Conclusion. An individualized, multicomponent physical exercise program that includes low-intensity resistance, balance, and walking exercises performed during the course of hospitalization (average of 5 days) can reverse functional decline associated with acute hospitalization in very elderly patients. Furthermore, this in-hospital exercise intervention is safe and has a high adherence rate, and thus represents an opportunity to improve quality of care in this vulnerable population.
Commentary
Frail elderly patients are highly susceptible to adverse outcomes of acute hospitalization, including functional decline, disability, nursing home placement, rehospitalization, and mortality.1 Mobility limitation, a major hazard of hospitalization, has been associated with poorer functional recovery and increased vulnerability to these major adverse events after hospital discharge.2-4 Interdisciplinary care models delivered during hospitalization (eg, Geriatric Evaluation Unit, Acute Care for Elders) that emphasize functional independence and provide protocols for exercise and rehabilitation have demonstrated reduced hospital LOS, discharge to nursing home, and mortality, and improved functional status in elderly patients.5-7 Despite this evidence, significant gaps in knowledge exist in understanding whether early implementation of an individualized, multicomponent exercise training program can benefit the oldest old patients who are acutely hospitalized.
This study reported by Martinez-Velilla and colleagues provides an important and timely investigation in examining the effects of an individualized, multicomponent (ie, low-intensity resistance, balance, and walking) in-hospital exercise intervention on functional outcomes of hospitalized octogenarians and nonagenarians. The authors reported that such an intervention, administered 2 sessions per day for 5 to 7 consecutive days, can be safely implemented and reverse functional decline (ie, improvement in Barthel Index and SPPB score over course of hospital stay) typically associated with acute hospitalization in these vulnerable individuals. These findings are particularly significant given the paucity of randomized controlled trials evaluating the impact of exercise intervention in preserving functional capacity of geriatric patients in the setting of acute hospitalization. While much more research is needed to facilitate future development of a consensus opinion in this regard, results from this study provide the rationale that implementation of an individualized multicomponent exercise program is feasible and safe and may attenuate functional decline in hospitalized older patients. Finally, the beneficial effects of in-hospital exercise intervention may extend to cognitive capacity, mood status, and QoL—domains that are essential to optimizing patient-centered care in the frailest elderly patients.
The study was well conceived with a number of strengths, including its randomized clinical trial design. In addition, the trial patients were advanced in age (35.1% were nonagenarians), which is particularly important because this is a vulnerable population that is frequently excluded from participation in trials of exercise interventions and because the evidence-base for physical activity guidelines is suboptimal. Moreover, the authors demonstrated that an individualized multicomponent exercise program could be successfully implemented in elderly patients in an acute setting via daily exercise sessions. This test of feasibility is significant in that clinical trials in exercise intervention in geriatrics are commonly performed in nonacute settings in the community, long-term care facilities, or subacute care. The major limitation in this study centers on the generalizability of its findings. It was noted that some patients were not assessed for changes from baseline to discharge on the Barthel Index (6.1%) and SPPB (2.3%) because of their poor condition. The exclusion of the most debilitated patients limits the application of the study’s key findings to the frailest elderly patients, who are most likely to require acute hospital care.
Applications for Clinical Practice
Functional decline is an exceedingly common adverse outcome associated with hospitalization in older patients. While more evidence is needed, early implementation of an individualized, multicomponent exercise regimen during hospitalization may help to prevent functional decline in vulnerable elderly patients.
—Fred Ko, MD, MS