COMPREHENSIVE GERIATRIC CARE VERSUS STANDARD CARE FOR ELDERLY REFERRED TO A REHABILITATION UNIT – A RANDOMIZED CONTROLLED TRIAL

D. Zintchouk¹, T. Lauritzen², E.M. Damsgaard¹

1. Aarhus University Hospital, Department of Geriatrics, Aarhus C, Denmark; 2. Department of Public Health, Section of General Medical Practice, Aarhus University, Aarhus C, Denmark.

Corresponding Author: Dmitri Zintchouk, MD, Aarhus University Hospital, Department of Geriatrics, P.P. Oerumsgade 11, 8000 Aarhus C, Denmark, dmizin@rm.dk, tel. 004526700903, fax 004578461930.

J Aging Res Clin Practice 2017;inpress
Published online December 15, 2016, http://dx.doi.org/10.14283/jarcp.2016.126

Abstract

Objective: To investigate the effect of comprehensive geriatric care (CGC) in elderly referred to a rehabilitation unit. This article describes the considerations behind the study. Design: Participants were randomized to either CGC or standard care. Setting: Participants were recruited from two community care rehabilitation units in Aarhus Municipality, Denmark, in the period between 2012 and 2015. Participants: Inclusion: Elderly patients aged 65 and older admitted from home or hospital. Exclusion: Persons receiving palliative care or assessed by a geriatrician during the past month. Intervention: Medical history, physical examination, blood tests, medication adjustment and follow-up by a geriatrician. The control group received standard care with the general practitioners (GPs) as back-up. Outcomes: Primary outcome: Hospital contacts drawn from national registers. Secondary outcomes: GPs contacts, institutionalization, medication status and mortality collected from national registers, activities of daily living (ADL), physical and cognitive function and quality of life measures collected by a blinded occupational therapist. All outcomes were assessed at day 10, 30 and 90 after arrival at the rehabilitation unit. Conclusion: A new model of care for elderly referred to community rehabilitation was developed and implemented. The potential benefits of this model were compared with usual care in a community rehabilitation unit in a pragmatic randomized clinical trial. We hypothesized that the geriatrician-performed CGC in elderly referred to a rehabilitation unit will reduce the hospital contacts by 25 % without increase in mortality and in contacts to GPs and home care services. We expect that this model will prevent deterioration in ADL, physical and cognitive functioning, and reduce the risk of institutionalization. If the results are positive, community rehabilitation services should be encouraged to change their routines for treatment of this population accordingly.

Key words: Randomized controlled trial, comprehensive geriatric care, hospitalization, rehabilitation, activity of daily living.

Introduction

Older people are the fastest growing sector of the population and they account for the largest increase in hospital admissions (1). More survivors with chronic diseases mean increasing numbers of overlapping comorbidities and increased risk of acute illness (2,3). Admissions to hospital for older people are combined with risk of rapid decline in functional ability, cognitive impairment, and change to residential care (4, 5). Despite a multitude of efforts to reduce hospital attendances and admissions worldwide, the numbers are increasing year after year (6).
To give patients the best life possible and to save health care resources, we intend to evaluate the effect of Comprehensive Geriatric Care performed by a geriatrician in a community operated rehabilitation unit.

Comprehensive geriatric assessment (CGA) and comprehensive geriatric care (CGC)

CGA is defined as a “multidimensional interdisciplinary diagnostic process focusing on a frail older person’s medical, psychological and functional capability”(7). In practice the assessment is followed by an intervention and sometimes by a follow-up based on the assessment. The recently suggested concept of comprehensive geriatric care (CGC) covers the combined assessment and follow-up interventional process more precisely (8).
Several models of CGA and CGC have been proposed. The last meta-analysis from Ellis et al. (9) showed that only inpatient CGA in acute geriatric units is effective and results in an increased likelihood of a patient returning home and avoiding admission to residential care or deterioration and death. Randomized studies of post-hospital discharge CGA found inconsistent benefits in functional status, acute care visits, depression, and patient satisfaction (10, 11). However, post-discharge intervention was associated with reduction in costs and readmission rates (12, 13), and CGC may be beneficial for hip fracture patients by reducing complications, mortality, readmissions, and delirium (8, 14-17).
A few randomized studies on different care models were published in the last five years. Senior and colleagues (18) showed that the model of restorative care services delivered within both residential care and at home by a multi-disciplinary team, included a case manager, nurse, occupational therapist and physiotherapist, tend to reduce the risk of death or permanent residential care. The absolute risk reduction for death or permanent residential care of 14.3% was not significant compared to usual care group at 24 months follow-up. Moreover, the intervention group had more frequent utilization of personal care, home help, career support, respite, day center and day activity centers than the usual care group. The same research group (19) showed that locally based care model managed by experienced nurses working with strong partnerships with family physicians reduces the risk of death and permanent residential care placement in frail older adults by 10.2% compared to usual community care coordinated by a centrally based needs assessor.
A recent Danish study shows that home-visits by a geriatrician and a specialized nurse on the first days after discharge from hospital reduce the readmission rate for acute medical patients by almost 50%, compared to patients accompanied home or subsequently receiving a telephone call. Rehospitalization was reduced, but 30-day mortality did not differ significantly between groups (20).

Geriatrician-performed comprehensive geriatric care in community rehabilitation settings

Physicians alone can perform many aspects of CGA followed by intervention. Often this is not practicable given the limited time available and the workload of instituting a complex care plan (21). We have deliberately chosen to focus on the role of the geriatrician in community rehabilitation. The staff of community rehabilitation units has some expertise in care of elderly with deteriorating function. Involvement of a larger team from the geriatric department may confuse the patients and cause unnecessary expenditure.
To our knowledge, no randomized studies have evaluated the effect of geriatrician-performed CGC comprising CGA and intervention with follow-up in elderly referred to a community rehabilitation unit.

Objective

The objective of this study is to investigate the effect of the geriatrician-performed CGC compared to a control group with standard care in elderly referred to a community rehabilitation unit.

Methods

The study is a pragmatic open assessor-blinded randomized clinical trial with 90 days’ follow-up.

Participants and settings

The inclusion criteria were: 1) age 65 years or older; 2) referral to a community rehabilitation unit from home or a hospital department. The exclusion criteria were: 1) palliative care; 2) assessment by a geriatrician during the past one month. The participants were all residents of two community rehabilitation units, Vikaergaarden (64 rooms) and Thorsgaarden (24 rooms) in Aarhus Municipality, Denmark. For study flow, see Figure.

Figure 1
Study flow in the Comprehensive Geriatric Care versus Standard Care for Elderly referred to a Rehabilitation Unit –
a Randomized Controlled Trial

Recruitment

Participants were consecutively recruited from unit Vikaergaarden in the period January 17, 2012 to May 29, 2015, and from unit Thorsgaarden from October 20, 2014 to May 29, 2015. Eligible elderly and/or their relatives were contacted by the project manager or research nurse, who provided the oral and written information. Participants with cognitive impairment were also included. All had twenty-four hours to consider or discuss with relatives before the written informed consent was obtained.
During the study enrolment the following adjustments were made to accelerate the inclusion of the participants: inclusion age was lowered from 70+ to 65+ from May 14, 2012, previous contact with a geriatrician within three months was reduced to one month from December 2, 2012. All the changes have been submitted to Clinical.Trials.gov (NCT01506219).

Randomization

The random allocation of the participants to the intervention and control groups was done by an independent external organization (“TrialPartner”, Public Health and Quality Improvement, Central Denmark Region). The permuted block sizes stratified the randomization according to sex, age and place of referral. The randomization took place within three days after the participants’ arrival to the rehabilitation unit. In the intervention group the geriatrician informed participants and relatives about the allocation and gave the personal contact information card to participants or relatives.

Blinding

Owing to the nature of this study, it was impossible to blind participants and their relatives to the allocation group. The project manager screened the patients for eligibility, collected data on age, gender, place of referral and comorbidity before randomization, and conducted the intervention. The project manager had no contact with the control participants after randomization. The project manager was blinded to the study outcomes, which were collected from the registers or by the blinded research occupational therapist. Rehabilitation units’ staffs, particularly physiotherapists, were not blinded.

Standard care in the rehabilitation unit

The patients were referred for rehabilitation either from hospital or home by the hospital personnel or by the home care staff. Rehabilitation services are not free of charge, and a moderate fee for the stay is paid by the patients themselves. The typical standard rehabilitation and care program lasts five weeks. The interdisciplinary approach is based on the patient’s whole situation, capability and wishes/needs. On the first day of rehabilitation, the patient’s functional status is observed by the rehabilitation unit’s physiotherapists and occupational therapists, and a nutritional screening is performed by the rehabilitation unit’s nutritionist. The team members discuss the patient’s discharge destination and necessary arrangements with the patient and his/her relatives at the mid-term meeting and before discharge from the rehabilitation unit. Municipality nurse participates in these meeting personally or by telephone. Destination after discharge is based upon the patient’s motivation, functional and medical status.
The patient’s GPs visit the patients during the stay if required or occasionally by own initiative depending on practice routine and geographical distance. GPs mostly visit frail and high-risk elderly patients especially if recently hospitalized. Acute medical aid is called for in case of illness after 4.p.m. and on weekends and public holidays.

Care in the intervention group

Participants randomized to the intervention group underwent the geriatrician-performed CGC during the rehabilitation stay. The intervention was performed by a physician specialized in geriatric medicine. The primary assessments lasted about an hour and included review of diagnoses, organ functional status, medication, and life expectancy evaluation. Individual disease management and coping was provided using the holistic approach during the face-to-face counselling, where the actual problems, expectations and aims were defined in dialogue with the patient and/or relatives. Afterwards, targeted problem solving with focus on the potentially reversible causes of functional deterioration was established. Finally, medication adjustment was carried out with particular attention to drugs which may lead to iatrogenic functional deterioration, delirium, falls, and malnutrition. A simple tool like the STOPP (Screening Tool of Older Person’s Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment) criteria have been used as an evidence-based approach to reduce inappropriate prescribing and to encourage appropriate prescribing in the older adult (22, 23). When no evidence base existed for drug use, the approach was based on clinical judgment only, and the balance of risks and benefits of the drug for the individual was presented to the participants and/or relatives. In collaboration with rehabilitation unit’s staff the geriatrician followed the participants with regard to any change in symptoms, signs, or relevant laboratory and diagnostic test results that might indicate a restart of a specific medication, which had been discontinued.
The geriatrician was present at the rehabilitation unit for about four days a week, and could be contacted on telephone for any reason by participants, their relatives or the unit’s staff on weekdays from 8 a.m. to 3 p.m. In acute situations the geriatrician could also be contacted. The follow-up period by the geriatrician at the rehabilitation units was individualized (generally four weeks). The geriatrician sent the discharge summary for each intervention group participant to the GP. The geriatrician also provided education and support to the staff of the rehabilitation units and informed and advised the GPs and primary care services if needed. After discharge from the rehabilitation units GP are responsible for treatment.
See Table 1 for patient treatment in the intervention versus control group.

Table 1
Patient treatment in the Comprehensive Geriatric Care versus Standard Care for Elderly referred to a Rehabilitation Unit – a Randomized Controlled Trial

* Hemoglobin, Leucocytes, C-reactive protein, P-albumin, P-Potassium, P-Sodium, glomerular filtration rate.

Outcomes

Baseline data

Baseline characteristics were registered by the project manager from medical records and/or interview, comprising age, gender, place of referral (own home or hospital), marital status, residential status, diagnoses, comorbidity, and list of medications. The functional tests and quality of life at baseline (day 3) were done by the research occupational therapist after randomization.

Primary outcome

Primary outcome was total number of hospital contacts within 90 days after admission to the rehabilitation units.

Secondary outcomes

Secondary outcomes included all hospital and GPs contacts and number of participants with the hospital and GPs contacts, number of days spent in hospital, use of homecare services, transfer to nursing homes or sheltered housing, changes in medication status and number of deaths within 90 days. Moreover participant’s ADL, cognitive and physical functioning, and quality of life were assessed at day 3, 10, 30 and 90 after admission to the rehabilitation units. Trial outcome follow-up was completed August, 27. 2015.

Measurements

1) Mini-mental state (MMSE) (24). MMSE is a 10-minute bedside measure of impaired thinking. The items of the MMSE include tests of orientation, registration, recall, calculation and attention, naming, repetition, comprehension, reading, writing and drawing (25).
2) The Confusion Assessment Method (CAM) (26).
CAM is a standardized evidence-based tool that enables non-psychiatrically trained clinicians to identify and recognize delirium quickly and accurately in both clinical and research settings. The CAM includes four features found to be most effective in distinguishing delirium from other types of cognitive impairment.
3) Modified Barthel-100 Index (MBI) (27).
MBI is a 10-item instrument that provides a score of basic daily activities (feeding, bathing, grooming, dressing, bowels, bladder, toilet use, transfer, mobility, and stair climbing). The scores range from 0-100, with a higher score indicating greater independence.
4) The 30-second chair stand test (28).
The 30-second chair stand test measures body strength, by determining the number of times the participant can stand up fully and sit down in 30 seconds, with the arms crossed over the chest. We have used the modified version of this test, where use of armrest is allowed.
5) Depression List (DL) (29).
DL is a fifteen-item questionnaire, designed to assess quality of life in frail nursing home residents. DL addresses emotional well-being, social relationships, life satisfaction, comfort, functional competence, and autonomy. The scale ranges from 0 (best quality of life) to score 30 (poorest quality of life).
6) Charlson Comorbidity Index (CCI) (30) is used to categorize comorbidity in three levels:
0 = low, 1-2 = moderate, and 3 or more = high.
All the functional measurements, except for the modified version of “The 30-second chair stand test”, are validated for use in an elderly population. All questionnaires were performed as structured interviews. Trial outcome follow-up was completed August, 27. 2015.

Data collection

Data on hospital contacts and GPs contacts and mortality were collected from The National Patient Registry, The National Health Insurance Service Register and Danish Civil Registration System via Researcher Service, Statens Serum Institut, Danish Ministry of Health. Data on causes on hospital contacts were collected by the primary investigator from the Electronic Patient Record. Data on district nurses availability, extent of personal social services, walking aids and residential status were recorded through the Aarhus Community Care Record.
The actual medication usage and the number of Defined Daily Doses (DDD) within the different The Anatomical Therapeutic Chemical (ATC) Classification System were clarified and recorded under the personal medication review and through the Electronic Patient Record and the Aarhus Community Care Record by the primary investigator and the research nurse.
The functional tests and evaluation of the health-related quality of life during the follow-up period were performed by the research occupational therapist.
For data collection details, see Table 2.

Table 2
Outcomes in the Comprehensive Geriatric Care versus Standard Care for Elderly referred to a Rehabilitation Unit –
a Randomized Controlled Trial

Ethics

Written informed consent was obtained from the participants by the project manager or research nurse within two days of arrival at the rehabilitation unit. Under the consent procedure the project manager assessed the elderly’s cognitive capacities. Cognitive impairment was defined by: (1) MMSE score of < 25; (2) CAM indicating delirium; or (3) a clinical cognitive evaluation undertaken by the project manager. Patients who were not cognitively impaired gave their written informed consent. Consent of cognitively impaired patients was given by a relative.
The project manager informed the participant’s GPs by letter about the study participation without information about the allocation. In the intervention group the GPs were shortly informed by the geriatrician about the treatment plan per mail in the Electronic Patient Record.
The CGC contained all known and commonly used and approved testing methods. All data are treated in confidence and participants are assured anonymity. The study is approved by the Danish Data Protection Agency, journal no. 2012-58-006, and the Ethical Committee of Central Denmark Region, journal no. M-20110262.
An interim-analysis was performed on the mortality when 50 % of participants have been randomized and have completed the 90 days’ follow-up. The interim-analysis was performed by an independent statistician, blinded for the treatment allocation. Results were evaluated by an independent researcher in order to stop the study prematurely if significant mortality differences were found.

Sample size and data analysis

Power calculation

For power calculation we used data on hospital contacts from The National Patient Registry in persons receiving rehabilitation at the rehabilitation unit Vikaergaarden from 1 April 2009 to 31 March 2010. There were 153 hospital contacts among 550 65+ year old persons within three months after the admission at rehabilitation. An analysis of hospital contacts over 30 days in 68 participants in a pilot project showed 33% fewer hospital contacts in the intervention group (number of persons with hospital contacts=7, total number of contacts=12) compared to the control group (number of persons with hospital contacts=7, total number of contacts=19).
For the sample size calculation we expected a 25% reduction of the hospital contacts, which we regarded as a clinically relevant change. Estimated dropout was set to 20% in both groups, as mortality was expected to be high. To obtain 80% statistical power and a significance level at 0.05 we had to recruit 370 patients.

Data analysis

All data are being entered in a database (Access 2010) by the research nurse. The statistical analyses will be conducted based on a predefined statistical protocol using STATA (version 13, STATA Corporation, Texas). Both descriptive and analytic analysis will be performed. Descriptive data will be calculated in percent, while median, average and minimum and maximum will be used for continuous variables. Continuous variables will be analyzed for normal distribution with the Kolmogorov-Smirnov test. The principle of repeated measurements will be used to analyze continuous variables. Variables with dichotomous outcomes will be analyzed using the logistic regression. Non-normally distributed data will be analyzed with the Mann-Whitney U test/Wilcoxon matched-pair’s test. Mortality will be analyzed with Kaplan-Meier analysis. Survival analysis will be performed with Cox Regression model adjusting for the sex, age, comorbidity and place of referral. In order to ensure the statistical robustness of the intervention outcomes, two different longitudinal imputation methods (last value carried forward and worst value imputation) will be used in case of missing values on sensitive analysis. There will be a bilateral significance level of 5% for evaluation of statistical significance in the primary and secondary endpoints. Intention-to-treat analysis will be performed.

Discussion

To our knowledge this is the first randomized controlled study to evaluate the effect of the CGC performed by a geriatrician in elderly citizens referred to community rehabilitation. In a systematic review the authors found that no particular model of geriatric care in community rehabilitation facilities could be recommended (31). In spite of multiple recent advances in providing rehabilitation in community settings, organization of these services, particularly the role of the geriatrician, remains poorly addressed.

Strengths and limitations of the study

Design

The RCT design was chosen to investigate the broad population of elderly with functional loss and multimorbidity, often excluded from RCTs (32-34). This must be considered as a strength. However, it has a price because the heterogeneity of the study population requires a much greater number of participants to demonstrate a possible significant difference.

Study population

The strength of the study population was the broad inclusion criteria, which insured enrolment of participants with a wide range of medical conditions.
We also decided to include elderly with dementia or confusion on arrival at the rehabilitation unit. We expected these persons to benefit most from the geriatrician-performed CGC.
On the other hand the recruitment was expected to be challenged due to difficulties in obtaining written informed consent. In order to detect possible selection bias among participants information about age, gender, place of referral and comorbidity (CCI) was obtained for participants as well as non-participants.

Intervention

The intervention was individualized and holistic based on a dialogue with the patient and/or relatives setting realistic common aims and expectation for treatment. This pragmatic clinical approach attempts to maximize external validity (35). The individual needs of the elderly are complicated by medical, functional, psychological, and social problems (36).This may lead to an atypical clinical presentation requiring flexibility and variation of the treatment.
Yet, the intervention was as systematic as possible in order to be reproducible. However, the medication adjustments by the geriatrician were not standardized. We were not able to use the STOPP-START tool strictly due to a systematic lack of the patient dimension. Medicine adjustments in elderly may conflict with established guidelines not addressing the care of people with multiple conditions (37). Such discrepancies may confuse the participant, the home career or the GP and result in readministration of discontinued drugs.
A specialist physician in geriatric medicine performed the intervention. This has strengths: the rehabilitation units’ staff could easily contact the geriatrician, who was physically available at an office in the rehabilitation units. In the majority of cases the primary investigator/project manager was also the geriatrician who conducted the intervention. It makes continuity possible and optimizes communication with the patients, their relatives and the staff of the rehabilitation units. It may promote the compliance and be more cost effective. On the other hand when the intervention depends on one physician the results are less generalizable and should be confirmed by further studies.
A stronger cooperation was established between the geriatric department and the rehabilitation units, likewise educational courses on common geriatric problems were carried out for the staff during the study period. Both the intervention and the control group were treated by the same personnel, which may have a positive spillover effect reducing a possible difference between the groups.

Blinding

A strength of our study was the systematical efforts tried to minimize information bias. The geriatrician was blinded to the primary endpoint data that were drawn from The National Patient Registry via Researcher Service. The dataset was generated by the Registry’s staff blinded to the patient allocation.
It was a weakness that it was impossible to blind the participants and their relatives or the geriatrician and the rehabilitation units’ staff to the allocation group. The research nurse was not blinded to patient allocation for practical reasons. The research occupational therapist was blinded to treatment allocation, but it could not be ruled out that the participants may have mentioned their allocation during the assessment. Thus, the performance-based measure of physical and cognitive functioning could be biased.

Outcome measures

A strength of this study was the use of functional measurements and questionnaires well validated for elderly. The modified version of the “30-second chair stand test”, in which the use of armrest is allowed, was the only test not validated. However, it is suited for our study population, as the majority of the participants were not able to perform the original version of the test.

Conclusion

A new model of care for elderly referred to community rehabilitation was developed and implemented. The potential benefits of this model were compared with usual care in a community rehabilitation unit in a pragmatic randomized clinical trial. This pragmatic approach closely mimics the true clinical situation. We hypothesize that the geriatrician-performed CGC in elderly referred to a rehabilitation unit will reduce the hospital contacts by 25 %. This should be done without increasing mortality, GP contacts or home care services. We expect this model to prevent deterioration in ADL, physical and cognitive functioning, and to reduce the risk of institutionalization. Data collection was recently completed. The results may soon be published.

Acknowledgements: This trial is funded by Geriatric Department Aarhus University Hospital and received donations from the Health Insurance Fund (Helsefonden) and Public Health in the Central Region Fund (Folkesundhed i Midten).
Authors’ contributions: DZ in collaboration with EMD and TL designed the study. DZ carried out the interventions. DZ drafted the manuscript. All authors revised the manuscript critically and have given their final approval of this version to be published.

Conflict of Interest: There is no conflict of interest to declare. DZ is a specialist in geriatrics and a member of network of Danish physicians and medical students “Physicians without sponsor”.

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CLINICAL CHARACTERISTICS ASSOCIATED WITH DYSPHAGIA IN THE HOSPITALIZED ELDERLY

Department of Rehabilitation, St. Francis Hospital, Nagasaki City, Japan

Corresponding Author: Yoshitoshi Kuroda, Department of Rehabilitation, St. Francis Hospital, 9-20 Komine-machi, Nagasaki City, 852-8125 Japan, Telephone: +81-95-846-1888, Fax: +81-95-845-7600, Email: kuroda@athena.ocn.ne.jp

Abstract

The aim of this study was to determine the factors associated with dysphagia in the hospitalized older adults. The dysphagia group consisted of 46 patients (23 men and 23 women) while the non-dysphagia group consisted of 40 patients (10 men and 30 women). The measurements included Mini Nutritional Assessment Short-Form (MNA-SF) scores, serum albumin levels, anthropometrics, and a mobility index. The dysphagia group was older and had significantly higher rates of male sex, respiratory disease on admission, dementia, other neurological disease, and impaired mobility than the non-dysphagia group. The dysphagia group also showed significantly lower values in nutritional measurements including MNA-SF scores, serum albumin levels. Logistic regression analysis showed that the factors significantly and independently associated with dysphagia were impaired mobility, dementia, and male gender. The results of present study showed that hospitalized elderly with dysphagia are likely to present with problems including physical and mental disabilities and malnutrition.

Key words: Dysphagia, elderly, hospitalization, disability, malnutrition.

Introduction

Dysphagia is a common condition among the elderly. Recent studies have reported the prevalence of oropharyngeal dysphagia as 27.2% in independently living elderly (1) and 47.4 % in hospitalized elderly (2). Studies have also reported that dysphagia in the older population is associated with malnutrition (2-4), impaired activities of daily living (1, 4), increased rates of lower respiratory tract infection (3, 5), and higher mortality rates (5). These findings clearly indicate that dysphagia is a major health problem in this population.

One reason for the high prevalence of dysphagia in the elderly may be that diseases that can cause dysphagia increase with age (6). However, it is not uncommon to observe elderly patients developing dysphagia in the absence of any disease that is known to directly cause dysphagia. Another reason may be that a wide variety of stressors, such as acute illness, can induce dysphagia because the elderly have a diminished functional reserve available for swallowing (6). Although the latter hypothesis seems plausible, it does not fully explain the underlying mechanism considering that some patients have persistent or progressive dysphagia in the absence of acute illness. Thus, currently there are no well-grounded hypotheses that can account for the underlying mechanism that result in the increased incidence of dysphagia in the elderly.

In order to provide effective intervention, further understanding of the underlying mechanism is mandatory. In the present study, we conducted a retrospective investigation comparing clinical characteristics between those with and without dysphagia among the hospitalized elderly. The aim of this study was to determine the factors associated with dysphagia in hospitalized older adults.

Subjects and methods

Subjects were retrospectively selected from patients admitted to a hospital for acute care between April 2013 and September 2014. Included were patients aged 65 years or older who were rated as having “malnutrition” or being “at risk of malnutrition” by the Mini Nutritional Assessment Short-Form (MNA-SF) (7) and who underwent a series of nutritional and physical assessments as described below. Excluded were those with active malignancy and those with feeding tubes. A total of 86 patients (33 men and 53 women) with a mean age (standard deviation [SD]) of 85.7 (7.7) years were enrolled as subjects. Primary diseases on admission were respiratory disease (n = 46), orthopedic disease (n = 8), digestive disease (n = 7), cardiac disease (n = 6), renal disease (n = 4), inactive cancer (n = 4), and others (n = 11). Patients who were referred to speech therapists for swallowing management during hospitalization were defined as the dysphagia group and those who had no problems with swallowing, as the non-dysphagia group. The dysphagia group consisted of 46 patients (23 men and 23 women) while the non-dysphagia group consisted of 40 patients (10 men and 30 women). The severity of dysphagia was evaluated using the food intake level scale, with a range from 1 (no oral intake and no swallowing training) to 10 (normal oral food intake) (8). The scores of the dysphagia group ranged from 3 to 9 (median = 5) while all subjects in the non-dysphagia group scored 10.

Nutritional assessment included MNA-SF scores, calf circumference (CC), mid-upper arm circumference (MUAC), mid-arm muscle circumference (MAMC), and serum albumin levels. Physical ability was evaluated with a mobility index, measured as follows: 0, completely bedridden; 1, able to sit with a little assistance; 2, able to sit without assistance; 3, able to move from bed to wheel chair with a little assistance; 4, able to move from bed to wheelchair without assistance; 5, able to walk with a little assistance; and 6, able to walk without assistance. cymbalta The two groups were compared for the age, sex, presence of respiratory disease (as a primary disease on admission), dementia, and other neurological diseases, and the above variables. In order to make the analyses more readily comparable, the continuous variables were converted into dichotomous variables based on cut off points. The cut-off points were applied for age (85 or older), MNA-SF score (< 8, suggesting malnutrition), CC (< 31.3 cm for men and < 29.9 cm for women), MUAC (< 22.5 cm for men and < 20.8 cm for women), MAMC (< 19.1 cm for men and < 16.6 cm for women), and serum albumin levels (< 2.8 g/dL). The cut-off points of the anthropometrics were values 2 standard deviations below the normal population aged 40-44 years for each sex (9).

Comparative analyses between the two groups were performed using the Student’s t-test, Mann-Whitney test, and chi square test. Logistic regression analysis was performed using dysphagia as the dependent variable and other dichotomous measures as independent variables. In the multivariate analysis, respiratory disease was excluded from the analysis because it is clearly a frequent result of dysphagia (5). Statistical significance was set at p < 0.05.

Results

Comparison between the dysphagia group and the non-dysphagia group is shown in Table 1. The dysphagia group was older (p < 0.001) and had significantly higher rates of male sex (p = 0.014), respiratory disease on admission (p < 0.001), dementia (p < 0.001), other neurological disease (p = 0.047), and impaired mobility (p < 0.001) than the non-dysphagia group. The dysphagia group also showed significantly lower MNA-SF scores (p < 0.001) and serum albumin levels (p = 0.03), but no significant differences in MUAC (p = 0.141) and MAMC (p = generic cymbalta 0.206) measures. The results from the analysis using dichotomous variables were similar to those from the above analysis using continuous variables with the exception that the dysphagia group exhibited a significantly higher rate of decreased MAMC compared with the non-dysphagia group (p = 0.018), and the difference in the rate of decreased CC did not reach a significant level ( p = 0.090).

Table 1 Comparison between the dysphasia group and non-dysphagia group

Logistic regression analysis showed that the factors significantly and independently associated with dysphagia were impaired mobility (OR 13.70 95% CI 3.43-54.80), dementia (OR 11.0 95% CI 3.01-40.10), and male gender (OR 6.81 95% CI 1.69-27.50) (Table 2).

Table 2 Variables associated with dysphagia (multivariate logistic regression analysis)

Discussion

The dysphagia group was older than the non-dysphagia group, which was consistent with previous studies (1-3, 5). It is of note that our results showed that male gender was significantly associated with dysphagia, which was inconsistent with the findings from Spanish studies (1-3, 5). Considering that a Korean study (10) and a Japanese study (11) also reported the association of male gender with dysphagia, such an association may be related to ethnicity.

Dementia and neurological disease were significantly associated with dysphagia which was consistent with previous findings (2, 5). However, such an association was not observed in a study in independently living elderly (3), which was probably related to the very low prevalence (< 10%) of each condition in the study cohort. Therefore, we consider that the association between dysphagia and dementia or neurological condition is typically apparent only in clinical populations.

The dysphagia group exhibited significantly impaired mobility compared to the non-dysphagia group. Furthermore, the multivariate analyses showed that impaired mobility was the most important predictor of dysphagia. Given that many studies have also demonstrated the association between dysphagia and activities of daily living in the elderly (1-5), the relationship between swallowing impairment and physical disability is of importance. Recent studies have proposed that sarcopenia is a common underlying cause of impaired physical ability and dysphagia (12-14). Further investigations regarding the effects of the loss of muscle mass and strength on swallowing function are needed.

The dysphagia group showed significantly lower values in the nutritional measures of MNA-SF score and serum albumin levels, suggesting an association between dysphagia and malnutrition. Anthropometric assessment using dichotomous variables also showed that the dysphagia group had significantly higher rate of decreased MAMC, suggesting a reduction of muscle mass may be a predictor for dysphagia. The difference in CC lost significance after applying the dichotomous variables, which was probably related to the very high prevalence (85% or more) of the decreased condition.

Taken together, the results of the present study showed that older patients with dysphagia are likely to present with impaired mobility, dementia, and malnutrition. The results were mostly consistent with recent findings (2-5). We consider that dysphagia in elderly patients is rarely a condition specific to the swallowing mechanism, and in many cases, it can be understood as part of a systemic decline including physical, mental, and nutritional deterioration. Currently, there is no sound evidence that traditional dysphagia intervention techniques are effective for this clinical population. Given that many countries are facing challenges associated with aging populations, there is a great need to clarify the underlying mechanism of dysphagia in the elderly in order to improve its prevention and treatment.

The limitations of this study were as follows: First, the study sample was small and obtained from one institution, which may limit the generalization of the results. Second, dysphagia was assessed only with an observational scale. Third, the cross-sectional design did not allow for causative analysis.

In conclusion, hospitalized elderly with dysphagia are likely to present with problems including physical and mental disabilities and malnutrition.

Conflicts of interests: The author has no conflict of interest to disclosure, and do not receive any funding for this study.

References

1. Serra-Prat M, Hinojosa G, Palomera E, Arreola V, Clavé P. Prevalence of oropharyngeal dysphagia and impaired safety and efficacy of swallowing in independently living older persons. JAGS 2011; 59: 186-187.

2. Carrión S, Cabré M, Monteis R, Roca M, Palomera E et al. Oropharyngeal dysphagia is a prevalent risk factor for malnutrition in a cohort of older patients admitted with an acute disease to a general hospital. Clin Nutr 2015; 34: 436-442.

3. Serra-Prat M, Palomera M, Gomez C, Sar-Shalom D, Saiz A et al. Orpharyngeal dysphagia is a risk factor for malnutrition and lower respiratory tract infection in independently living older persons: a population-based prospective study. Age Aging 2012; 41: 376-381.

4. Wakabayashi H, Matsushima M. Dysphagia assessed by the 10-item eating assessment tool is associated with nutritional status and activities of daily living in elderly individuals requiring long-term care. J Nutr Health Aging 2015. doi:10.1007/s12603-015-0481-4.

5. Cabré M, Serra-Prat M, Force LI, Almirall J, Palomera E et al. Oropharyngeal dysphagia is a risk factor for readmission for pneumonia in the very old persons: observational prospective study. J Gerontol A Biol Sci Med Sci 2014; 69: 330-337.

6. Ney D, Weiss J, Kind A, Robbins J. Senescent swallowing: impact, strategy and interventions. Nutr Clin Pract 2009; 24: 395-413.

7. Kaiser ML, Bauer JM, Ramsch C, Uter W, Guigoz Y et al. Validation of the Mini Nutritional Assessment short-form (MNA-SF): a practical tool for identification of nutritional status. J Nutr Health Aging 2009; 13: 782-788.

8. Kunieda K, Ohno T, Fujishima I, Hojo K, Morita T. Reliability and validity of a tool to measure the severity of dysphagia: the food intake level scale. J Pain Symptpm Manage 2913; 46: 201-206.

9. Hosoya N, Okada T, Muto Y, Yamamoru H, Tashiro T et al. Japanese anthropometric reference data 2001 (JARD 2001). Jpn J Nutr Assess 2002; 19(Suppl): 1-81 (Japanese).

10. Yang EJ, Kim MH. Lim JY, Paik NJ. Oropharyngeal dysphagia in a community-based elderly cohort: the Korean longitudinal study on Health and Aging. J Korean Med Sci 2013; 28: 1534-1539.

11. Furuta M, Komiya N. Akifusa S, Shimazaki Y, Adachi M et al. Interrelationship of oral health status, swallowing function, nutritional status and cognitive ability with activities of daily living in Japanese elderly people receiving home care services due to physical disabilities. Community Dent Oral Epidemiol 2013; 41: 173-181.

12. Kuroda Y. Relationship between swallowing function, functional and nutritional status in hospitalized elderly individuals. Int J Speech Lang Pathol Audiol 2014; 2: 20-26.

13. Wakabayashi H. Presbyphagia and sarcopenic dysphagia: association between age, sarcopenia, and deglutition disorders. J Frail Aging 2014; 3: 97-103.

14. Maeda K, Akagi J. Sarcopenia is an independent risk factor of dysphagia in hospitalized older people. Geriatric Gerontol Int 2015. doi:10.1111/ggi.12486.

PHYSICAL ACTIVITY IN HOSPITALIZED OLD MEDICAL PATIENTS; HOW ACTIVE ARE THEY, AND WHAT

M. Holst, P.L. Hansen, L.A. Pedersen, S. Paulsen, C.D. Valentinsen, M. Kohler

Aalborg University Hospital, Aalborg, Denmark, mette.holst@rn.dk

Corresponding Author: Mette Holst, Aalborg University Hospital, Aalborg, Denmark, mette.holst@rn.dk

Abstract

Objective: To examine how physically active Danish old medical patients are during hospitalization and to achieve knowledge of motivation and barriers to physical activity. Background: Functional decline in frail old patients during hospitalization is an important clinical problem with potential long-lasting undesirable outcomes and complications. Design: A mixed methods study including qualitative and quantitative methods. Methods: Patients >60 years of age were recruited at two medical departments during one week. Three SenseWear armband monitors were used for quantitative monitoring of physical activity. Semi Structured interviews were used for qualitative data. Results: The study comprised 13 patients, five female and eight male, mean age 73 (SD 9); BMI 19.4-32.1, mean 25.2 (SD 3.7). Only 11 patients completed 24-hours of SenseWear armband monitoring. Half of the participants walked less than 50 steps a day. The majority were bedridden 9 to 15 hours a day. Five of 11 patients had very low activity score. Four patients were moderately active for 19-38 minutes. Five patients sleep less than 6,3 hours, mean 9 (SD 3.3). Lying down was recorded for a mean of 11 hours (SD 4). Factors motivating to physical activity were: Praise and recognition from the staff, experienced boredom, continued ability to perform Activities of Daily Living. Barriers: Symptoms of illness, fear of falling, lack of meaningful activities, inadequate facilities and staff’s lack of focus. Organisational routines such as waiting for physical examinations and rounds, were barriers for patients to get out of bed. Conclusion: Old medical patients were very inactive during hospitalization. Motivation for physical activity was continued ADL abilities, boredom and staff interest, however often hindered by organizational barriers, lack of meaningful activities and focus from staff.

Key words: Old, patients, physical activity, hospitalization, ADL, bed rest, steps, MET, nurses, organization.

Introduction

Functional decline in frail old patients during hospitalization is an important clinical problem with potential long-lasting undesirable outcomes and complications. Sedentary older medical patients are at risk of developing complications during and after hospitalization, and it is therefore important to know to which extent these patients are actually inactive in hospitals, and what motivates patients to active behavior.

Age related decrease in physical fitness and function is commonly seen in older people due to the normal process of aging, where a reduction of muscle strength in both upper and lower limbs as well as changes in body-composition is seen (1).

Functional decline and any accompanying dependence of daily assistance, has important implications for the individual older person. Muscle strength generally decreases with approximately 1.5% annually from 60-80 years in both men and women, while the explosive muscle strength decreases by around 3.5% annually (2). The explosive muscle strength is a measure of how fast a muscle or muscle group can develop maximum power. The ability to quickly develop maximal force is needed to stave off decline, to rise and for walking on stairs. With the loss of explosive muscle power comes reduced ability to cope with activities of daily living (ADL) (3, 4). With profound physical inactivity, such as bed rest during disease, loss of muscle strength in the old occurs after only one day. Functional decline in frail old patients during hospitalization is an important clinical problem with potential long-lasting undesirable outcomes and complications, including nosocomial infections, falls and pressure ulcers. The older medical patients are particularly at risk of developing complications during and after hospitalization, due to physical inactivity and prolonged immobilization (5, 6). This is furthermore important for the high number of readmissions in this patient group (7-11). Functional decline has been strongly related to patients’ age and preadmission activities of daily living status (12, 13). Patients with shorter stays seemed to be more physically active during hospital stay, than patients with longer lengths of stay (14).

Two recent reviews showed that early physical rehabilitation care for acute hospitalized old adults leads to functional benefits (10, 15). Another recent nurse driven mobility intervention study, showed that older adults maintained or improved functional status and reduced length of stay (16). Other studies however contradict these findings, as physical training did not sufficiently improve physical function (17, 18).

In Denmark, as well as in many other well-established countries, there is an actual overall demographic transition, with an increase in the old population, and chronic diseases. This transition leads to a need for an increased focus on the wellbeing of the old population, including focus on the maintenance of physical function and ADL, during hospitalization (13).

Despite the fact that international studies indicate that an increased focus on physical activity during hospitalization including can reduce hospitalizations and the number of readmissions, there is limited knowledge about the extent to which hospitalized old medical patients are actually physically active (19-21).

The motivation for old hospitalized patients to be physically active has been sought in an American study. This study found that motivating factors included avoiding complications to prolonged bed rest, promoting a sense of well-being, promoting functional recovery, and being asked to exercise. Barriers against physical activity included symptoms of illness, institutional barriers, and fear of injury (22). Thus it seems relevant to examine the activity level of Danish old medical patient’s during hospitalization, as well as finding factors that are important for achieving an acceptable level of activity.

The aim of this pilot study was to:

I. Examine how physically active Danish old medical patients <60 years of age are during hospitalization

II. To achieve knowledge of motivation and barriers to physical activity in the same patients.

Methods

With regard to the two aims of the study, two methods were used in the same sample of patients.

As this was a pilot study, recruiting patients for one week only, the sample of patients were those who could be included within the week in question. Therefore no sample size or data-satiety was considered. Three SenseWear Armband monitors were available, and used to measure daily steps and Metabolic Equivalent of Task (MET) for 24 hours in each participant. Semi Structured interviews were used to investigate motivation and barriers.

The setting

Patients were recruited at two medical departments in a university hospital with 900 beds. The departments were a hematology department, where patients are admitted for diagnostics, treatment and care of hematological diseases, and department for kidney disease, where patients are admitted for acute and chronic kidney diseases. Both departments furthermore have an acute intake of patients with internal medical diseases, i.e. pneumonia, sepsis, and vertigo. The specialty patients are mainly younger patients, especially on the hematology department, and the internal medical patients are most often old patients with complex illness and multiple diseases. Combining these factors, the choice fell on including patients <60 in both departments, instead of having different inclusion criteria between the two departments. Patient bed rooms in both departments, had room for two patients.

Sample and inclusion

Patients were recruited at two medical departments during one week. Inclusion was therefore cross sectional, regarding all patients <60 years of age, who were hospitalized within the two departments during the actual week. On every morning of the week, a list was made of patients who met the criteria: 60 years of age or older, ability to walk with or without a walker and not going to be discharged within the next two days. This was important, since the activity monitoring lasted 24 hours, and time was needed to inform patients in a reasonable timely manner, so they had time to consider participation and ask questions before inclusion. The investigators went through the lists from both departments, and found patients suitable for inclusion. Secondly, the patients were discussed in collaboration with the nurse in charge of the patient in focus. This was in order to be certain of the patient’s ability to carry through an interview session, due to physical and psychological strength and cognitive abilities. Finally, in this pilot study, we strived for a selection of participants which was not distinctly homogenous. Thus, the aim was to include male and female participants, with a broad variation within older age.

Preparation of the patient

When patients were found relevant for inclusion, they were informed orally and in writing about the study. The patients were asked to “act as usual” wearing the armband, and just do as they would have done otherwise. If the patient decided to participate, an agreement was made about time and a setting.

Activity monitoring

Activity was measured by The SenseWear™ Armband (SWA) (BodyMedia, Inc. Pittsburgh, PA) for 24 hours in each patient. The SenseWear Armband is a type of accelerometer. An accelerometer is designed to carry out the objective measurement of physical activity by the movement patterns(11). The SenseWear Armband is worn on the upper left arm, and is completely harmless to the patient. It measures different parameters of activity. One is Metabolic Equivalent of Task (MET). MET is a standard parameter that is independent of time, weight and gender. MET describes the body’s ability to burn calories, 1 MET is equivalent to 1 kcal/kg/hour. An average person has a MET of 1.0 (0.9-1.1) when resting, reflecting the person’s resting metabolic rate (REE). Obese people generally have a lower MET, while bodybuilders and athletes with a higher musclemass pr. BMI, often have a higher MET. The program works with a fixed threshold of 3 MET for physical activity and therefore records all activity where MET is 3 or more. A MET 1,5-3 is equivalent of an ordinary persons walking speed. The armband also measures the patient’s average total energy expenditure (TEE). This measurement reflects the patient’s resting energy expenditure (REE) and the patient’s active energy consumption (AEE). The SenseWear Armband measures the duration of sleep and how much the patient is lying down, furthermore the relationship between duration of sleep and duration of lying down (RSE) is measured. RSE is considered normal if it is 0.8. Finally the armband measures step count.

SenseWear Armband has been validated for use in the activity measurements in healthy people, mainly regarding physical activity in weight loss programs(23). However it is also used in the clinic at Aalborg University Hospital at Centre for Nutrition and Bowel Disease as well as at Manchester University Hospital for evaluation of energy expenditure in patients with short bowel syndrome.

Motivation and barriers to physical activity

The methods used for interviews were inspired by two Danish qualitative methodology experts. The interviews was carried out as a qualitative research interview from a phenomenological and hermeneutical theory of science approach, where the aim is to better understand the studied problems, which can be used to generate new hypotheses and interpretations of reality(24).

Planning, executing and processing the interviews is based on the basis of Steiner Kvale`s seven phases: 1. Thematisation: Aim, subjects, what and why. 2. Design: What components does the study design consist off, making sure that you can obtain the knowledge you want to reach with the investigation. 3. Interview: interviews conducted from interview guides and thoughtful perspectives on the knowledge seeked. 4. Transcription: The interview material is made ready for the analysis phase. 5. Analysis: Based on the study’s purpose, subject and collected data , the method of analysis is desided with regard to providing the best analysis results. 6. Verification: The interviews are analyzed and discussed for generalizability, reliability and validity. 7. Reporting: Communicating results and findings. (25).

The interviews were undertaken as a conversation between interviewer and participant. The interviews took place either in the patients’ bed room, or in an office inside the unit. The patients were given the opportunity to decide whether they preferred to carry through the interview in bed, or sitting in a chair.

Ethical considerations

Prior to inclusion, the patients were given written and oral information about the SenseWear monitoring, and about the interview. The participants were informed that they at any time before or during the interview could withdraw from participation. The study was conducted according to the rules of the Helsinki Declaration of 2002. The study was put forward to the local ethic committee, which found that the study was not within claim of notification. .

Analysis I

Data from SenseWear Armband were analyzed in the statistical program SPSS 1.0. Medians and standard deviations for patient’s activity were calculated.

Analysis II

Data were analysed using a qualitative content and constant comparative method. Meaningful data were compared within the single interview, and between interviews. Inclusions continued until data-satiety was achieved in clear and stable patters, that did not change with adding more interviews. The interviews were recorded. Subsequently interviews were transcribed by interviewers and re-read for understanding. The interviews were then coded into units of meaning to the research question.

Results

Demographics

The study comprised 13 patients, five female and eight male, mean age 73 (SD 9); BMI 19.4-32.1, mean 25.2 (SD 3.7). Due to one sudden discharge and one transferral to other department, only 11 patients fulfilled the 24 hours of SenseWear armband monitoring. Since the two patients had already been interviewed, they remained included in the study. Ten patients were interviewed about motivation and barriers for physical activity during hospitalization. Three patients withdrew from this part due to feeling ill, and having to be present at sudden physical examinations. Table 1 shows demographic information and the distribution of data in the study.

Table 1 Demographic information and distribution of data

Of the included patients, only two patients received help for daily activities in own home. One of these patients had daily help for activities, including getting dressed, cleaning, cooking and grocery shopping, on a daily basis at home, prior to this hospitalization. One other patient had community help for housecleaning every two weeks. The remaining patients found themselves active, and of good health, prior to this disease and hospitalization.

How physically active

The included patients, in general, had very low activity rate regarding steps taken during the day, with a median of 46 steps, as shown in table 2.

Table 2 Distribution of number of daily steps

The patients (n=11) lie down in their bed between nine and 15 hours a day, mean 11 hours (SD 3 hours 53 min). Mean time of sleep was nine hours ( SD 3 hours 25 min). Five of the included patients, however were registered for sleeping less than 6 hours and 22 minutes.

Levels of activity: Five of the included patients were active (walking or more) less than 19 minutes during the 24 hours, due to the monitoring. Four patients were recorded for “moderate activity” for between 19 and 38 minutes.

Motivation and barriers to physical activity

The units of meaning identified in the interviews were clustered into the following significant themes, which are divided between motivation and barriers in the description. These are illustrated in Figure 1.

Motivation

Praise and recognition from the staff

Boredom

Awareness that physical activity is important for continued ability to perform activities of daily living

Self-determination

Praise and recognition from the staff

Patients found it very motivating when staff praised and recognised their effort to get out of bed. This was mentioned most often, if patients put on their own clothes and the effort thereby was more obvious. Recognition would keep patients from crawling back into bed.

Boredom

Boredom from just lying in bed was common and could make patients get up. One patient put it quite clear; (P7)»I do not want to lie in bed. I am bored simply“.

Awareness that physical activity is important for continued ability to perform activities of daily living:

Patients recognized that physical activity is important with regard to well-being, and especially for being able to go back to performing activities of daily living, as they did before this period of illness. One patient referred to physical well-being as; (P9) «I mean, we should not stay in a bed, we need to … The limbs prefer to be moved“. Others talked about physical abilities and psychological self-preservation as one whole; (P10) «I think… probably it’s a bit too “Sorry” if I do not get out of bed. It’s okay if you have to sleep. But it also has something to do with putting demands on yourself. For one must not come to a standstill. And once you go home .. there’s no dear mother. Then you only have yourself «. Another patient puts it this way; (P4)”I find it very important (to be active ..red), otherwise I won’t be able to do anything when I come home”.

Self-determination

The importance of self-determination and autonomy, and the relation to physical activity and being able to do things on their own decision, was obvious throughout the interviews, even though the grading of what was seen as autonomy was different within the patients; (P6) «I’m used to being in vigor, and fix things when they should be taken care of, and it gives a greater enjoyment of life». And; (P3)»Let me do something myself. I like to go out and wash myself and things like that».

Barriers

Organizational routines

The interviews often led to a need for the more concrete questions, as could be narrowed down to: Q: To what extent have you been out of bed, for instance, today? Patients had many responses to this, and most of them related to organizational issues; (P7) “I would, but “a little cuckoo came into the machinery”. I was supposed to have a scan at 10. Before then, I had to drink 1 ½ liters of water and wait for the porter. Then it was postponed until 3 o`clock, so now I can sit here and drink 1 ½ liters of water again». Most patients talked about the daily routines, which are also categorised as organizational in this interpretation; (P8) «Well, one needs to be here (at bedside. red) at rounds and so. I don’t know what time it is, so it’s no good, if I run around at the other end (of the department. red)“. And; (P9) “Yes, but not that much, because I expect a doctor to come”.

Lack of meaningful activities

More patients state that staff take over and do things for them, including bringing food and drinks. This attention is provided despite the fact, that these patients could easily fetch what they need themselves. This was problematized with the words; (P6) «You are well looked after, up to where ends meet. I’m used to doing everything myself, and all of a sudden you have to do nothing». The patient also describes that she, after her former hospitalization had lost energy, and was physically weaker after discharge. This is explained with the words; «Yes, but that was because, I didn’t keep going and all that. The only thing I did was to sit and knit». This patient signals that she is motivated to physical activity awareness, of what inactivity could mean for her well-being after discharge. But the staff’s well-meaning attention turns into a kind of barrier against physical activity. Lack of other meaningful activities besides walking up and down the corridor is requested. One patient says, that she has offered to help make coffee for the staff, and tidy the patient living room. Another patient has heard that some departments have a gym bike, so they could keep fit, and still “stick around”.

Staff help and individual focus

While some help was found too much and inappropriate as seen above, others found that lack of relevant help to be physical active is considered a barrier. One patient would rather go to the bathroom and wash herself with assistance for her safety and comfort, but finds she is not offered the relevant help, and therefore she does not dare to do so; (P4) “They could help just by standing beside me (bathroom red). Confidence alone, it means quite a lot. Especially, after I fell. I’m terrified of that».

One patient was fortunate to have had the presence of a physiotherapist. However he found that the therapy was not individually adjusted to his abilities, and were therefore useless; (P1) “They gave me this, so I can sit and strengthen my hands, but it is too easy, so bother – hell I won’t“.

Discussion

In this pilot study we investigated physical activity among old medical patients, and the motivation for as well as barriers against, being physically active during hospitalization. We monitored physical activity by SenseWear Armbands. By step count, patients were found to be generally very inactive, and indeed less active than recommended for the healthy population, in order to maintain functional abilities (9). Compared to former studies in other settings, patients in our setting were even more inactive. In the study by Brown et al, they monitored mobility levels in old patients during hospital stay. Like our results, they found that older hospitalized patients spent most of their time lying in bed, despite an ability to walk independently (20). Patients in the study by Fisher et al. were slightly more active, and took a mean number of 739 steps (range 89-1014) steps per day during their hospital stay. In the study by Fisher et al, however, the physical environment was designed to promote ambulation and provide incentive for patients to increase mobility and participate in activities during their hospital stay. In the present study, the lack of possibilities for meaningful activities was perceived as one of the main barriers. (14). Furthermore we find, that the reasons the patients in the present study are less active, can be that we found patients who were quite ill compared to those in other studies, and that the staffing in the two departments, including the focus on physical activity is low, as also advocated by patients. A comparison between resting time, low and moderate activity compared to steps taken on the day of monitoring, indicated that MET could be elevated due to metabolic changes related to disease rather than to physical activity/ or steps. Thereby, moderate activity as registered by SenseWear, might not be due to actual activity, but rather to metabolic disease activity.

Furthermore, the qualitative interviews indicated, that patients found themselves more active- or at least, wanting to be more active, than they actually were, seen by SenseWear monitoring. Only a few patients overcame the barriers and felt motivated to walk more steps, than just walking a bit around the patient bedroom, and for a few to fetch their own meals. Since this was a pilot study with only 13 patients, of which only 11 were monitored by SenseWear, the results should of course be considered with caution.

As seen in a former study, the encouragement and help from nurses to mobilize, helps motivate patients to be physically active (16). While one single study showed, that muscle strength did not decrease during hospitalization and 30 days after discharge in acutely admitted older medical patients, despite a low level of mobility during hospitalization (17). Other multidisciplinary intervention studies, focusing more on facilitating ADL, contrary to exercise programs aimed at improving functional outcomes”, showed, that at the time of discharge, patients who had participated in a multidisciplinary program or exercise program, improved more on physical functional tests and were less likely to be discharged to a nursing home, compared to patients receiving only usual care. In addition, multidisciplinary programs reduced the length of hospital stay significantly (15,18). In this study we did not investigate thoroughly the medical or social reasons that might impact the length of stay. The impact of staff was very central in our findings (Figure 1).

The patients in the present study found that relevant help and encouragement from staff would motivate them to get out of bed and be more active, and vise-versa, a barrier against physical activity when not provided. One patient felt unsafe out of bed, because of a former fall incidence, and was not offered relevant assistance. Therefore she was not likely to be physically active. This indicates, that dependencies of help, i.e the patient who was afraid of falling and therefore wished for help walking and staying in the bathroom with her, are not always provided, which may influence physical abilities and function, and have a negative impact on clinical outcome as length of stay and ADL function after discharge.

Another study showed that, unlike patients, the staff attributed low mobility among hospitalized older adults to lack of patient motivation (19). The same study found that lack of ambulatory devices, including meaningful activities, was a barrier against activity (19). In the same study they found, that lack of staff, patient clothing, disease symptoms and physical environment affected the old patient’s physical activity negatively. In the present study disease symptoms were only mentioned briefly by patients. Clothing was not directly mentioned as a barrier, however, motivation was found by staffs praise and recognition, when patients were actually out of bed, and praise was especially experienced, when patients were in own clothing. In general, the lack of individual focus towards physical activity, including mobilization, was seen as de-motivating.

The lack of staff, as seen as a barrier in the former study, might also be one of the reasons, for the lack of focus towards physical activity, especially mentioned regarding the nurses, but also, regarding lack of individually targeted care by the physiotherapist, as seen in the one fortunate patient, who was actually associated with such. Within the past couple of years, the hospital has been through a serious wielding, especially towards the staff caring for patients. With the shorter hospital stay, and increase in patient age and complexity, this might have influenced the focus to other than the core medical treatment.

Organizational issues were seen as serious barriers in this study. Patients did not find themselves able to leave the bed, in case they would miss the physician at rounds, and one patient had to spend the whole day close to a toilet and drinking water. Improved appointment systems, information and clarity about expectations between patients and staff, might improve the ability for patients to – at least- walk around the department, and maybe even use an exercise bike, as one of the patients suggested.

Methodological considerations: The study aimed to include only old patients. However there were not enough relevant patients during the week feasible for the study. As this was a pilot study only, we decided to include also patients a bit younger, however with chronic concurrent disease. During this study, it has become unclear whether SenseWear was actually able to correctly count the small short steps (toddle steps), that can possibly be taken of old ill patients. However, these short steps would anyhow not add significantly to the total MET activity score, as has been recommended for activity in the population(9). The inconstancy between bed rest and actual sleeping time indicates that SenseWear might have problems separating elevated back rest from lying down and sitting, and/or that patients may suffer from poor sleep quality. In our upcoming studies, we will include information about actual and concurrent disease, as well as body-composition and other physical function measurements.

Conclusion

Old medical patients in this study were very inactive. Reasons were organizational, lack of staff help and focus as well as lack of meaningful activities. Motivation for physical activity was found in self-preservation of continued functional abilities, help and recognition by staff, and meaningful activities.

Relevance to clinical practice

This study shows us that nurses can have important positive impact of the life threatening immobility in the hospitalized old patients. By giving attention and help to patients who need support towards the feeling of safety in being physically active, nurses can affect the most vulnerable patients’ action in a positive and self caring direction. Positive remarks, noticing and appraising the individual for getting out of bed and chair, takes a very little effort for nurses, thus means a very lot to the patients in this study, and may contribute to an improved quality of life, and clinical outcome.

Acknowledgements: The authors are thankful to patients and staff at department of hematology and department for kidney disease, at Aalborg University Hospital for kind and willing participation.

Funding: There was no funding to this study.

Conflict of interest: All authors declare no conflict of interest to this study.

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