Date Published: July 5, 2019
Publisher: Public Library of Science
Author(s): Mikel L. Sáez de Asteasu, Nicolás Martínez-Velilla, Fabricio Zambom-Ferraresi, Álvaro Casas-Herrero, Eduardo L. Cadore, Arkaitz Galbete, Mikel Izquierdo, Carol Brayne
Abstract: BackgroundAcute illness requiring hospitalization frequently is a sentinel event leading to long-term disability in older people. Prolonged bed rest increases the risk of developing cognitive impairment and dementia in acutely hospitalized older adults. Exercise protocols applied during acute hospitalization can prevent functional decline in older patients, but exercise benefits on specific cognitive domains have not been previously investigated. We aimed to assess the effects of a multicomponent exercise intervention for cognitive function in older adults during acute hospitalization.Methods and findingsWe performed a secondary analysis of a single-blind randomized clinical trial (RCT) conducted from February 1, 2015, to August 30, 2017 in an Acute Care of the Elderly (ACE) unit in a tertiary public hospital in Navarre (Spain). 370 hospitalized patients (aged ≥75 years) were randomly allocated to an exercise intervention (n = 185) or a control (n = 185) group (usual care). The intervention consisted of a multicomponent exercise training program performed during 5–7 consecutive days (2 sessions/day). The usual care group received habitual hospital care, which included physical rehabilitation when needed. The main outcomes were change in executive function from baseline to discharge, assessed with the dual-task (i.e., verbal and arithmetic) Gait Velocity Test (GVT) and the Trail Making Test Part A (TMT-A). Changes in the Mini Mental State Examination (MMSE) test and verbal fluency ability were also measured after the intervention period. The physical exercise program provided significant benefits over usual care. At discharge, the exercise group showed a mean increase of 0.1 m/s (95% confidence interval [CI], 0.07, 0.13; p < 0.001) in the verbal GVT and 0.1 m/s (95% CI, 0.08, 0.13; p < 0.001) in the arithmetic GVT over usual care group. There was an apparent improvement in the intervention group also in the TMT-A score (−31.1 seconds; 95% CI, −49.5, −12.7 versus −3.13 seconds; 95% CI, −16.3, 10.2 in the control group; p < 0.001) and the MMSE score (2.10 points; 95% CI, 1.75, 2.46 versus 0.27 points; 95% CI, −0.08, 0.63; p < 0.001). Significant benefits were also observed in the exercise group for the verbal fluency test (mean 2.16 words; 95% CI, 1.56, 2.74; p < 0.001) over the usual care group. The main limitations of the study were patients’ difficulty in completing all the tasks at both hospital admission and discharge (e.g., 25% of older patients were unable to complete the arithmetic GVT, and 47% could not complete the TMT-A), and only old patients with relatively good functional capacity at preadmission (i.e., Barthel Index score ≥60 points) were included in the study.ConclusionsAn individualized, multicomponent exercise training program may be an effective therapy for improving cognitive function (i.e., executive function and verbal fluency domains) in very old patients during acute hospitalization. These findings support the need for a shift from the traditional (bedrest-based) hospitalization to one that recognizes the important role of maintaining functional capacity and cognitive function in older adults, key components of intrinsic capacity.Trial registrationClinicalTrials.gov Identifier: NCT02300896.
Partial Text: The provision of inpatient acute care for frail older adults has become a crucial clinical issue in our aging societies [1–3]. Acute medical illnesses and subsequent hospitalization are major events leading to disability in older people [4–6]. In addition to functional decline, acute care hospitalization increases the likelihood of developing cognitive impairment in old patients . Indeed, cognitive impairment is highly prevalent in this patient group and is independently associated with multiple adverse outcomes, including functional decline, increased length of hospital stays, institutionalization, and mortality .
The study flow diagram is shown in Fig 1. No significant differences were found between groups at baseline for demographic and clinical characteristics for study endpoints (Table 1). Of the 370 patients included in the analyses, 209 were women (56.5%); the mean age was 87.3 (4.9) years (range 75–101 years), with 130 patients (35.1%) being nonagenarians). The median length of hospital stay was 8 days in both groups (interquartile range [IQR], 4 and 4 days, respectively). The mean number of intervention days for each patient was 5.3 ± 0.5 days, with most training days being consecutive (97%). The number of completed morning and evening sessions per patient averaged 5 ± 1 and 4 ± 1, respectively. Mean adherence to the intervention was 97% (95% CI, 95.67, 98.36) for the morning sessions (i.e., 806 successfully completed sessions of 841 total possible sessions) and 85% (95% CI, 79.70, 89.40) in the evening sessions (574 of 688). No adverse effects or falls associated with the prescribed exercises were recorded, and no patient had to interrupt the intervention or had their hospital stay modified because of it.
This secondary analysis of the RCT suggests that an individualized exercise intervention, delivered over a mean of 5 days, may provide benefits over usual care in acutely hospitalized older adults and may help reverse the cognitive impairment often associated with this patient group. To our knowledge, this is the first study to point towards the beneficial effects of a multicomponent intervention, including low-intensity resistance training exercises on specific cognitive domains such as executive function and verbal fluency, in hospitalized patients of advanced age.