day, 5 days/week supervised Mean age 85.2 years T1 Discharge T0 181 T0 38 by a physiotherapist 86% female GU, ACH T1 205 T1 28 Control (n=22) Conventional physiotherapy, matching the IADL TUG T1 0 14.95 NA patients abilities and treatment needs Mean age 84.6 years T0 141 T0 35 25 min/day, 5 days/week 73% female GU, ACH T1 190 T1 29 * * Nikolaus 1999 [25] Intervention with In-hospital and post-discharge follow-up T0 Admission Mean BI score: NA T2 18.2 33.5 T1 4.4 follow-up (n=181) † treatment by an interdisciplinary team. Physical or occupational therapy twice a Mean age 81.4 years T1 Discharge T0 71.0 T2 16.6 week up to twice a day for 30 min Female 73.4%, GU, UH T2 1 year post-discharge T1 91.8 T2 81.2 Mean LB score: T1 5.7 T2 5.6 * * Intervention without In-hospital treatment by an interdisciplinary Mean score BI: T2 16.8 40.7 T1 7.3 follow-up (n=179) † team, followed by usual care at home Mean age 81.4 years T0 71.0 T2 18.4 Female 73.4%, GU, UH T1 92.6 T2 82.3 Mean LB score: T1 5.5 T2 4.1 * * Control (n=185) † Usual care in hospital Mean score BI: T2 17.3 42.7 T1 8.1 Mean age 81.4 years T0 71.0 T2 22.7 Female 73.4%, GU, UH T1 91.1 T2 80.9 Mean LB score: T1 5.5 T2 4.3 Kosse et al. BMC Geriatrics 2013, 13:107 Page 10 of 16 http://www.biomedcentral.com/1471-2318/13/107 Table 2 Setting and study characteristics physical functioning (Continued) Siebens 2000 [28] Intervention (n=149) † Hospital-based exercise program twice a day. T0 2 weeks pre-admission Mean number of Independent T1 6.7 12.0 NA Encouragement to continue the program at home independent IADL walking Mean age 78.2 years T1 1 month post-discharge T0 5.3 T0 59.7% 62% female, ACH T1 5.1 T1 64.2% Control (n=151) † Usual care Mean number of Independent T1 6.6 10.5 IADL independence walking Mean age 78.5 years T0 5.3 T0 50.3% 59% female, ACH T1 4.6 T1 65.5% † = included only community dwelling old adults; ADL= Activities of Daily Living; IADL= Instrumental Activities of Daily Living; ICF=Intramural Care Facility; AGU=Acute Geriatric Unit; GU=Geriatric Unit; MU=Medical Unit; UH=University Hospital; CH=City Hospital; ACH=Acute Care Hospital; * = significant (p > 0.05); PPME=Physical Performance and Mobility Examination; WIQ=Walking Impairment Questionnaire; TUG=Timed Up and Go; FAC=Functional ambulation classification; NA=not available. Kosse et al. BMC Geriatrics 2013, 13:107 Page 11 of 16 http://www.biomedcentral.com/1471-2318/13/107 Table 3 Overview of the instruments used to measure (I)ADL and physical performance Instrument Study Assessment Score Min Max Interpretation Katz index/ADL index Courtney [20] Ability to perform: Bathing, eating, dressing, continence, transfer to toilets 0 6 0 independent - 6 dependent and locomotion Bizon-Blanc [18] 0 12 0 independent - 12 dependent Counsell and Landefeld [19,24] Ability to perform: Bathing, dressing, using the toilet, moving from a bed to 0 5 0 independent – 5 dependent a chair, and eating (modified) Barthel index Asplund and Salvedt [17,26] Feeding, urinary and faecal continence, personal toilet, dressing, toilet use, 0 20 1 dependent – 20 independent transferring, walking outdoors, climbing stairs and bathing Abizanda, Jones, De Morton, 0 100 0 dependent - 100 independent Nicolaus [16,22,23,25] Lawton index/IADL index Nikolaus and Salvedt [25,26] Ability to use telephone, shopping, food preparation, housekeeping, laundry, mode 0 8 0 dependent - 8 independent of transportation, responsibility for medication and ability to handle finances Counsell, Courtney, Landefeld Ability to use telephone, shopping, food preparation, housekeeping, mode of 0 7 0 dependent - 7 independent and Siebens [19,20,24,28] transportation, responsibility for medication and ability to handle finances Timed IADL Laver [14] The time needed to complete tasks addressing five IADL domains: Lower scores indicates greater ability (1) communication, (2) finance, (3) cooking, (4) shopping, and (5) medicine. SIVIS dependency scales Sleats [29] SIVIS independency scale: 20 questions relating to orientation, communication, NA mobility, transfers, ADL, continence, catheter use, and decubitus Functional Independence Laver and Siebens [14,28] Measures the level of a patient’s disability and indicates how much 18 126 18 dependent – 126 independent Measure (FIM) assistance is required for the individual to carry out activities of daily living: Eating, Grooming, Bathing, Upper and lower body dressing, Toileting, Bladder and bowel management, Bed to chair transfer, Toilet and shower transfer, Locomotion, Stairs, Cognitive comprehension, Expression, Social interaction, Problem solving, Memory Walking Impairment Courtney [20] Walking distance, walking speed and climbing stairs 0 100 Higher scores indicates Questionnaire (WIQ) greater ability Timed Up and Go (TUG) Jones, Laver, Time taken for the patient to rise from a chair, walk 3 m, turn and walk Lower scores indicates De Morton [14,22,23] back to the chair greater ability Functional Ambulation Classification De Morton [22] Ability to ambulate over a 10 foot distance and 4 m length of foam 0 6 0 dependent - 6 independent Physical activity scale Siebens [28] Questionnaire about walking ¼ mile, walking up 10 steps, NA crouching/kneeling, lifting/carrying 10 lbs Mobility Counsell [19] Walking to a table, walking inside the house, walking a block, walking NA uphill or upstairs, and running a short distance Physical Performance and Counsell [19] Bed mobility, transfer skills, multiple stands, standing balance, step up 0 6 0 dependent – 6 independent Mobility Examination one step and timed 6 m walk Short Physical Performance Battery Laver [14] Three standing balance measures (tandem, semi-tandem, and side-by-side 0 12 0 dependent – 12 independent stands), five continuous chair stands, and a 2.44-meter walk. Modified Berg Balance Scale Laver [14] NA NA=Not available. Kosse et al. BMC Geriatrics 2013, 13:107 Page 12 of 16 http://www.biomedcentral.com/1471-2318/13/107 Two multidisciplinary programs found that patients in discharge. Conversely, the other study [20] reports that exercise group compared to the patients in usual care the exercise group had greater improvement over time group significantly improved more and worsened less in (up to 24 weeks after discharge) in walking distance, the number of basic ADL activities they were able to walking speed and stair climbing. Similar contradicting perform [24,29]. The other studies did not find a signifi- results were found on more general outcome measures cant group difference in ADL at time of discharge. How- of physical functioning, provided by a health question- ever, one study with an exercise intervention found a naire that contained physical well-being and physical ac- significant interaction effect between group and admis- tivity. No group differences were found for the National sion scores on the modified Barthel index meaning that Health Survey Physical Activity Scale at one month patients with a low admission score who received an ex- follow-up [28], while the other study found that the ex- ercise intervention showed greater improvement in ADL ercise group scored higher than the usual care group on than those patients who received only usual care [23]. physical health related quality of life at 4, 12, and Two studies reported a ceiling effect for the Barthel 24 weeks after discharge [21]. In short, follow-up results index and a floor effect for the Katz index [22,23]. on physical performance are contradictory. Nevertheless, Remaining studies did not found a significant difference at time of discharge most studies show a greater im- on ADL between early physical rehabilitation programs provement for patients in the multidisciplinary and exer- and usual care (see Table 2). cise group than for the patients in the usual care group. Of the eight studies that reported follow-up data on (I)ADL [17-20,24-26,28] only the three studies with Length of stay and discharge destination an exercise intervention that provided patients with All included randomized controlled trials reported about follow-up treatment after hospital discharge reported the length of stay, which varied between the 4.7 days larger improvements in the exercise group than in and 42.7 days. Four studies (three multidisciplinary pro- the usual care group after 1, 6 and 12 months grams) reported a significant difference shorter length of [20,25,28]. One study that did not provide patients stay of the exercise group than for the usual care group with follow-up treatment also found a positive effect of the [17,25,27,29]. intervention on ADL at 3 months post-discharge. However, From the seven studies [17,19,22-25,29] that reported this study included patients who died by assigning them a on discharge destination, five studies found that a higher score of zero, whereas the mortality rate was higher in the proportion of patients in the early physical rehabilitation usual care group than the multidisciplinary group [26]. group than in the usual care group were discharged home, instead of being transferred to additional (sub- Physical performance acute) hospital treatment or to institutionalized care, how- Seven studies reported measures of physical performance; ever, results were significant in three studies (Table 2). Table 3 gives an overview of the used measurement in- Two multidisciplinary programs found that respectively struments [14,19,20,22,23,28,29]. Three (2 multidisciplin- 14% and 18% of the patients in the multidisciplinary group ary programs and 1 exercise programs) of the five studies were discharged to a long-term care institution opposed describing physical performance at time of admission and to 22% and 27% of usual care patients [24,29]. The third discharge found that the intervention groups improved study, an exercise intervention, included only patients more or declined less than the usual care groups who had lived at home before admission and found that [19,23,29]. However, for one study the difference in the 4% of the patients in the exercise group and 8% of the pa- Timed Up and Go (TUG) was not significant after tients in the usual care group were discharged to long- adjusting for confounders such as patient characteristics, term care institutions [25]. admission modified Barthel Index, comorbidity, and men- tal scores [23]. Feasibility For the TUG a floor effect was found. In one study, al- Feasibility of early physical rehabilitation programs, was most 40% of the patients were physically unable to per- explicitly assessed in four studies (Table 4) comparing form the TUG at both admission and discharge [23], usual care with an exercise intervention program whereas in another study 23% of all patients were unable [14,30-32]. In addition included randomized controlled to perform the TUG at admission to the hospital [22]. trails with an exercise program reported on enrolment Two studies reported follow-up results on physical (n=3), adherence rate (n=2) and adverse events (n=5), performance, but the results are ambiguous [20,28]. One while multidisciplinary studies reported on enrolment study [28] reported no significant difference between the (n=3) only. patients in the exercise group and in the usual care Subjects enrolled in the studies explicitly assessing group in the change in physical performance scores feasibility were respectively above the age of 60 or 70. obtained 2 weeks before admission and one month after The most common exclusion criteria were severe Kosse et al. BMC Geriatrics 2013, 13:107 Page 13 of 16 http://www.biomedcentral.com/1471-2318/13/107 Table 4 Setting and study characteristics feasibility Study Population & setting Intervention Feasibility Brown 2006 [30] Intervention (n=7) Exercise sessions twice a day, 7 days a week. After discharge n=605 admitted, n=76 included 20-30 min walk each day and resistance exercise every other day Mean age 70.2 years, n=66 declined participation 0% female Control (n=2) Usual care which included physical therapy if a consult was initiated by the physician Mean age 70.2 years, 0% female Mallery 2003 [31] Intervention (n=19) Usual care plus resistance exercise 3 times per week, n=395 admitted, n=39 included 30-40 min, assisted by a physiotherapist Mean age 82.7 years Participation 71%, 74% female, GU, UH Adherence 63% No adverse events Control (n=20) Usual care plus passive range of motion training Participation 96%, 3 times per week, 30-40 min, assisted by a physiotherapist Mean age 81.4 years Adherence 95% 45% female, GU, UH No adverse events Nolan 2008 [32] Intervention (n=196) Participated in the Functional Maintenance Exercise n=1021 admitted, n= 220 included Program, 6 times per week, 30 min Mean age 83.6 years, 33 withdrawn 68% female, GU, UH Control (n=24) Usual care with usual physiotherapy Mean age 85.4 years 67% female, GU, UH Laver 2012 [14] Intervention (n=22) Individual interactive video game program (Wii Fit) n=235 admitted, n=44 included 25 min/day, 5 days/week supervised by a physiotherapist Mean age 85.2 years 90% adherence rate 86% female GU, ACH No adverse events Control (n=22) Conventional physiotherapy, matching the patients 91% adherence rate abilities and treatment needs 25 min/day, 5 days/week Mean age 84.6 years 1 adverse event, conscious collapse 73% female GU, ACH GU=Geriatric Unit; UH=University Hospital. impairments in physical performance and cognition, re- Instead, patients were discharged before therapy could quiring palliative care, expected short length of stay, and begin or were unavailable due to diagnostic tests or ap- medical instability. One study specifically targeted frail pointments with healthcare professionals. patients that were at risk of functional decline [32]. Adherence rates were fairly high between the 60% and Feasibility was measured quantifying patients enrol- 90% [14,20,31,32]. The most common reasons for drop- ment, patient adherence to the program and at patient’s ping out of the intervention programs were early dis- safety in the context of the exercise program. Nine of charge, being transferred to intensive or palliative care, the 11 studies found that between the 14% and 48% of being medically unstable, and death [17-19,22,23,28,32]. the admitted patients met the inclusion to be enrolled in A final measure of feasibility is patient safety during the programs, and between 3 and 19% of the patients the exercise program. One feasibility study and six RCT were not willing to participate [14,17,19,22-24,28,31,32]. studies included in this review reported on potential side In general patients not willing to participate stated that effects such as injuries, accidents, and more specifically, they did not feel like exercising or that they did not be- fall incidents, related to participating in the early phys- lieve they could exercise. They felt unwell and/or were ical rehabilitation programs [14,16,18,20,23,28,31]. None scared that exercising would make them feel worse. of the studies found any differences in the number of in- In one study [30] only 2% of all admitted patients were cidents between the exercise groups and usual care included. Of the 76 patients that met the inclusion cri- groups. teria only 10 consented to participating while 87% of the eligible patients refused to take part in the program. In Discussion fact none of the included patients were able to start with The first aim of this review was to evaluate the effect of the exercise program. Reasons for not participating in early physical rehabilitation programs for geriatric hospi- the exercise program were not of a physical nature. talized patients on physical functioning. A total of 15 Kosse et al. BMC Geriatrics 2013, 13:107 Page 14 of 16 http://www.biomedcentral.com/1471-2318/13/107 articles, reporting on 13 studies, were included that pro- nursing home admission found positive effects of an ex- vided early physical rehabilitation programs in a hospital ercise program on ADL, length of stay and discharge setting. The present review shows that early physical re- destination [20,25,26]. This result indicates that frail old habilitation programs might be beneficial to prevent adults and nursing home patients may benefit from early rapid decline in physical functioning. rehabilitation. Targeting the right population for early A classification could be made between multidisciplin- physical rehabilitation may be seen as crucial. ary programs with an exercise component and usual care The outcomes with regard to physical functioning with an exercise component. Multidisciplinary programs were measured by a variety of instruments and at differ- reduced the length of stay for patients in the exercise ent points in time, some of these instruments demon- groups compared to the patients receiving usual care. strated floor and ceiling effects. Floor and ceiling effects Additionally, the patients in the multidisciplinary pro- could influence the outcomes and distort the results. grams were less likely to be discharged to a nursing home There were also cases in which information could only or other forms of institutionalized care than patients in be collected with the help of close relatives and care- the usual care group. The usual care programs with an ex- givers, because relevant information could not be ercise intervention had the main aim to improve func- obtained from the patients themselves. The limitations tional outcomes, some of the studies showed indeed an of the current used measurement instruments implies improvement on ADL and physical performance. that there might be a need for more sensitive instru- The two types of exercise interventions, e.g. multidis- ments that measure aspects of physical functioning in ciplinary programs with an exercise component and usual hospitalized old adults. care with an exercise component, did not find different re- Finally, the second aim of this review was to investi- sults in physical functioning at time of discharge. At time gate the feasibility of early physical rehabilitation pro- of discharge, results on physical performance were to grams for acute ill older patients. The early physical some extent contradicting, but the majority of the in- rehabilitation programs must be safe to perform and cluded studies showed that patients in the exercise groups may not cause high numbers of drop outs. There were had better ADL and physical performance than patients in four studies identified reporting on the feasibility of in- the usual care groups, although those results were not al- hospital exercise programs [14,30-32]. Additionally, a ways significant. Follow-up results on ADL and physical part of the randomized controlled trials, used to deter- performance showed that persistent positive effects were mine the effect on physical functioning, reported also on mainly found in studies that provided patients with con- some feasibility points. Several studies included in this tinuous interventions after hospital discharge. The studies review affirmed the safety of early rehabilitation pro- that provided patients with only in-hospital exercise inter- grams. Patients in the early physical rehabilitation ventions found little or no effect on ADL and physical groups were not more often injured, nor did they experi- performance at follow-up examinations. These results are ence more adverse events or falls than usual care pa- in line with other studies that investigate the effects of tients. Results on patient recruitment were contradictory care in geriatric units and of inpatient rehabilitation for and should be interpreted with care due to the limited geriatric patients on functional parameters [10,33]. The ef- number of available studies. Adherence rates were high fects of only in-hospital interventions were clearly positive for most studies. Patient as well as the intervention pro- at time of discharge but were greatly reduced during vider’s satisfaction was higher when patients were follow-up. These results suggest that the recovery of pa- treated with a early physical rehabilitation program in- tients could further benefit from a community based or stead of usual care [19]. There was one study that en- in-home intervention programs which build on in- countered difficulties in recruiting patients and was hospital programs. Such programs could consist of phys- unable to have any patients participate in the exercise program at all [30]. Patients refused to participate or ical or occupational therapy. In addition, the present re- view shows in home visits and follow-up telephone calls were unavailable at scheduled time of therapy. One of might be effective for adherence for home-based exercise the greatest barriers in the implementation of interven- tion research, according to the opinion of nurses, was a [20]. Further research is needed to clarify the effects and feasibility of community based and in-home intervention lack of awareness and knowledge [34]. Equally important programs in old adults after hospital discharge. in this regard were difficulties in the cooperation of interdisciplinary team members [34]. Education of staff The studies presented in this review included very het- erogeneous groups. Half of all studies excluded nursing and patients about the safety and the benefits of early home patients. Probably, due to the aim of those studies physical rehabilitation as well as regular team confer- to facilitate discharge home. The studies in this review ences that improve coordination might help to increase that targeted frail older patients, patients with increased the success rate of intervention programs with regard to risk for readmission or patients with a high risk for participate. Kosse et al. BMC Geriatrics 2013, 13:107 Page 15 of 16 http://www.biomedcentral.com/1471-2318/13/107 Limitations Author details University of Groningen, University Medical Center Groningen, Center for The total number of included studies in this review is Human Movement Sciences, Groningen, The Netherlands. Geriatrics Center small and the methodological quality for most studies Oldenburg, Carl von Ossietzky Universität Oldenburg, Oldenburg, Germany. was moderate. Most articles scored particularly low on Received: 15 May 2013 Accepted: 8 October 2013 blinding the assessor, the care provider, and the partici- Published: 10 October 2013 pant. However, it may be regarded as almost impossible to assure blinding in the context of early physical re- References habilitative interventions. One of the major limitations 1. OECD: Health at a Glance: Europe 2012. OECD Publishing; 2012 [http://dx.doi. of the included studies lies with the poor descriptions of org/10.1787/9789264183869-en]. 2. Creditor MC: Hazards of Hospitalization of the Elderly. Ann Intern Med exercise in early physical rehabilitation programs. Since 1993, 118(3):219. there is often no clear description on type, duration, fre- 3. Sager MA, Franke T, Inouye SK, Landefeld CS, Morgan TM, Rudberg MA, quency, and intensity of exercises that patients receive. Sebens H, Winograd CH: Functional outcomes of acute medical illness and hospitalization in older persons. Arch Intern Med 1996, 156(6):645–652. Furthermore, because many multidisciplinary programs 4. Covinsky KE, Palmer RM, Fortinsky RH, Counsell SR, Stewart AL, Kresevic D, are focused on outcomes beyond functionality, e.g. early Burant CJ, Landefeld CS: Loss of independence in activities of daily living discharge planning, it is difficult to determine what the in older adults hospitalized with medical illnesses: increased vulnerability with age. J Am Geriatr Soc 2003, 51(4):451–458. effect of the exercise component on physical functioning 5. 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Baztan JJ, Suarez-Garcia FM, Lopez-Arrieta J, Rodriguez-Manas L, Rodriguez-Artalejo F: Effectiveness of acute geriatric units on functional maintaining positive effects on functionality for longer decline, living at home, and case fatality among older patients admitted periods of time. Early physical rehabilitation for acutely to hospital for acute medical disorders: meta-analysis. BMJ 2009, 338:b50. hospitalized older adults seem to be safe to execute in 11. de Morton NA, Keating JL, Jeffs K: The effect of exercise on outcomes for older acute medical inpatients compared with control or alternative terms of adverse events such as falls or other injuries, treatments: a systematic review of randomized controlled trials. but recruiting the most suitable patients and getting Clin Rehabil 2007, 21(1):3–16. them to participate regularly in the program can be a 12. Verhagen AP, de Vet HC, de Bie RA, Kessels AG, Boers M, Bouter LM, Knipschild PG: The Delphi list: a criteria list for quality assessment of challenge. Therefore, the commitment and collaboration randomized clinical trials for conducting systematic reviews developed of staff is of great importance. Further research is by Delphi consensus. J Clin Epidemiol 1998, 51(12):1235–1241. needed to quantify the physical activity of patients in 13. Olivo SA, Macedo LG, Gadotti IC, Fuentes J, Stanton T, Magee DJ: Scales to assess the quality of randomized controlled trials: a systematic review. early physical rehabilitation programs and to determine Phys Ther 2008, 88(2):156–175. the effects and feasibility of community-based and in- 14. Laver K, George S, Ratcliffe J, Quinn S, Whitehead C, Davies O, Crotty M: Use home exercise programs. of an interactive video gaming program compared with conventional physiotherapy for hospitalised older adults: a feasibility trial. Disabil Rehabil 2012, 34(21):1802–1808. Competing interests 15. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gotzsche PC, Ioannidis JP, Clarke The authors declare that they have no proprietary, financial, professional, or M, Devereaux PJ, Kleijnen J, Moher D: The PRISMA statement for reporting other personal competing interests of any nature or kind. systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. J Clin Epidemiol 2009, Authors’ contribution 62(10):e1–e34. Nienke Kosse and Alisa Dutmer managed the review process and wrote the 16. Abizanda P, Leon M, Dominguez-Martin L, Lozano-Berrio V, Romero L, draft of the full manuscript together with Claudine Lamoth. All authors Luengo C, Sanchez-Jurado PM, Martin-Sebastia E: Effects of a short-term critically revised the manuscript and approved the final version. occupational therapy intervention in an acute geriatric unit. A randomized clinical trial. Maturitas 2011, 69(3):273–278. Acknowledgements 17. Asplund K, Gustafson Y, Jacobsson C, Bucht G, Wahlin A, Peterson J, Blom This review is part of the project “Telemedicine & Personalized Care – project JO, Angquist KA: Geriatric-based versus general wards for older acute fall prevention” and co-financed, in the context of the INTERREG IV A medical patients: a randomized comparison of outcomes and use of Program Deutschland-Netherlands, by the European Regional Development resources. J Am Geriatr Soc 2000, 48(11):1381–1388. Fund (ERDF) and the Ministries of Economic Affairs of the Netherlands and 18. Blanc-Bisson C, Dechamps A, Gouspillou G, Dehail P, Bourdel-Marchasson I: the German states of Nordrhein-Westfalen and Niedersachsen. A randomized controlled trial on early physiotherapy intervention versus Kosse et al. BMC Geriatrics 2013, 13:107 Page 16 of 16 http://www.biomedcentral.com/1471-2318/13/107 usual care in acute care unit for elderly: potential benefits in light of dietary intakes. J Nutr Health Aging 2008, 12(6):395–399. 19. Counsell SR, Holder CM, Liebenauer LL, Palmer RM, Fortinsky RH, Kresevic DM, Quinn LM, Allen KR, Covinsky KE, Landefeld CS: Effects of a multicomponent intervention on functional outcomes and process of care in hospitalized older patients: a randomized controlled trial of Acute Care for Elders (ACE) in a community hospital. J Am Geriatr Soc 2000, 48(12):1572–1581. 20. Courtney MD, Edwards HE, Chang AM, Parker AW, Finlayson K, Bradbury C, Nielsen Z: Improved functional ability and independence in activities of daily living for older adults at high risk of hospital readmission: a randomized controlled trial. J Eval Clin Pract 2012, 18(1):128–134. 21. Courtney M, Edwards H, Chang A, Parker A, Finlayson K, Hamilton K: Fewer emergency readmissions and better quality of life for older adults at risk of hospital readmission: a randomized controlled trial to determine the effectiveness of a 24-week exercise and telephone follow-up program. J Am Geriatr Soc 2009, 57(3):395–402. 22. de Morton NA, Keating JL, Berlowitz DJ, Jackson B, Lim WK: Additional exercise does not change hospital or patient outcomes in older medical patients: a controlled clinical trial. Aust J Physiother 2007, 53(2):105–111. 23. Jones CT, Lowe AJ, MacGregor L, Brand CA, Tweddle N, Russell DM: A randomised controlled trial of an exercise intervention to reduce functional decline and health service utilisation in the hospitalised elderly. Australas J Ageing 2006, 25(3):126–133. 24. Landefeld CS, Palmer RM, Kresevic DM, Fortinsky RH, Kowal J: 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(20):1338–1344. 25. Nikolaus T, Specht-Leible N, Bach M, Oster P, Schlierf G: A randomized trial of comprehensive geriatric assessment and home intervention in the care of hospitalized patients. Age Ageing 1999, 28(6):543–550. 26. Saltvedt I, Jordhoy M, Opdahl Mo ES, Fayers P, Kaasa S, Sletvold O: Randomised trial of in-hospital geriatric intervention: impact on function and morale. Gerontology 2006, 52(4):223–230. 27. Saltvedt I, Mo ES, Fayers P, Kaasa S, Sletvold O: Reduced mortality in treating acutely sick, frail older patients in a geriatric evaluation and management unit. A prospective randomized trial. J Am Geriatr Soc 2002, 50(5):792–798. 28. Siebens H, Aronow H, Edwards D, Ghasemi Z: A randomized controlled trial of exercise to improve outcomes of acute hospitalization in older adults. J Am Geriatr Soc 2000, 48(12):1545–1552. 29. Slaets JP, Kauffmann RH, Duivenvoorden HJ, Pelemans W, Schudel WJ: A randomized trial of geriatric liaison intervention in elderly medical inpatients. Psychosom Med 1997, 59(6):585–591. 30. Brown CJ, Peel C, Bamman MM, Allman RM: Exercise program implementation proves not feasible during acute care hospitalization. J Rehabil Res Dev 2006, 43(7):939–946. 31. Mallery LH, MacDonald EA, Hubley-Kozey CL, Earl ME, Rockwood K, MacKnight C: The feasibility of performing resistance exercise with acutely ill hospitalized older adults. BMC Geriatr 2003, 3:3. 32. Nolan J, Thomas S: Targeted individual exercise programmes for older medical patients are feasible, and may change hospital and patient outcomes: a service improvement project. BMC Health Serv Res 2008, 8:250. 33. Bachmann S, Finger C, Huss A, Egger M, Stuck AE, Clough-Gorr KM: Inpatient rehabilitation specifically designed for geriatric patients: systematic review and meta-analysis of randomised controlled trials. BMJ 2010, 340:c1718. Submit your next manuscript to BioMed Central 34. Hutchinson AM, Johnston L: Bridging the divide: a survey of nurses’ and take full advantage of: opinions regarding barriers to, and facilitators of, research utilization in the practice setting. J Clin Nurs 2004, 13(3):304–315. • Convenient online submission doi:10.1186/1471-2318-13-107 • Thorough peer review Cite this article as: Kosse et al.: Effectiveness and feasibility of early • No space constraints or color figure charges physical rehabilitation programs for geriatric hospitalized patients: a systematic review. 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Effectiveness and feasibility of early physical rehabilitation programs for geriatric hospitalized patients: a systematic review

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Springer Journals
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Copyright © 2013 by Kosse et al.; licensee BioMed Central Ltd.
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Medicine & Public Health; Geriatrics/Gerontology; Aging; Rehabilitation
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1471-2318
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10.1186/1471-2318-13-107
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Abstract

Background: Old adults admitted to the hospital are at severe risk of functional loss during hospitalization. Early in-hospital physical rehabilitation programs appear to prevent functional loss in geriatric patients. The first aim of this review was to investigate the effect of early physical rehabilitation programs on physical functioning among geriatric patients acutely admitted to the hospital. The second aim was to evaluate the feasibility of early physical rehabilitation programs. Methods: Two searches, one for physical functioning and one for feasibility, were conducted in PubMed, CINAHL, and EMBASE. Additional studies were identified through reference and citation tracking. To be included articles had to report on in-hospital early physical rehabilitation of patients aged 65 years and older with an outcome measure of physical functioning. Studies were excluded when the treatment was performed on specialized units other than geriatric units. Randomized controlled trials were included to examine the effect of early physical rehabilitation on physical functioning, length of stay and discharge destination. To investigate feasibility also non randomized controlled trials were added. Results: Fifteen articles, reporting on 13 studies, described the effect on physical functioning. The early physical rehabilitation programs were classified in multidisciplinary programs with an exercise component and usual care with an exercise component. Multidisciplinary programs focussed more on facilitating discharge home and independent ADL, whereas exercise programs aimed at improving functional outcomes. At time of discharge patients who had participated in a multidisciplinary program or exercise program improved more on physical functional tests and were less likely to be discharged to a nursing home compared to patients receiving only usual care. In addition, multidisciplinary programs reduced the length of hospital stay significantly. Follow-up interventions improved physical functioning after discharge. The feasibility search yielded four articles. The feasibility results showed that early physical rehabilitation for acutely hospitalized old adults was safe. Adherence rates differed between studies and the recruitment of patients was sometimes challenging. Conclusions: Early physical rehabilitation care for acutely hospitalized old adults leads to functional benefits and can be safely executed. Further research is needed to specifically quantify the physical component in early physical rehabilitation programs. Keywords: Acute care, Rehabilitation, Hospital, Aged, Functional outcomes, Feasibility, ADL, Physical performance * Correspondence: n.m.kosse@umcg.nl University of Groningen, University Medical Center Groningen, Center for Human Movement Sciences, Groningen, The Netherlands Full list of author information is available at the end of the article © 2013 Kosse et al.; licensee BioMed Central Ltd. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Kosse et al. BMC Geriatrics 2013, 13:107 Page 2 of 16 http://www.biomedcentral.com/1471-2318/13/107 Background knowledge of which patient population benefit from the The rapidly growing population of old adults in Western program is required. Furthermore, it is important to know countries has become a major concern for health care if there will be adverse events during early physical re- systems. Due to a poorer health status, old adults con- habilitation programs in terms of falls or other injuries sume a disproportionate amount of medical care. In and what the adherence rate of the patients will be during some European countries, more than 40% of patients ad- the treatment sessions. Therefore, the first aim of this re- mitted to the hospital for an overnight stay are aged view is to evaluate the effects of early physical rehabilita- 65 years and older, while their total share of the popula- tion programs on physical functioning of geriatric patients tion is less than 20% [1]. acutely admitted to a hospital. In this review early physical Unfortunately, old adults admitted to the hospital are rehabilitation in acutely ill patients refers to physical ther- at severe risk of functional decline, both during hospi- apy, occupational therapy, and physical exercises initiated talization and after discharge [2,3]. A number of studies immediately upon achieving physiologic stability and con- found that approximately 33% of the patients have se- tinued throughout the hospital stay. Such activities start vere functional deterioration at time of discharge com- within 1 or 2 days after hospitalization. The second aim of pared to their status before hospital admission [3-5]. For the present review is to evaluate the feasibility of early patients 90 years or older this number even increases to physical rehabilitation programs in the hospitalized geriat- 63% [4]. Functional decline during and after hospital stay ric patients. has shown to be an important risk factor for nursing home placement [6,7]. Method The decline in functional capacity seems to be partly Search strategy the result of the hospitalization itself, unrelated to diag- A systematic literature search was conducted in three nostic or therapeutic interventions. Older patients have electronic databases, PubMed, CINAHL, and EMBASE in decreased physiological and functional reserves that August 2013. Keywords used to perform the search were: make them more vulnerable to the effects of bed rest “aged” or “elderly” or “geriatric”, “hospital” or “hospital- and decrease in dietary intake, which both are highly ized”, “exercise” or “rehabilitation”, “ADL” or “physical prevalent during hospitalization. Due to immobilisation, functioning” or “mobility” or “physical performance”,and muscle strength and aerobic capacity tend to decline “acute” or “acutely”. The articles included were random- rapidly. After only ten days of bed rest healthy old adults ized controlled trials (RCT), written in English, including lose 12-14% of both their VO and lower extremity participants aged 65 years or older who were acutely ad- 2max muscle strength [8]. Without any voluntary muscle con- mitted to the hospital. The interventions investigated in tractions muscle strength can even decrease by 5% per thearticles needed to includeaphysicalexercise part with day [2]. a physical functioning measure as outcome. Studies were Altogether, functional decline is a common problem excluded if the included patients required treatment on a that is significantly associated with negative outcomes specialized unit other than an acute geriatric unit or when such as institutionalization, re-hospitalization and subse- the evaluated intervention aimed at a specific disorder or quent mortality [3]. The primary focus of hospital care is surgical process. Articles about the feasibility of early treating acute and chronic illnesses. A physical rehabili- physical rehabilitation of inpatients were retrieved by tation intervention that may preserve physical function adding the keywords “feasibility” or “feasible” or “adher- is often not part of the treatment. To preclude a rapid ence rate” or “safety” to the keywords mentioned above. decline in physical function it is important that hospital The articles about feasibility had the same in and exclu- programs are also directed explicitly towards activating sion criteria as the articles addressing physical functioning the older patient early after hospital admission. Early with the exception that also non randomized controlled physical rehabilitation might help to prevent decline in trials were included. For the inclusion process title and ab- physical functioning arising from immobility and pro- stract were examined and when necessary the full article longed bed rest [9]. was obtained and read. Additional studies were identified Over the years, several multidisciplinary and exercise through reference and citation tracking. Two reviewers types of early rehabilitation interventions have been stud- independently screened title, abstract and full text. Dis- ied. Previous studies showed that early rehabilitation pro- agreement about inclusion of articles was resolved by dis- grams improved both patient (e.g. physical functioning) cussion and consensus between the two reviewers. and hospital outcomes (e.g. reducing costs) for acute ill geriatric patients [10,11]. However, an important issue not Data extraction and analysis yet addressed in the current literature is the feasibility of Data were extracted against pre-defined categories by in-hospital early exercise programs for acute geriatric pa- two researchers. The data compiled from the studies in- tients. To start an early physical rehabilitation program, cluded information on: study design, characteristics of Kosse et al. BMC Geriatrics 2013, 13:107 Page 3 of 16 http://www.biomedcentral.com/1471-2318/13/107 participants and setting, the intervention and control for the feasibility assessment. The article of Laver et al. group treatment, time of assessment, ADL, physical per- [14] was included in both the physical functioning and the formance, length of stay and discharge destination. Fur- feasibility section. PRISMA guidelines were followed in thermore, the feasibility outcomes were the ability to this systematic review [15]. enrol patients into the rehabilitation program, and the adherence rate and safety of the patients during the ther- Methodological quality apy sessions. The information extracted from the articles In Table 1 the quality scores on the Delphi Scale for the was organized into tables and systematically compared. different RCT studies are reported. Total quality scores ranged from 3 to 7 with a median score of 5. The meth- Methodological quality odological quality was moderate for most studies. The methodological quality of the included RCTs was Randomization methods and eligibility criteria were assessed using the Delphi scale [12]. The Delphi scale is clearly defined in all 13 studies. The studies scored par- a quality assessment tool for RCTs and has shown to be ticularly low on blinding the assessor, the care provider valid and reliable [13]. It consists of 9 different criteria and the participant. The Delphi scores were good for the which can be scored positive, negative, or unclear (“yes”, concealed treatment allocation, the similarity of the “no”,and “don’t know”). One point was given for each intervention and control groups at baseline and the clar- “yes” and zero points for each “no” or “don’t know”, the ity of the specified eligibility criteria. total quality sore ranged from 0 (low quality) to 9 (high quality). Inclusion criteria and patient characteristics Table 2 summarizes the characteristics of patients, study Results settings, early physical rehabilitation programs and out- Selected studies comes of the included RCT studies in this review. The The literature search for physical functioning yielded a mean age for patients admitted to acute care in the hos- total of 772 papers (Figure 1). After removing 765 arti- pital for a general medical condition varied between 78 cles based on title and abstract, 9 articles were qualified and 86 years old. The most common reasons for admis- for full text reading. Four articles were removed after full sion were cardiac problems, respiratory problems, text reading and ten articles were added after reference gastrointestinal problems, neurological problems, infec- checking. The remaining 15 articles, describing 13 stud- tions and injuries caused by a fall. The living situation of ies, were included to this review. The search for feasibil- the patients before they were admitted to the hospital ity studies yielded 50 papers. After removing 47 articles varied, patients came from nursing homes and other by title, abstract and full text reading and adding one art- types of institutionalised care or from the community icle after reference checking, four studies were included where they lived alone or with family. However, the Physical Functioning Feasibility Records identified through Records identified through Additional records identified Additional records identified database searching (n =57) database searching (n = 859) through other sources (n = 10) through other sources (n = 1) Records after duplicates removed Records after duplicates removed (n =51) (n = 782) Records screened Records screened Records excluded (n =773) Records excluded (n =46) (n = 782) (n =51) Full-text articles assessed Full-text articles excluded (n =1) Full-text articles assessed Full-text articles excluded (n =4) for eligibility (n = 5) Reasons: for eligibility (n = 19) Reasons: No acute care =1 No exercise part =2 No RCT =2 Studies included in Studies included in synthesis (n = 15) synthesis (n =4) Figure 1 Flowcharts of search results. Included Eligibility Screening Identification Included Eligibility Screening Identification Kosse et al. BMC Geriatrics 2013, 13:107 Page 4 of 16 http://www.biomedcentral.com/1471-2318/13/107 Table 1 Methodological quality scores on the Delphi scale for each RCT study Study Randomized Treatment Groups Eligibility Outcome Care Patient Variability Intention-to-treat Total allocation similar at criteria assessor provider blinded measures analysis (max 9) concealed baseline specified blinded blinded Abizanda [16]1 1 0 1 1 1 1 1 0 7 Asplund [17]1 1 1 1 0 0 0 0 0 4 Blanc-Bisson [18]1 0 1 1 0 0 0 1 1 5 Counsell [19]1 1 1 1 0 0 0 1 1 6 Courtney [20,21]1 1 1 1 1 0 0 1 1 7 De Morton [22]1 0 0 1 0 0 1 1 1 5 Jones [23]1 1 0 1 0 0 0 1 1 5 Landefeld [24]1 0 1 1 0 0 0 0 0 3 Laver [14]1 1 1 1 1 0 0 1 1 7 Nikolaus [25]1 1 1 1 1 0 0 1 0 6 Saltvedt [26,27]1 1 1 1 0 0 0 1 0 5 Siebens [28]1 1 1 1 0 0 0 0 1 5 Slaets [29]1 1 1 1 0 0 0 0 0 4 studies did not include all patients in the intervention, The aim of the exercise programs was predominantly to reasons for exclusion were medical instability [18,22,23], improving functional outcomes by training strength, mo- need for specialized care [17,19,22,24], living in nursing bility, and balance. Strength exercises were progressed homes [19,20,22,23,25,26,28], small survival chance or by increasing the number of sets and repetitions and need for palliative care [18,22,23,25,28], and being diag- walking exercises were progressed in intensity (from nosed with an illness causing functional impairment slow to moderate pace) or duration (from 5 to 30 mi- [18,23,28]. Overall, there was a great heterogeneity nutes). In one study an interactive video gaming pro- among the participants between the different studies. gram was used to exercise. A Nintendo Wii fit group trained 25 min/day, 5 days/week under supervision of a Setting and intervention physical therapist [14]. Some exercise programs sup- Table 2 gives an overview of the settings and interven- ported participants to continue exercise after discharge tions of each included randomized controlled trial. The [20,25,28]. This was achieved by educational materials, studies were performed on acute geriatric units, geriatric by (two or more regular) encouraging phone calls and units and medical units of university hospitals, city hos- home visits [20,28], or by a follow-up treatment, twice a pitals and acute care hospitals. Early physical rehabilita- week up to twice a day, including physical and occupa- tion programs could be divided into two categories, (1) tional therapy [25]. The control groups of the studies multidisciplinary programs with an exercise component generally received usual care according to the general and (2) usual care with an additional exercise program. routines of the hospital they were admitted to. In the review we refer to these categories as multidiscip- linary programs and exercise programs, respectively. The Physical functioning main aim of the multidisciplinary programs was to All included studies provided at least one outcome maintain or obtain independent ADL and encourage measure related to physical functioning. Most studies returning home. Multidisciplinary intervention teams used measures of activities of daily living (ADL) and usually consisted of a geriatrician, (geriatric) nurses, so- physical performance to describe physical functioning. cial workers, physical therapists and occupational thera- Additional information about length of stay and dis- pists [17,19,24,26,29]. The specific exercise component charge destination were also documented. of the multidisciplinary intervention studies is hardly de- scribed, and information on intensity, duration, and fre- Activities of daily living quency of exercises is often lacking. Usual care with an The included studies gained information on patient’s additional exercise program was provided in eight stud- ADL by conducting interviews and (self-administered) ies [14,16,18,20,22,23,25,28]. The patients in the exercise questionnaires. Table 3 gives on overview of the used in- programs were supervised by allied health assistants, a struments to measure (I)ADL. Eleven of the thirteen physiotherapist or an occupational therapist. Patients studies reported the effects of their intervention on performed exercises five times a week up to twice daily. (I)ADL at time of hospital discharge [14,16-19,21-25,29]. Kosse et al. BMC Geriatrics 2013, 13:107 Page 5 of 16 http://www.biomedcentral.com/1471-2318/13/107 Table 2 Setting and study characteristics physical functioning Study Population & Setting Intervention Time of assessment (I)ADL Physical Mortality LOS Discharge Performance (%) (days) ICF (%) Multidisciplinary care with an exercise component Asplund 2000 [17] Intervention (n=190) Multidisciplinary team, with physical and occupational T0 Admission BI ≥ 19 points NA T1 4.2 5.9 T1 11.6 therapy. Discharge planning and early rehabilitation. Mean age 80.9 years T1 Discharge T0 52% T2 11.1 T2 11.6 58% female, AGU, UH T2 3 months post-discharge T2 44% Control (n=223) General medical unit care BI ≥ 19 points T1 2.7 7.3 T1 19.3 Mean age 81.0 years T0 44% T2 7.6 T2 18.4 63% female, MU, UH T2 43% Counsell 2000 [19] Intervention (n=767) † Multidisciplinary team, with daily assessment of T0 2 weeks pre-admission ADL decline PPME score T1 2.7 6.1 T1 12.9 physical functioning and protocols to improve Mean age 80 years T1 Discharge T1 30% T1 5.6 T2 9.0 T2 10.3 self-care and mobility. Early discharge planning. 60% female, CH T2 1 months post-discharge T2 27% T3 15.9 T3 8.9 T3 3 months post-discharge T3 26% T4 22.6 T4 7.5 T4 6 months post-discharge T4 22% T5 31.4 T5 6.7 T5 1 year post-discharge T5 25% Control (n=764) † Usual physician and nursing staff care ADL decline PPME score T1 3.7 6.3 T1 15.6 Mean age 79 years T1 34% T1 5.0 T2 11.3 T2 10.1 61% female, CH T2 29% T3 26% T3 17.4 T3 7.2 T4 30% T5 30% T4 22.5 T4 8.0 T5 29.2 T5 7.3 Landefeld 1995 [24] Intervention (n=327) Multidisciplinary program, with daily assessment T0 Admission ADL score: NA T1 7.3 7.3 T1 5.8 of physical functioning and protocols to improve Mean age 80.2 years T1 Discharge T0 3.0 T2 20.8 T2 13.1 self-care and mobility 68% female, MU, CH T2 3 months post-discharge T1 3.6 T2 4.0 IADL score: T0 2.8 T1 3.3 T2 3.9 Kosse et al. BMC Geriatrics 2013, 13:107 Page 6 of 16 http://www.biomedcentral.com/1471-2318/13/107 Table 2 Setting and study characteristics physical functioning (Continued) Control (n=324) Usual care services provided by ADL score: T1 7.4 8.3 T1 11.7 physicians and nurses Mean age 80.1 years T0 3.0 T2 19.8 T2 18.8 65% female, MU, CH T2 3.8 IADL score: T0 2.8 T2 3.8 * * Saltvedt 2002 [26,27] Intervention (n=127) † Interdisciplinary program to prevent T0 Admission ADL dependence NA T1 11.8 15 NA complications, with early mobilization, Mean age 81.8 years T1 3 months post-discharge T1 21% T3 26.8 rehabilitation and discharge planning 81% female, GU, UH T2 6 months post-discharge T2 13% T3 1 year post-discharge T3 25% IADL dependence T1 46% T2 44% T3 45% * * Control (n=127) † Usual care ADL dependence T1 27.6 7 Mean age 82.4 years T1 12% T2 33.9 84% female, MU, UH T2 13% T3 23% IADL dependence T1 39% T2 40% T3 44% * * Slaets 1997 [29] Intervention Multidisciplinary program added to the T0 Admission Improved ADL Improved NA 19.7 T2 18 (n=140) usual care. Geriatrician, physiotherapist mobility and liaison nurse obtained optimal ADL * * Mean age 82.5 years T1 Discharge T1 61% T1 48% and mobility in 2 hours training a day. 67% female , MU, CH T2 1 year post-discharge * * Control (n=97) Usual care: services provided by physicians Improved ADL Improved 24.8 T2 27 and nurses. mobility * * Mean age 83.2 years T1 46% T1 44% 75% female, MU, CH Kosse et al. BMC Geriatrics 2013, 13:107 Page 7 of 16 http://www.biomedcentral.com/1471-2318/13/107 Table 2 Setting and study characteristics physical functioning (Continued) Usual care programs with an exercise intervention Abinzanda 2011 [16] Intervention (n=198) Conventional treatment plus occupational T0 Admission 55.6% improved NA T1 7.6 9.1 NA therapy: 5 days per week, 30 - 45 min a day ≥ 10 BI points Mean age 83.7 years T1 Discharge 56.6% female, AGU, UH Control (n=202) Conventional treatment: medical treatment, 36.7% improved T1 11.9 8.7 nursing care, physical therapy, and social ≥ 10 BI points Mean age 83.3 years assistance according with the usual practice of the unit. 56.9% female, AGU, UH Blanc-Bisson 2008 [18] Intervention (n=38) Usual care plus early intensive physical therapy T0 Admission Mean Katz index NA T1 5.3 T1 NA program: start day 1-2, strength training twice 12.6 Mean age 85.5 years T1 Clinical stability T0 6.7 T2 7.9 a day half an hour, 5 days a week until T1 66% female, AGU, UH T2 1 month after clinical T1 5.3 stability T2 4.5 Control (n=38) Usual care: transferred to arm-chair asap. Start Mean Katz index T1 5.3 T1 day 3-6 walking 3 times a week with human 12.6 Mean age 85.4 years T0 6.0 T1 5.3 help or without assistance. Physical therapy at home for 1 month 79% female, AGU, UH T1 4.7 T2 3.0 Courtney 2009 [20,21] Intervention (n=64) † Individual exercise program and nursing T0 Admission ADL: Mean score WIQ distance T1 1.6 4.6 NA visits, performed daily or several times a Mean age 78.1 years T1 4 weeks post-discharge index of ADL T0 23.54 T2 3.1 week. The intervention continued at home with home visits and regular telephone 62% female, MU, CH T2 12 weeks post-discharge T0 0.36 T1 53.62 T3 3.1 follow-up by a nurse. T3 24 weeks post-discharge T1 0.07 T2 54.83 T2 0.18 T3 62.89 T3 0.16 WIQ speed IADL: Mean T0 16.21 IADL scale T0 2.16 T1 41.30 T1 1.47 T2 44.62 T2 1.27 T3 48.56 T3 1.13 WIQ stairs T0 27.70 T1 46.73 T2 51.23 T3 57.20 Kosse et al. BMC Geriatrics 2013, 13:107 Page 8 of 16 http://www.biomedcentral.com/1471-2318/13/107 Table 2 Setting and study characteristics physical functioning (Continued) Control (n=64) † Routine care, discharge planning and ADL: Mean score WIQ distance T1 4.7 4.7 rehabilitation advice. If necessary, index of ADL in-home follow-up. Mean age 79.4 years T0 0.35 T0 20.22 T2 4.7 63% female, MU, CH T1 0.69 T1 28.90 T3 4.7 T2 0.75 T2 21.59 T3 1.27 T3 19.93 IADL: Mean WIQ speed IADL scale T0 2.62 T0 14.43 T1 3.29 T1 22.09 T2 3.56 T2 17.89 T3 4.33 T3 16.58 WIQ stairs T0 24.12 T1 26.06 T2 24.40 T3 22.18 De Morton 2007 [22] Intervention (n=110) † Usual care plus an individual exercise T0 Admission Mean BI: Mean TUG (s): T1 1.8 5.0 T1 18.2 program. Twice daily, 5 days a week, Mean age 78 years T1 Discharge T0 66 T0 35 for 20-30 minutes. 54% female, MU, ACH T1 79 T1 36 Mean FAC: T0 4.0 T1 4.8 Control (n=126) † Usual care: daily medical assessment, 24 hour Mean BI: Mean TUG (s): T1 1.6 6.0 T1 20.6 nursing assistance, and allied health service Mean age 80 years T0 68 T0 30 on referral from medical, nursing or other allied health staff. 56% female, MU, ACH T1 75 T1 26 Mean FAC: T0 3.9 T1 4.7 Kosse et al. BMC Geriatrics 2013, 13:107 Page 9 of 16 http://www.biomedcentral.com/1471-2318/13/107 Table 2 Setting and study characteristics physical functioning (Continued) Jones 2006 [23] Intervention (n=80) † Usual care plus an individual exercise T0 Admission T1 Discharge Mean change Mean change T1 5.0 9 T1 32.5 program Twice daily for approximately mBI: 11 points TUG: 5.4 sec Mean age 81.9 years 30 minutes. 54% female, MU, ACH Control (n=80) † Usual care: medical, nursing and allied health Mean change Mean change T1 2.5 11 T1 51.3 intervention and discharge planning consistent mBI: 9 points TUG: 1.2 sec Mean age 82.9 years with the patient’s diagnosis and resources available on the acute general medical wards. 61% female, MU, ACH Laver 2012 [14] Intervention (n=22) Individual interactive video game program T0 Admission IADL TUG T1 0 12.3 NA (Wii Fit) 25 min/day, 5 days/week supervised Mean age 85.2 years T1 Discharge T0 181 T0 38 by a physiotherapist 86% female GU, ACH T1 205 T1 28 Control (n=22) Conventional physiotherapy, matching the IADL TUG T1 0 14.95 NA patients abilities and treatment needs Mean age 84.6 years T0 141 T0 35 25 min/day, 5 days/week 73% female GU, ACH T1 190 T1 29 * * Nikolaus 1999 [25] Intervention with In-hospital and post-discharge follow-up T0 Admission Mean BI score: NA T2 18.2 33.5 T1 4.4 follow-up (n=181) † treatment by an interdisciplinary team. Physical or occupational therapy twice a Mean age 81.4 years T1 Discharge T0 71.0 T2 16.6 week up to twice a day for 30 min Female 73.4%, GU, UH T2 1 year post-discharge T1 91.8 T2 81.2 Mean LB score: T1 5.7 T2 5.6 * * Intervention without In-hospital treatment by an interdisciplinary Mean score BI: T2 16.8 40.7 T1 7.3 follow-up (n=179) † team, followed by usual care at home Mean age 81.4 years T0 71.0 T2 18.4 Female 73.4%, GU, UH T1 92.6 T2 82.3 Mean LB score: T1 5.5 T2 4.1 * * Control (n=185) † Usual care in hospital Mean score BI: T2 17.3 42.7 T1 8.1 Mean age 81.4 years T0 71.0 T2 22.7 Female 73.4%, GU, UH T1 91.1 T2 80.9 Mean LB score: T1 5.5 T2 4.3 Kosse et al. BMC Geriatrics 2013, 13:107 Page 10 of 16 http://www.biomedcentral.com/1471-2318/13/107 Table 2 Setting and study characteristics physical functioning (Continued) Siebens 2000 [28] Intervention (n=149) † Hospital-based exercise program twice a day. T0 2 weeks pre-admission Mean number of Independent T1 6.7 12.0 NA Encouragement to continue the program at home independent IADL walking Mean age 78.2 years T1 1 month post-discharge T0 5.3 T0 59.7% 62% female, ACH T1 5.1 T1 64.2% Control (n=151) † Usual care Mean number of Independent T1 6.6 10.5 IADL independence walking Mean age 78.5 years T0 5.3 T0 50.3% 59% female, ACH T1 4.6 T1 65.5% † = included only community dwelling old adults; ADL= Activities of Daily Living; IADL= Instrumental Activities of Daily Living; ICF=Intramural Care Facility; AGU=Acute Geriatric Unit; GU=Geriatric Unit; MU=Medical Unit; UH=University Hospital; CH=City Hospital; ACH=Acute Care Hospital; * = significant (p > 0.05); PPME=Physical Performance and Mobility Examination; WIQ=Walking Impairment Questionnaire; TUG=Timed Up and Go; FAC=Functional ambulation classification; NA=not available. Kosse et al. BMC Geriatrics 2013, 13:107 Page 11 of 16 http://www.biomedcentral.com/1471-2318/13/107 Table 3 Overview of the instruments used to measure (I)ADL and physical performance Instrument Study Assessment Score Min Max Interpretation Katz index/ADL index Courtney [20] Ability to perform: Bathing, eating, dressing, continence, transfer to toilets 0 6 0 independent - 6 dependent and locomotion Bizon-Blanc [18] 0 12 0 independent - 12 dependent Counsell and Landefeld [19,24] Ability to perform: Bathing, dressing, using the toilet, moving from a bed to 0 5 0 independent – 5 dependent a chair, and eating (modified) Barthel index Asplund and Salvedt [17,26] Feeding, urinary and faecal continence, personal toilet, dressing, toilet use, 0 20 1 dependent – 20 independent transferring, walking outdoors, climbing stairs and bathing Abizanda, Jones, De Morton, 0 100 0 dependent - 100 independent Nicolaus [16,22,23,25] Lawton index/IADL index Nikolaus and Salvedt [25,26] Ability to use telephone, shopping, food preparation, housekeeping, laundry, mode 0 8 0 dependent - 8 independent of transportation, responsibility for medication and ability to handle finances Counsell, Courtney, Landefeld Ability to use telephone, shopping, food preparation, housekeeping, mode of 0 7 0 dependent - 7 independent and Siebens [19,20,24,28] transportation, responsibility for medication and ability to handle finances Timed IADL Laver [14] The time needed to complete tasks addressing five IADL domains: Lower scores indicates greater ability (1) communication, (2) finance, (3) cooking, (4) shopping, and (5) medicine. SIVIS dependency scales Sleats [29] SIVIS independency scale: 20 questions relating to orientation, communication, NA mobility, transfers, ADL, continence, catheter use, and decubitus Functional Independence Laver and Siebens [14,28] Measures the level of a patient’s disability and indicates how much 18 126 18 dependent – 126 independent Measure (FIM) assistance is required for the individual to carry out activities of daily living: Eating, Grooming, Bathing, Upper and lower body dressing, Toileting, Bladder and bowel management, Bed to chair transfer, Toilet and shower transfer, Locomotion, Stairs, Cognitive comprehension, Expression, Social interaction, Problem solving, Memory Walking Impairment Courtney [20] Walking distance, walking speed and climbing stairs 0 100 Higher scores indicates Questionnaire (WIQ) greater ability Timed Up and Go (TUG) Jones, Laver, Time taken for the patient to rise from a chair, walk 3 m, turn and walk Lower scores indicates De Morton [14,22,23] back to the chair greater ability Functional Ambulation Classification De Morton [22] Ability to ambulate over a 10 foot distance and 4 m length of foam 0 6 0 dependent - 6 independent Physical activity scale Siebens [28] Questionnaire about walking ¼ mile, walking up 10 steps, NA crouching/kneeling, lifting/carrying 10 lbs Mobility Counsell [19] Walking to a table, walking inside the house, walking a block, walking NA uphill or upstairs, and running a short distance Physical Performance and Counsell [19] Bed mobility, transfer skills, multiple stands, standing balance, step up 0 6 0 dependent – 6 independent Mobility Examination one step and timed 6 m walk Short Physical Performance Battery Laver [14] Three standing balance measures (tandem, semi-tandem, and side-by-side 0 12 0 dependent – 12 independent stands), five continuous chair stands, and a 2.44-meter walk. Modified Berg Balance Scale Laver [14] NA NA=Not available. Kosse et al. BMC Geriatrics 2013, 13:107 Page 12 of 16 http://www.biomedcentral.com/1471-2318/13/107 Two multidisciplinary programs found that patients in discharge. Conversely, the other study [20] reports that exercise group compared to the patients in usual care the exercise group had greater improvement over time group significantly improved more and worsened less in (up to 24 weeks after discharge) in walking distance, the number of basic ADL activities they were able to walking speed and stair climbing. Similar contradicting perform [24,29]. The other studies did not find a signifi- results were found on more general outcome measures cant group difference in ADL at time of discharge. How- of physical functioning, provided by a health question- ever, one study with an exercise intervention found a naire that contained physical well-being and physical ac- significant interaction effect between group and admis- tivity. No group differences were found for the National sion scores on the modified Barthel index meaning that Health Survey Physical Activity Scale at one month patients with a low admission score who received an ex- follow-up [28], while the other study found that the ex- ercise intervention showed greater improvement in ADL ercise group scored higher than the usual care group on than those patients who received only usual care [23]. physical health related quality of life at 4, 12, and Two studies reported a ceiling effect for the Barthel 24 weeks after discharge [21]. In short, follow-up results index and a floor effect for the Katz index [22,23]. on physical performance are contradictory. Nevertheless, Remaining studies did not found a significant difference at time of discharge most studies show a greater im- on ADL between early physical rehabilitation programs provement for patients in the multidisciplinary and exer- and usual care (see Table 2). cise group than for the patients in the usual care group. Of the eight studies that reported follow-up data on (I)ADL [17-20,24-26,28] only the three studies with Length of stay and discharge destination an exercise intervention that provided patients with All included randomized controlled trials reported about follow-up treatment after hospital discharge reported the length of stay, which varied between the 4.7 days larger improvements in the exercise group than in and 42.7 days. Four studies (three multidisciplinary pro- the usual care group after 1, 6 and 12 months grams) reported a significant difference shorter length of [20,25,28]. One study that did not provide patients stay of the exercise group than for the usual care group with follow-up treatment also found a positive effect of the [17,25,27,29]. intervention on ADL at 3 months post-discharge. However, From the seven studies [17,19,22-25,29] that reported this study included patients who died by assigning them a on discharge destination, five studies found that a higher score of zero, whereas the mortality rate was higher in the proportion of patients in the early physical rehabilitation usual care group than the multidisciplinary group [26]. group than in the usual care group were discharged home, instead of being transferred to additional (sub- Physical performance acute) hospital treatment or to institutionalized care, how- Seven studies reported measures of physical performance; ever, results were significant in three studies (Table 2). Table 3 gives an overview of the used measurement in- Two multidisciplinary programs found that respectively struments [14,19,20,22,23,28,29]. Three (2 multidisciplin- 14% and 18% of the patients in the multidisciplinary group ary programs and 1 exercise programs) of the five studies were discharged to a long-term care institution opposed describing physical performance at time of admission and to 22% and 27% of usual care patients [24,29]. The third discharge found that the intervention groups improved study, an exercise intervention, included only patients more or declined less than the usual care groups who had lived at home before admission and found that [19,23,29]. However, for one study the difference in the 4% of the patients in the exercise group and 8% of the pa- Timed Up and Go (TUG) was not significant after tients in the usual care group were discharged to long- adjusting for confounders such as patient characteristics, term care institutions [25]. admission modified Barthel Index, comorbidity, and men- tal scores [23]. Feasibility For the TUG a floor effect was found. In one study, al- Feasibility of early physical rehabilitation programs, was most 40% of the patients were physically unable to per- explicitly assessed in four studies (Table 4) comparing form the TUG at both admission and discharge [23], usual care with an exercise intervention program whereas in another study 23% of all patients were unable [14,30-32]. In addition included randomized controlled to perform the TUG at admission to the hospital [22]. trails with an exercise program reported on enrolment Two studies reported follow-up results on physical (n=3), adherence rate (n=2) and adverse events (n=5), performance, but the results are ambiguous [20,28]. One while multidisciplinary studies reported on enrolment study [28] reported no significant difference between the (n=3) only. patients in the exercise group and in the usual care Subjects enrolled in the studies explicitly assessing group in the change in physical performance scores feasibility were respectively above the age of 60 or 70. obtained 2 weeks before admission and one month after The most common exclusion criteria were severe Kosse et al. BMC Geriatrics 2013, 13:107 Page 13 of 16 http://www.biomedcentral.com/1471-2318/13/107 Table 4 Setting and study characteristics feasibility Study Population & setting Intervention Feasibility Brown 2006 [30] Intervention (n=7) Exercise sessions twice a day, 7 days a week. After discharge n=605 admitted, n=76 included 20-30 min walk each day and resistance exercise every other day Mean age 70.2 years, n=66 declined participation 0% female Control (n=2) Usual care which included physical therapy if a consult was initiated by the physician Mean age 70.2 years, 0% female Mallery 2003 [31] Intervention (n=19) Usual care plus resistance exercise 3 times per week, n=395 admitted, n=39 included 30-40 min, assisted by a physiotherapist Mean age 82.7 years Participation 71%, 74% female, GU, UH Adherence 63% No adverse events Control (n=20) Usual care plus passive range of motion training Participation 96%, 3 times per week, 30-40 min, assisted by a physiotherapist Mean age 81.4 years Adherence 95% 45% female, GU, UH No adverse events Nolan 2008 [32] Intervention (n=196) Participated in the Functional Maintenance Exercise n=1021 admitted, n= 220 included Program, 6 times per week, 30 min Mean age 83.6 years, 33 withdrawn 68% female, GU, UH Control (n=24) Usual care with usual physiotherapy Mean age 85.4 years 67% female, GU, UH Laver 2012 [14] Intervention (n=22) Individual interactive video game program (Wii Fit) n=235 admitted, n=44 included 25 min/day, 5 days/week supervised by a physiotherapist Mean age 85.2 years 90% adherence rate 86% female GU, ACH No adverse events Control (n=22) Conventional physiotherapy, matching the patients 91% adherence rate abilities and treatment needs 25 min/day, 5 days/week Mean age 84.6 years 1 adverse event, conscious collapse 73% female GU, ACH GU=Geriatric Unit; UH=University Hospital. impairments in physical performance and cognition, re- Instead, patients were discharged before therapy could quiring palliative care, expected short length of stay, and begin or were unavailable due to diagnostic tests or ap- medical instability. One study specifically targeted frail pointments with healthcare professionals. patients that were at risk of functional decline [32]. Adherence rates were fairly high between the 60% and Feasibility was measured quantifying patients enrol- 90% [14,20,31,32]. The most common reasons for drop- ment, patient adherence to the program and at patient’s ping out of the intervention programs were early dis- safety in the context of the exercise program. Nine of charge, being transferred to intensive or palliative care, the 11 studies found that between the 14% and 48% of being medically unstable, and death [17-19,22,23,28,32]. the admitted patients met the inclusion to be enrolled in A final measure of feasibility is patient safety during the programs, and between 3 and 19% of the patients the exercise program. One feasibility study and six RCT were not willing to participate [14,17,19,22-24,28,31,32]. studies included in this review reported on potential side In general patients not willing to participate stated that effects such as injuries, accidents, and more specifically, they did not feel like exercising or that they did not be- fall incidents, related to participating in the early phys- lieve they could exercise. They felt unwell and/or were ical rehabilitation programs [14,16,18,20,23,28,31]. None scared that exercising would make them feel worse. of the studies found any differences in the number of in- In one study [30] only 2% of all admitted patients were cidents between the exercise groups and usual care included. Of the 76 patients that met the inclusion cri- groups. teria only 10 consented to participating while 87% of the eligible patients refused to take part in the program. In Discussion fact none of the included patients were able to start with The first aim of this review was to evaluate the effect of the exercise program. Reasons for not participating in early physical rehabilitation programs for geriatric hospi- the exercise program were not of a physical nature. talized patients on physical functioning. A total of 15 Kosse et al. BMC Geriatrics 2013, 13:107 Page 14 of 16 http://www.biomedcentral.com/1471-2318/13/107 articles, reporting on 13 studies, were included that pro- nursing home admission found positive effects of an ex- vided early physical rehabilitation programs in a hospital ercise program on ADL, length of stay and discharge setting. The present review shows that early physical re- destination [20,25,26]. This result indicates that frail old habilitation programs might be beneficial to prevent adults and nursing home patients may benefit from early rapid decline in physical functioning. rehabilitation. Targeting the right population for early A classification could be made between multidisciplin- physical rehabilitation may be seen as crucial. ary programs with an exercise component and usual care The outcomes with regard to physical functioning with an exercise component. Multidisciplinary programs were measured by a variety of instruments and at differ- reduced the length of stay for patients in the exercise ent points in time, some of these instruments demon- groups compared to the patients receiving usual care. strated floor and ceiling effects. Floor and ceiling effects Additionally, the patients in the multidisciplinary pro- could influence the outcomes and distort the results. grams were less likely to be discharged to a nursing home There were also cases in which information could only or other forms of institutionalized care than patients in be collected with the help of close relatives and care- the usual care group. The usual care programs with an ex- givers, because relevant information could not be ercise intervention had the main aim to improve func- obtained from the patients themselves. The limitations tional outcomes, some of the studies showed indeed an of the current used measurement instruments implies improvement on ADL and physical performance. that there might be a need for more sensitive instru- The two types of exercise interventions, e.g. multidis- ments that measure aspects of physical functioning in ciplinary programs with an exercise component and usual hospitalized old adults. care with an exercise component, did not find different re- Finally, the second aim of this review was to investi- sults in physical functioning at time of discharge. At time gate the feasibility of early physical rehabilitation pro- of discharge, results on physical performance were to grams for acute ill older patients. The early physical some extent contradicting, but the majority of the in- rehabilitation programs must be safe to perform and cluded studies showed that patients in the exercise groups may not cause high numbers of drop outs. There were had better ADL and physical performance than patients in four studies identified reporting on the feasibility of in- the usual care groups, although those results were not al- hospital exercise programs [14,30-32]. Additionally, a ways significant. Follow-up results on ADL and physical part of the randomized controlled trials, used to deter- performance showed that persistent positive effects were mine the effect on physical functioning, reported also on mainly found in studies that provided patients with con- some feasibility points. Several studies included in this tinuous interventions after hospital discharge. The studies review affirmed the safety of early rehabilitation pro- that provided patients with only in-hospital exercise inter- grams. Patients in the early physical rehabilitation ventions found little or no effect on ADL and physical groups were not more often injured, nor did they experi- performance at follow-up examinations. These results are ence more adverse events or falls than usual care pa- in line with other studies that investigate the effects of tients. Results on patient recruitment were contradictory care in geriatric units and of inpatient rehabilitation for and should be interpreted with care due to the limited geriatric patients on functional parameters [10,33]. The ef- number of available studies. Adherence rates were high fects of only in-hospital interventions were clearly positive for most studies. Patient as well as the intervention pro- at time of discharge but were greatly reduced during vider’s satisfaction was higher when patients were follow-up. These results suggest that the recovery of pa- treated with a early physical rehabilitation program in- tients could further benefit from a community based or stead of usual care [19]. There was one study that en- in-home intervention programs which build on in- countered difficulties in recruiting patients and was hospital programs. Such programs could consist of phys- unable to have any patients participate in the exercise program at all [30]. Patients refused to participate or ical or occupational therapy. In addition, the present re- view shows in home visits and follow-up telephone calls were unavailable at scheduled time of therapy. One of might be effective for adherence for home-based exercise the greatest barriers in the implementation of interven- tion research, according to the opinion of nurses, was a [20]. Further research is needed to clarify the effects and feasibility of community based and in-home intervention lack of awareness and knowledge [34]. Equally important programs in old adults after hospital discharge. in this regard were difficulties in the cooperation of interdisciplinary team members [34]. Education of staff The studies presented in this review included very het- erogeneous groups. Half of all studies excluded nursing and patients about the safety and the benefits of early home patients. Probably, due to the aim of those studies physical rehabilitation as well as regular team confer- to facilitate discharge home. The studies in this review ences that improve coordination might help to increase that targeted frail older patients, patients with increased the success rate of intervention programs with regard to risk for readmission or patients with a high risk for participate. Kosse et al. BMC Geriatrics 2013, 13:107 Page 15 of 16 http://www.biomedcentral.com/1471-2318/13/107 Limitations Author details University of Groningen, University Medical Center Groningen, Center for The total number of included studies in this review is Human Movement Sciences, Groningen, The Netherlands. Geriatrics Center small and the methodological quality for most studies Oldenburg, Carl von Ossietzky Universität Oldenburg, Oldenburg, Germany. was moderate. Most articles scored particularly low on Received: 15 May 2013 Accepted: 8 October 2013 blinding the assessor, the care provider, and the partici- Published: 10 October 2013 pant. However, it may be regarded as almost impossible to assure blinding in the context of early physical re- References habilitative interventions. One of the major limitations 1. OECD: Health at a Glance: Europe 2012. OECD Publishing; 2012 [http://dx.doi. of the included studies lies with the poor descriptions of org/10.1787/9789264183869-en]. 2. 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Bachmann S, Finger C, Huss A, Egger M, Stuck AE, Clough-Gorr KM: Inpatient rehabilitation specifically designed for geriatric patients: systematic review and meta-analysis of randomised controlled trials. BMJ 2010, 340:c1718. Submit your next manuscript to BioMed Central 34. Hutchinson AM, Johnston L: Bridging the divide: a survey of nurses’ and take full advantage of: opinions regarding barriers to, and facilitators of, research utilization in the practice setting. J Clin Nurs 2004, 13(3):304–315. • Convenient online submission doi:10.1186/1471-2318-13-107 • Thorough peer review Cite this article as: Kosse et al.: Effectiveness and feasibility of early • No space constraints or color figure charges physical rehabilitation programs for geriatric hospitalized patients: a systematic review. 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