Exercise as it relates to Disease/Reducing functional decline in very-elderly hospital patients through exercise prescription

This article is a critical analysis of the following paper: Martínez-Velilla N, Casas-Herrero A, Zambom-Ferraresi F, Sáez de Asteasu ML, Lucia A, Galbete A, et al. Effect of Exercise Intervention on Functional Decline in Very Elderly Patients During Acute Hospitalization: A Randomized Clinical Trial. JAMA Intern Med

What is the background to this research?
Ageing effects systemic physiological degeneration including muscle mass loss, proprioceptive dysfunction, hardening of vascular walls and reduced bone strength result in a high incidence of elderly hospital admissions (~46% of all total patient admittances). Research shows that whilst recovering in hospital, patients are subject to muscle atrophy, which is particularly concerning in the elderly demographic who already show signs of dwindling muscle mass. As a result, the need for appropriate exercise which minimises atrophy, and at least maintains patient functionality is crucial. This study investigates the impact of a multi-component exercise program in order to reduce the incidence of diseases that affect functionality in the elderly population.

Where is this research from?
The research was published in the, one of the world's top medical journals by Dr. Nicolás Martínez-Velilla, head of the Department of Geriatrics at the Navarra Hospital complex in Spain, who has published over a dozen papers in the field of elderly decline.

The study population includes elderly patients from a hospital in Spain (370 patients included: 209 women, 161 men, mean age = 87.3±4.9 years, median hospital stay = 8 days) and builds on the research generated for the Acute Care of Elderly (ACE) rehabilitation programs which are designed to meet the acute, non-life-threatening health needs of older people at risk of functional decline as a result of hospitalisation.

What kind of research was this?
This study was conducted as a blind (RCT), which is the gold standard for collecting data in a first-hand investigation, and thus a valid protocol for the study. An RCT is designed to test the degree to which an intervention is successful, by comparing the results of a control group with those of an intervention group. Within this focus, the researchers have produced a study that provides accurate and well-established data, along with appropriate evidence-based interventions to rectify a clear oversight in the treatment of elderly hospital patients.

Setup
Initially individuals were screened, with the following criteria used to select participants for the study:
 * 1) ≥75 years of age
 * 2) Barthel scale of 60 or above
 * 3) Being able to ambulate
 * 4) Being able to communicate with the research team

Eligible participants were then randomly assigned into either the control group or intervention group. Baseline results were gathered for each participant in the Short Physical Performance Battery (SPPB) test, and (scale: 0 = severe functional dependence, 100 = functional independence) (Table 1).

Procedure
The program included 2 x 20 min sessions on 7 days a week. The morning session included resistance, balance, and walking training (2-3 x 8-10 x 30-60%), with 3 exercises focusing on lower body muscles (squats from a chair, leg press and knee extension), and 1 targeting the upper body (chest press). Balance and gait sessions included semi-tandem foot standing, line walking, walking with small obstacles, and proprioceptive exercises on unstable surfaces. In the evening, participants completed exercises using light loads which targeted knee extension/flexion, hip abduction, walking, and grip strength. The program was concluded for each patient when a change occurred in Short Physical Performance Battery (SPPB) test results by at least 1 point, and there was at least a 5 point increase in Barthel Index of independence scores.

Evaluation of the study
The considered methodology, which includes a large sample size, innovative protocol, and low exclusion criteria increases the applicability of the study to other programs and studies created in the future. However, poor condition of some patients precluded assessment of change which means that the outcomes were not applicable to most debilitated patients. Functional and cognitive data was not taken pre-incident, and thus the true value of the developed programs is unclear.

Key Findings
The results show that standard hospitalisation procedures led to an impairment in functional capacity (mean change = -5.0 pts on Barthel Index - Table 2), and that the intervention group showed improvements in all measured areas compared to the control group (Table 2). In short, the results suggest that current rehabilitation programs in hospitals are not adequate in promoting functionality within elderly patients.

What conclusions can we take from this research?
Current exercise prescription in hospitals is inadequate. There needs to be a shift towards a more complete intervention which enables patients to return home at baseline or even above pre-accident levels. Specifically, hospital-developed rehabilitation programs need to include exercises which develop strength in functional movements to increase independency, such as getting out of a chair, reaching to a shelf and picking up objects. This view is shared by a plethora of other studies. Ellis et al,. suggest that elderly individuals who undertake appropriate exercise intervention are less likely to suffer death or deterioration (OR: 0.76) while Gill et al., demonstrate that completing no physical activity increased risk of developing moderate or severe disability from having no prior disability (HR, 2.59; 95% CI, 2.23-3.02; and HR, 8.03; 95% CI, 5.28-12.21). Evidently, it is critical that elderly individuals complete regular physical activity, and, by extension, that hospitals provide adequate rehabilitation programs for this demographic which are designed with specificity towards maintaining or regenerating independency.

Practical advice
The primary message from this study, as aforementioned, is that hospitals need to increase the thoroughness of exercise prescriptions to all patients and elderly individuals need to undertake regular resistance training which specifically maintains functionality. However, programs developed must enable the participants to have confidence in completing exercise, which can be achieved through increasing efforts to provide education about the vast benefits of exercise and providing proper technique coaching as part of the program. However, before undertaking physical activity, consultation with a trained healthcare professional is crucial. This process will help to inform the participant which exercises may be beneficial and which are likely to cause harm, as well as identifying underlying medical conditions which require consideration.

Further information/resources
Individuals who wish to further their understanding of the need for exercise within the elderly population can visit the World Health Organisation (WHO) page on physical activity in elderly populations, or the WHO report which outlines global recommendations on physical activity.