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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.


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

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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.

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