Effect of Exercise Intervention on Functional Decline in Very Elderly Patients | Dementia and Cognitive Impairment | JN Learning | AMA Ed Hub [Skip to Content]
[Skip to Content Landing]

Effect of Exercise Intervention on Functional Decline in Very Elderly Patients During Acute HospitalizationA Randomized Clinical Trial

Educational Objective
To assess the effects of an innovative multicomponent exercise intervention on the functional status of acutely hospitalized older patients.
1 Credit CME
Key Points

Question  Can the functional and cognitive impairment associated with the acute hospitalization of older adults be reversed?

Findings  This randomized clinical trial including 370 hospitalized elderly patients shows that the prescribed exercise intervention provided significant benefits over usual care. At discharge, significant differences between the exercise intervention and the control groups were noted for functional independence as well as cognitive and quality of life level.

Meaning  An individualized, multicomponent exercise program proved safe and effective to reverse the functional decline associated with acute hospitalization in very elderly patients.

Abstract

Importance  Functional decline is prevalent among acutely hospitalized older patients. Exercise and early rehabilitation protocols applied during acute hospitalization can prevent functional and cognitive decline in older patients.

Objective  To assess the effects of an innovative multicomponent exercise intervention on the functional status of this patient population.

Design, Setting, and Participants  A single-center, single-blind randomized clinical trial was conducted from February 1, 2015, to August 30, 2017, in an acute care unit in a tertiary public hospital in Navarra, Spain. A total of 370 very elderly patients undergoing acute-care hospitalization were randomly assigned to an exercise or control (usual-care) intervention. Intention-to-treat analysis was conducted.

Interventions  The control group received usual-care hospital care, which included physical rehabilitation when needed. The in-hospital intervention included individualized moderate-intensity resistance, balance, and walking exercises (2 daily sessions).

Main Outcomes and Measures  The primary end point was change in functional capacity from baseline to hospital discharge, assessed with the Barthel Index of independence and the Short Physical Performance Battery (SPPB). Secondary end points were changes in cognitive and mood status, quality of life, handgrip strength, incident delirium, length of stay, falls, transfer after discharge, and readmission rate and mortality at 3 months after discharge.

Results  Of the 370 patients included in the analyses, 209 were women (56.5%); mean (SD) age was 87.3 (4.9) years. The median length of hospital stay was 8 days in both groups (interquartile range, 4 and 4 days, respectively). Median duration of the intervention was 5 days (interquartile range, 0); there was a mean (SD) of 5 (1) morning and 4 (1) evening sessions per patient. No adverse effects were observed with the intervention. The exercise intervention program provided significant benefits over usual care. At discharge, the exercise group showed a mean increase of 2.2 points (95% CI, 1.7-2.6 points) on the SPPB scale and 6.9 points (95% CI, 4.4-9.5 points) on the Barthel Index over the usual-care group. Hospitalization led to an impairment in functional capacity (mean change from baseline to discharge in the Barthel Index of −5.0 points (95% CI, −6.8 to −3.2 points) in the usual-care group, whereas the exercise intervention reversed this trend (1.9 points; 95% CI, 0.2-3.7 points). The intervention also improved the SPPB score (2.4 points; 95% CI, 2.1-2.7 points) vs 0.2 points; 95% CI, −0.1 to 0.5 points in controls). Significant intervention benefits were also found at the cognitive level of 1.8 points (95% CI, 1.3-2.3 points) over the usual-care group.

Conclusions and Relevance  The exercise intervention proved to be safe and effective to reverse the functional decline associated with acute hospitalization in very elderly patients.

Trial Registration  ClinicalTrials.gov identifier: NCT02300896

Sign in to take quiz and track your certificates

Buy This Activity

JN Learning™ is the home for CME and MOC from the JAMA Network. Search by specialty or US state and earn AMA PRA Category 1 CME Credit™ from articles, audio, Clinical Challenges and more. Learn more about CME/MOC

Article Information

Accepted for Publication: July 27, 2018.

Published Online: November 12, 2018. doi:10.1001/jamainternmed.2018.4869

Correction: This article was corrected on January 7, 2019, to update the middle initial and correct the surname of the fourth author (Dr Sáez de Asteasu), the institution name in the second affiliation, and an error in the Figure 2 figure key.

Corresponding Author: Mikel Izquierdo, PhD, Department of Health Sciences, Public University of Navarra, Av. De Barañain s/n 31008 Pamplona, Navarra, Spain (mikel.izquierdo@gmail.com).

Author Contributions: Drs Martínez-Velilla and Izquierdo had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Martínez-Velilla, Casas-Herrero, Zambom-Ferraresi, Sáez de Asteasu, Alonso-Renedo, Apezteguía Iráizoz, Rodríguez-Mañas, Izquierdo.

Acquisition, analysis, or interpretation of data: Martínez-Velilla, Casas-Herrero, Zambom-Ferraresi, Sáez de Asteasu, Lucia, Galbete, García-Baztán, González-Glaría, Gonzalo-Lázaro, Gutiérrez-Valencia, Rodríguez-Mañas, Izquierdo.

Drafting of the manuscript: Martínez-Velilla, Casas-Herrero, Zambom-Ferraresi, Lucia, Galbete, García-Baztán, Gonzalo-Lázaro, Izquierdo.

Critical revision of the manuscript for important intellectual content: Martínez-Velilla, Casas-Herrero, Zambom-Ferraresi, Sáez de Asteasu, Lucia, Galbete, Alonso-Renedo, González-Glaría, Apezteguía Iráizoz, Gutiérrez-Valencia, Rodríguez-Mañas, Izquierdo.

Statistical analysis: Zambom-Ferraresi, Lucia, Galbete, Izquierdo.

Obtained funding: Martínez-Velilla, Casas-Herrero, Zambom-Ferraresi, González-Glaría, Rodríguez-Mañas, Izquierdo.

Administrative, technical, or material support: Martínez-Velilla, Casas-Herrero, Zambom-Ferraresi, González-Glaría, Gutiérrez-Valencia, Rodríguez-Mañas, Izquierdo.

Supervision: Martínez-Velilla, Casas-Herrero, Zambom-Ferraresi, Sáez de Asteasu, Lucia, Alonso-Renedo, Gonzalo-Lázaro, Apezteguía Iráizoz, Rodríguez-Mañas, Izquierdo.

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was funded by a Gobierno de Navarra project Resolución grant 2186/2014 and acknowledged with the “Beca Ortiz de Landázuri” as the best research clinical project in 2014, as well as by a research grant PI17/01814 of the Ministerio de Economía, Industria y Competitividad (ISCIII, FEDER). Dr Lucia is funded by ISCIII and Fondos FEDER (PI15/00558).

Role of the Funder/Sponsor: The Gobierno de Navarra had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: We thank Fundacion Miguel Servet (Navarrabiomed) for its support during the implementation of the trial, as well as Fundación Caja Navarra and Fundación La Caixa. Finally, we thank our patients and their families for their confidence in the research team.

Additional Contributions: We thank the patients depicted in the videos for granting permission to publish this information.

References
1.
Rechel  B, Grundy  E, Robine  JM,  et al.  Ageing in the European Union.  Lancet. 2013;381(9874):1312-1322. doi:10.1016/S0140-6736(12)62087-XPubMedGoogle ScholarCrossref
2.
World Health Organization. World report on ageing and health: 2015. http://www.who.int/ageing/events/world-report-2015-launch/en/. Accessed July 13, 2018.
3.
Spillman  BC, Lubitz  J.  The effect of longevity on spending for acute and long-term care.  N Engl J Med. 2000;342(19):1409-1415. doi:10.1056/NEJM200005113421906PubMedGoogle ScholarCrossref
4.
Gilbert  T, Neuburger  J, Kraindler  J,  et al.  Development and validation of a Hospital Frailty Risk Score focusing on older people in acute care settings using electronic hospital records: an observational study.  Lancet. 2018;391(10132):1775-1782. doi:10.1016/S0140-6736(18)30668-8PubMedGoogle ScholarCrossref
5.
Gill  TM, Gahbauer  EA, Han  L, Allore  HG.  The role of intervening hospital admissions on trajectories of disability in the last year of life: prospective cohort study of older people.  BMJ. 2015;350:h2361. doi:10.1136/bmj.h2361PubMedGoogle ScholarCrossref
6.
Martínez-Velilla  N, Herrero  AC, Cadore  EL, Sáez de Asteasu  ML, Izquierdo  M.  Iatrogenic nosocomial disability diagnosis and prevention.  J Am Med Dir Assoc. 2016;17(8):762-764. doi:10.1016/j.jamda.2016.05.019PubMedGoogle ScholarCrossref
7.
Gill  TM, Allore  HG, Gahbauer  EA, Murphy  TE.  Change in disability after hospitalization or restricted activity in older persons.  JAMA. 2010;304(17):1919-1928. doi:10.1001/jama.2010.1568PubMedGoogle ScholarCrossref
8.
Boyd  CM, Landefeld  CS, Counsell  SR,  et al.  Recovery of activities of daily living in older adults after hospitalization for acute medical illness.  J Am Geriatr Soc. 2008;56(12):2171-2179. doi:10.1111/j.1532-5415.2008.02023.xPubMedGoogle ScholarCrossref
9.
Brown  CJ, Redden  DT, Flood  KL, Allman  RM.  The underrecognized epidemic of low mobility during hospitalization of older adults.  J Am Geriatr Soc. 2009;57(9):1660-1665. doi:10.1111/j.1532-5415.2009.02393.xPubMedGoogle ScholarCrossref
10.
Martínez-Velilla  N, Urbistondo-Lasa  G, Veintemilla-Erice  E, Cambra-Contín  K.  Determining the hours hospitalised patients are bedridden due to their medical condition and functional impairment and secondary mortality [in Spanish].  Rev Esp Geriatr Gerontol. 2013;48(2):96.PubMedGoogle ScholarCrossref
11.
Ehlenbach  WJ, Hough  CL, Crane  PK,  et al.  Association between acute care and critical illness hospitalization and cognitive function in older adults.  JAMA. 2010;303(8):763-770. doi:10.1001/jama.2010.167PubMedGoogle ScholarCrossref
12.
Baztán  JJ, Suárez-García  FM, López-Arrieta  J, Rodríguez-Mañas  L, Rodríguez-Artalejo  F.  Effectiveness of acute geriatric units on functional decline, living at home, and case fatality among older patients admitted to hospital for acute medical disorders: meta-analysis.  BMJ. 2009;338:b50. doi:10.1136/bmj.b50PubMedGoogle ScholarCrossref
13.
Ellis  G, Whitehead  MA, O’Neill  D, Langhorne  P, Robinson  D.  Comprehensive geriatric assessment for older adults admitted to hospital.  Cochrane Database Syst Rev. 2011;(7):CD006211.PubMedGoogle Scholar
14.
Greysen  SR.  Activating hospitalized older patients to confront the epidemic of low mobility.  JAMA Intern Med. 2016;176(7):928-929. doi:10.1001/jamainternmed.2016.1874PubMedGoogle ScholarCrossref
15.
de Morton  NA, Keating  JL, Jeffs  K.  Exercise for acutely hospitalised older medical patients.  Cochrane Database Syst Rev. 2007;(1):CD005955.PubMedGoogle Scholar
16.
Brown  CJ, Foley  KT, Lowman  JD  Jr,  et al.  Comparison of posthospitalization function and community mobility in hospital mobility program and usual care patients: a randomized clinical trial.  JAMA Intern Med. 2016;176(7):921-927. doi:10.1001/jamainternmed.2016.1870PubMedGoogle ScholarCrossref
17.
Cadore  EL, Casas-Herrero  A, Zambom-Ferraresi  F,  et al.  Multicomponent exercises including muscle power training enhance muscle mass, power output, and functional outcomes in institutionalized frail nonagenarians.  Age (Dordr). 2014;36(2):773-785. doi:10.1007/s11357-013-9586-zPubMedGoogle ScholarCrossref
18.
Loyd  C, Beasley  TM, Miltner  RS, Clark  D, King  B, Brown  CJ.  Trajectories of community mobility recovery after hospitalization in older adults.  J Am Geriatr Soc. 2018. doi:10.1111/jgs.15397PubMedGoogle Scholar
19.
Chan  AW, Tetzlaff  JM, Gøtzsche  PC,  et al.  SPIRIT 2013 explanation and elaboration: guidance for protocols of clinical trials.  BMJ. 2013;346:e7586. doi:10.1136/bmj.e7586PubMedGoogle ScholarCrossref
20.
Moher  D, Schulz  KF, Altman  DG; CONSORT.  The CONSORT statement: revised recommendations for improving the quality of reports of parallel group randomized trials.  BMC Med Res Methodol. 2001;1:2. doi:10.1186/1471-2288-1-2PubMedGoogle ScholarCrossref
21.
World Medical Association.  World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects.  JAMA. 2013;310(20):2191-2194. doi:10.1001/jama.2013.281053PubMedGoogle ScholarCrossref
22.
Mahoney  FI, Barthel  DW.  Functional evaluation: the Barthel Index.  Md State Med J. 1965;14:61-65.PubMedGoogle Scholar
23.
Martínez De La Iglesia  J, Onís Vilches  O, Dueñas Herrero  R,  et al.  The Spanish version of the Yesavage abbreviated questionnaire (GDS) to screen depressive dysfunctions in patients older than 65 years: adaptation and validation  [in Spanish].  MEDIFAM. 2002;12:620-630.Google ScholarCrossref
24.
Research Randomizer. http://www.randomizer.org. Accessed February 1, 2018.
25.
González-Saiz  L, Fiuza-Luces  C, Sanchis-Gomar  F,  et al.  Benefits of skeletal-muscle exercise training in pulmonary arterial hypertension: the WHOLEi+12 trial.  Int J Cardiol. 2017;231:277-283. doi:10.1016/j.ijcard.2016.12.026PubMedGoogle ScholarCrossref
26.
Izquierdo  M, Casas-Herrero  A, Zambom-Ferraresi  F, Martínez-Velilla  N, Alonso-Bouzón  C, Rodríguez-Mañas  L. Multi-component physical exercise program VIVIFRAIL. http://www.vivifrail.com/resources/send/3-documents/23-e-book-interactive-pdf. Published 2017. Accessed July 14, 2018.
27.
Guralnik  JM, Simonsick  EM, Ferrucci  L,  et al.  A short physical performance battery assessing lower extremity function: association with self-reported disability and prediction of mortality and nursing home admission.  J Gerontol. 1994;49(2):M85-M94. doi:10.1093/geronj/49.2.M85PubMedGoogle ScholarCrossref
28.
Perera  S, Mody  SH, Woodman  RC, Studenski  SA.  Meaningful change and responsiveness in common physical performance measures in older adults.  J Am Geriatr Soc. 2006;54(5):743-749. doi:10.1111/j.1532-5415.2006.00701.xPubMedGoogle ScholarCrossref
29.
van Bennekom  CA, Jelles  F, Lankhorst  GJ, Bouter  LM.  Responsiveness of the rehabilitation activities profile and the Barthel Index.  J Clin Epidemiol. 1996;49(1):39-44. doi:10.1016/0895-4356(95)00559-5PubMedGoogle ScholarCrossref
30.
Shah  S, Vanclay  F, Cooper  B.  Improving the sensitivity of the Barthel Index for stroke rehabilitation.  J Clin Epidemiol. 1989;42(8):703-709. doi:10.1016/0895-4356(89)90065-6PubMedGoogle ScholarCrossref
31.
Folstein  MF, Folstein  SE, McHugh  PR.  “Mini-Mental State”: a practical method for grading the cognitive state of patients for the clinician.  J Psychiatr Res. 1975;12(3):189-198. doi:10.1016/0022-3956(75)90026-6PubMedGoogle ScholarCrossref
32.
Badia  X, Roset  M, Montserrat  S, Herdman  M, Segura  A.  The Spanish version of EuroQol: a description and its applications: European Quality of Life scale [in Spanish].  Med Clin (Barc). 1999;112(suppl 1):79-85.PubMedGoogle Scholar
33.
Laukkanen  P, Heikkinen  E, Kauppinen  M.  Muscle strength and mobility as predictors of survival in 75-84-year-old people.  Age Ageing. 1995;24(6):468-473. doi:10.1093/ageing/24.6.468PubMedGoogle ScholarCrossref
34.
Inouye  SK, van Dyck  CH, Alessi  CA, Balkin  S, Siegal  AP, Horwitz  RI.  Clarifying confusion: the confusion assessment method: a new method for detection of delirium.  Ann Intern Med. 1990;113(12):941-948. doi:10.7326/0003-4819-113-12-941PubMedGoogle ScholarCrossref
35.
Van Ancum  JM, Scheerman  K, Jonkman  NH,  et al.  Change in muscle strength and muscle mass in older hospitalized patients: a systematic review and meta-analysis.  Exp Gerontol. 2017;92:34-41. doi:10.1016/j.exger.2017.03.006PubMedGoogle ScholarCrossref
36.
Artero  EG, Lee  DC, Lavie  CJ,  et al.  Effects of muscular strength on cardiovascular risk factors and prognosis.  J Cardiopulm Rehabil Prev. 2012;32(6):351-358. doi:10.1097/HCR.0b013e3182642688PubMedGoogle ScholarCrossref
37.
Karlsen  A, Loeb  MR, Andersen  KB,  et al.  Improved functional performance in geriatric patients during hospital stay.  Am J Phys Med Rehabil. 2017;96(5):e78-e84. doi:10.1097/PHM.0000000000000671PubMedGoogle ScholarCrossref
38.
Rodriguez-Mañas  L, Rodríguez-Artalejo  F, Sinclair  AJ.  The third transition: the clinical evolution oriented to the contemporary older patient.  J Am Med Dir Assoc. 2017;18(1):8-9. doi:10.1016/j.jamda.2016.10.005PubMedGoogle ScholarCrossref
39.
Martínez-Velilla  N, Cadore  L, Casas-Herrero  Á, Idoate-Saralegui  F, Izquierdo  M.  Physical activity and early rehabilitation in hospitalized elderly medical patients: systematic review of randomized clinical trials.  J Nutr Health Aging. 2016;20(7):738-751. doi:10.1007/s12603-016-0683-4PubMedGoogle ScholarCrossref
40.
Schweickert  WD, Pohlman  MC, Pohlman  AS,  et al.  Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial.  Lancet. 2009;373(9678):1874-1882. doi:10.1016/S0140-6736(09)60658-9PubMedGoogle ScholarCrossref
41.
Schaller  SJ, Anstey  M, Blobner  M,  et al; International Early SOMS-guided Mobilization Research Initiative.  Early, goal-directed mobilisation in the surgical intensive care unit: a randomised controlled trial.  Lancet. 2016;388(10052):1377-1388. doi:10.1016/S0140-6736(16)31637-3PubMedGoogle ScholarCrossref
42.
Gruther  W, Pieber  K, Steiner  I, Hein  C, Hiesmayr  JM, Paternostro-Sluga  T.  Can early rehabilitation on the general ward after an intensive care unit stay reduce hospital length of stay in survivors of critical illness? a randomized controlled trial.  Am J Phys Med Rehabil. 2017;96(9):607-615. doi:10.1097/PHM.0000000000000718PubMedGoogle ScholarCrossref
43.
Sáez de Asteasu  ML, Martínez-Velilla  N, Zambom-Ferraresi  F, Casas-Herrero  Á, Izquierdo  M.  Role of physical exercise on cognitive function in healthy older adults: a systematic review of randomized clinical trials.  Ageing Res Rev. 2017;37:117-134. doi:10.1016/j.arr.2017.05.007PubMedGoogle ScholarCrossref
44.
Jeffs  KJ, Berlowitz  DJ, Grant  S,  et al.  An enhanced exercise and cognitive programme does not appear to reduce incident delirium in hospitalised patients: a randomised controlled trial.  BMJ Open. 2013;3(6):e002569. doi:10.1136/bmjopen-2013-002569PubMedGoogle ScholarCrossref
45.
McCusker  J, Cole  M, Dendukuri  N, Belzile  E, Primeau  F.  Delirium in older medical inpatients and subsequent cognitive and functional status: a prospective study.  CMAJ. 2001;165(5):575-583.PubMedGoogle Scholar
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
jn-learning_Modal_LoginSubscribe_Purchase
Close
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
jn-learning_Modal_LoginSubscribe_Purchase
Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Close

Name Your Search

Save Search
Close
With a personal account, you can:
  • Track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
jn-learning_Modal_SaveSearch_NoAccess_Purchase
Close

Lookup An Activity

or

Close

My Saved Searches

You currently have no searches saved.

Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Close