eVALUACIONES FUNCIONALES PARA ADULTO MAYOR, Apuntes de Rehabilitación

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Clinical Interventions in Aging 2017:12 1929–1939 Clinical Interventions in Aging Dovepress submit your manuscript | www.dovepress.com Dovepress 1929 O r I g I n A l r e s e A r C h open access to scientific and medical research Open Access Full Text Article http://dx.doi.org/10.2147/CIA.S149665 effects of comprehensive geriatric assessment on physical fitness in an acute medical setting for frail elderly patients Kristina Åhlund1,2 Maria Bäck2,3 Birgitta Öberg2 niklas ekerstad4,5 1Department of Physiotherapy, nU hospital group, Trollhättan, 2Department of Medical and health sciences, Division of Physiotherapy, linköping University, linköping, 3Department of Occupational Therapy and Physiotherapy, sahlgrenska University hospital, gothenburg, 4Department of Cardiology, nU hospital group, Trollhättan, 5Department of Medical and health sciences, Division of health Care Analysis, linköping University, linköping, sweden Introduction: Frail elderly people often use emergency care. During hospitalization, physical decline is common, implying an increased risk of adverse health outcomes. Comprehensive Geriatric Assessment (CGA) has been shown to be beneficial for these patients in hospital care. However, there is very limited evidence about the effects on physical fitness. The aim was to compare effects on physical fitness in the acute care of frail elderly patients at a CGA unit versus conventional care, 3 months after discharge. Patients and methods: A clinical, prospective, controlled trial with two parallel groups was conducted. Patients aged $75 years, assessed as frail and in need of inpatient care, were assigned to a CGA unit or conventional care. Measurements of physical fitness, including handgrip strength (HS), timed up-and-go (TUG), and the 6-minute walk test (6-MWT) were made twice, at the hospital index care period and at the 3-month follow-up. Data were analyzed as the mean change from index to the 3-month follow-up, and dichotomized as decline versus stability/improvement in physical fitness. Results: In all, 408 participants, aged 85.7±5.4 years, were included. The intervention group improved significantly in all components of physical fitness. The controls improved in TUG and declined in HS and 6-MWT. When the changes were dichotomized the intervention group declined to a lesser extent; HS p,0.001, 6-MWT p,0.001, TUG p,0.003. The regression analysis showed the following odds ratios (ORs) for how these outcomes were influenced by the intervention; HS OR 4.4 (confidence interval [CI] 95% 2.2–9.1), 6-MWT OR 13.9 (CI 95% 4.2–46.2), and TUG OR 2.5 (CI 95% 1.1–5.4). Conclusion: This study indicates that the acute care of frail elderly patients at a CGA unit is superior to conventional care in terms of preserving physical fitness at 3 months follow-up. CGA management may positively influence outcomes of great importance for these patients, such as mobility, strength, and endurance. Keywords: frail elderly, comprehensive geriatric assessment, physical fitness, outcomes Introduction Old people with multimorbidity and disability are frequent visitors to acute medical hospital departments.1 In this group of patients, admissions are often inevitable, they often require a longer length of stay compared with their younger counterparts, and the readmission rate is high.2–5 Frailty is a clinical syndrome reflecting the dependence and vulnerability of these people.6 There are different ways to define frailty. The phe- notype model of frailty defined by Fried et al7 demonstrates predictive validity for the adverse outcomes that frail elderly people run the risk of experiencing, such as falls, hospitalizations, disability, institutionalization, and death. According to this definition, Correspondence: niklas ekerstad Department of Cardiology, nU (nÄl-Uddevalla) hospital group, lärketorpsvägen, 46100 Trollhättan, sweden Tel +46 73 624 9652 Fax +46 10 435 7129 email niklas.ekerstad@vgregion.se Journal name: Clinical Interventions in Aging Article Designation: Original Research Year: 2017 Volume: 12 Running head verso: Åhlund et al Running head recto: Comprehensive geriatric assessment and physical fitness in elderly DOI: http://dx.doi.org/10.2147/CIA.S149665 Clinical Interventions in Aging 2017:12submit your manuscript | www.dovepress.com Dovepress Dovepress 1930 Åhlund et al a person is considered frail when three or more of the follow- ing criteria are present: weakness (eg, low handgrip strength [HS]), poor endurance, slow walking speed, low physical activity, and shrinking. Another way to describe frailty is by the accumulation of deficits.8 Physical function describes a person’s capacity to carry out the physical activities of daily living (ADL).9 Physical fitness comprises a set of measurable health- and skill-related outcomes, such as cardiorespiratory endurance, muscle strength, muscle endurance, and balance.10 The relationship between frailty and physical fitness is evident and frailty is often said to herald physical decline.11 Age-related muscle loss, sarcopenia, is one key component of the frailty syn- drome and it negatively affects physical fitness.12,13 In a recently published study, physical fitness was measured objectively and found to be severely impaired in acutely hospitalized frail elderly patients.14 It is well known that frail elderly patients risk further deterioration in connec- tion with hospital care and the recovery rate appears to be low.5,15–19 A decrease in physical fitness is associated with an increased risk of disability and dependence20 and it negatively affects the ability to benefit from medical interventions, which worsens the prognosis still further.13,21–26 However, previous research indicates that it may be possible to reverse frailty.27 It is therefore of utmost interest to identify frailty in order to prevent, reduce, and postpone adverse health consequences.28 Today, the conventional acute medical ward is usually a specialized, organ-specific unit with the goal of providing care according to national and international guidelines adapted for specific diseases. Studies have shown that frail, multimorbid, and disabled patients are likely to benefit from a more holistic approach.29,30 In the context of hospital care, a health care model called Comprehensive Geriatric Assess- ment (CGA) has been shown to be consistently beneficial regarding mortality, disability, and cognitive functions.31 The CGA concept involves early identification of persons at the greatest risk of complications and adverse health outcomes.32 The initial purpose of CGA was to plan and/or deliver medical, psychosocial, and rehabilitative care and the model is defined as a multidimensional interdisciplinary diagnostic process intended to determine a frail elderly person’s medical, psychological and functional capabilities and limitations, in order to develop an overall plan for treatment and long- term follow-up.33 It explicitly involves an early-rehabilitation perspective.34 Previous studies have concluded that CGA implies func- tional benefits, in terms of ADL, for elderly patients with acute medical or orthopedic disorders, compared with con- ventional care.34–37 To our knowledge, there is no study which has objectively investigated how CGA in an acute medical setting specifically affects physical fitness, in severely frail elderly patients. Aim The aim was to compare the effects on physical fitness in the acute care of frail elderly patients at a CGA unit versus conventional care, 3 months after discharge. Patients and methods Design and setting This is a clinical prospective controlled trial with two parallel groups carried out at the NÄL-Uddevalla (NU) Hospital Group, in western Sweden. The total population of the NU health care system is 280,000 inhabitants. The study was approved by the regional ethical review board in Gothenburg (Dnr: 8883-12, December 12, 2012) and registered at the Swedish National Database of Research and Development; identifier 113021 (http://www.researchweb.org/is/vgr/ project/113021). Participants The study population was frail elderly patients included in the research project entitled “Is the treatment of frail elderly patients effective in an elderly care unit”. The inclusion crite- ria were patients $75 years, assessed to be in acute need of inhospital treatment and frail according to the FRail Elderly Support researcH group (FRESH) screening instrument.38,39 A patient clearly suited for care at an organ-specific medical unit, for example, patients with acute myocardial infarction, sepsis, or acute stroke, were excluded from the study, as were patients whose informed consent could not be obtained. Data collection The data collection has previously been described by Ekerstad et al40 and is therefore only briefly described. When the staff at the ambulance or the primary health care center identified a patient who met the inclusion criteria, they phoned a senior physician at the CGA unit or, if it was at night, the on-call physician. If the physician agreed that the patient fulfilled the inclusion criteria of the study protocol and there was a bed available at the CGA unit, the patient was admitted there directly and allocated to the intervention group. If no bed Clinical Interventions in Aging 2017:12 submit your manuscript | www.dovepress.com Dovepress Dovepress 1933 Comprehensive geriatric assessment and physical fitness in elderly strong dizziness. Walking aids were allowed. The 6-MWT is a test with good test-retest reliability (ICC =0.95) for community-dwelling elderly45 and is commonly used to mea- sure submaximal functional exercise capacity in patients with cardiorespiratory diseases.46 Analysis The sample size calculation (Sample Size Calculator; ClinCalc LLC, Arlington Heights, IL, USA) was based on the primary outcome decline in ADL (Katz index) from baseline to 3 months after discharge. No previous study with an identical primary variable (different follow-up times) was found. However, one similar study was found,47 which focused on the ADL function in less frail patients during hospitalization. Using a two-sided test, 80% power, and a significance level of α=0.05, it was necessary to include 150 patients in each study group. To compensate for the uncertainty, due to longer follow-up times which may reduce the difference in ADL decline, that is, expected reduction of treatment effect size, it was estimated that 200 patients in each study group, 400 in total, had to be included. The data were computerized and analyzed using the Statistical Package for Social Sciences (IBM SPSS Statistics for Windows, version 22.0; IBM Corporation, Armonk, NY, USA). Student’s t-test was used to compare continuous, parametric data between the groups and the chi-square test was used to compare categorical data. The 0- to 3-month changes were calculated first as the mean change and standard deviation for each group, after which they were dichotomized as decline versus stability/improvement. Adjustments for possible differences at baseline were made, using logistic regression models. Age, gender, CCI score, and the base- line value of measurement were counted as covariates in these models. An intention-to-treat principle was followed. Results Baseline characteristics of the study population From March 2013 to July 2015, a total of 419 evaluable patients were randomized of whom 408 patients were evaluable; 206 in the intervention group (CGA unit) and 202 in the control group (conventional care) (Figure 1). Their mean age was 85.7±5.4 years and 56% were female. There were no significant differences between the groups regarding age, gender, degree of frailty, or percentage living alone. Both groups were heavily affected by diseases, particularly renal impairment and cardiovascular disease. The intervention group had a slightly higher comorbidity burden (CCI 7.4±2.1 vs 6.2±1.5, p,0.001). In unadjusted measurements of physical fitness, the groups did not differ at baseline in terms of HS and 6-MWT, but the control group performed the TUG more slowly (p,0.05) (Table 2). The number of hospital days per patient during the index care episode was 11.2 (mean) in the intervention group; the number was 9.2 (mean) in the control group (p=0.002). At the 3-month follow-up, the total number (index +3 months after discharge) of hospital days were 16.2 in the intervention group, 16.9 in the control group (p=0.648).40 Physical fitness outcomes at the 3-month follow-up Analyses of unadjusted continuous variables for the 0- to 3-month change showed a significant improvement in the intervention group in all components of physical fitness. Patients in the control group significantly improved in their ability to perform the TUG, but declined in HS and 6-MWT. When comparing groups, there were significant improve- ments in the intervention group compared with the control group in terms of HS (p,0.001) and the 6-MWT (p,0.001), but not for TUG (p=0.132) (Table 3). After adjustment for age, gender, CCI, and the baseline value of measurement, the intervention group had sig- nificantly improved in all components of physical fitness. The patients in the control group improved in the TUG but declined in HS and the 6-MWT. Comparing groups, there were significant advantages for the intervention group in all components of physical fitness, HS (p,0.001), 6-MWT (p,0.001), and TUG (p=0.042) (Table 3). When dichotomizing the changes into the categories of decline versus stability/improvement, there were signifi- cant differences between groups for all three components of physical fitness. The intervention group declined to a lesser extent compared with the control group; HS p,0.001, 6-MWT p,0.001, TUG p=0.003. Figure 2 represents a visual picture of the results. In the regression analysis, the odds ratios (ORs) showed the extent to which the outcome was influenced by the intervention; the unadjusted ORs were: HS OR 3.2 (confi- dence interval [CI] 95% 1.7–6.1), 6-MWT OR 7.0 (CI 95% 2.8–17.7), and TUG OR 2.8 (CI 95% 1.3–5.9) (Table 4). After adjustment, the ORs were HS OR 4.4 (CI 95% 2.2–9.1), 6-MWT OR 13.9 (CI 95% 4.2–46.2), and TUG OR 2.5 (CI 95% 1.1–5.4) for the tests, respectively (Table 4). Clinical Interventions in Aging 2017:12submit your manuscript | www.dovepress.com Dovepress Dovepress 1934 Åhlund et al Discussion This study indicates that the acute medical care of frail elderly patients at a CGA unit is superior to the care at a conven- tional acute medical care unit when it comes to preserving physical fitness, such as HS, submaximal aerobic capacity, and functional mobility, at the 3-month follow-up. Moreover, the present study shows that it is possible to improve physical fitness in severely frail, hospitalized Figure 1 Flowchart of data collection – physical fitness. Notes: Flowchart completed here with information regarding participants’ performance of physical fitness instruments. Copyright © 2017. Dove Medical Press. Adapted from ekerstad n, Karlson BW, Dahlin Ivanoff s, et al. Is the acute care of frail elderly patients in a comprehensive geriatric assessment unit superior to conventional acute medical care? Clin Interv Aging. 2017;12:1–9.40 Abbreviations: hs, handgrip strength; TUg, timed up-and-go; 6-MWT, 6-minute walk test. Clinical Interventions in Aging 2017:12 submit your manuscript | www.dovepress.com Dovepress Dovepress 1935 Comprehensive geriatric assessment and physical fitness in elderly patients. The intervention group demonstrated improvements in submaximal aerobic capacity and HS, indicating that there is still rehabilitation potential. CGA management in hospital care may positively influence outcomes of great importance for the patients, such as walking ability, independence, and returning home. To our knowledge, this is the first study which specifically and objectively evaluated CGA in terms of physical fitness. However, the results are consistent with previous research on the effects of CGA on ADL.34,35,37 ADL is usually used for the evaluation of medical care for frail elderly persons using questionnaires (eg, Barthel ADL index48 or Katz index49), which are filled in by asking the patient, or by proxy.29 Self- reports are often used in large studies because they are easy to administer, provide few missing data, and capture the patient’s own perspective. However, there is a risk of over- and underestimation, recall bias, and social desirability.50,51 One review52 compiled different instruments for measuring frailty. The physical domain of the frailty syndrome was included in all the studied instruments. It was shown that the degree of frailty can be indicated in individual physical fitness tests. Tests of strength, walking ability, and endurance are most commonly used.14,21 In one study, returning home, autonomy, and walking ability were factors of great value, when elderly patients ranked the outcomes they considered most important in post-acute geriatric hospital care.53 These outcomes are all related to frailty and highlight the importance of developing interventions that may positively affect physical fitness and prevent or delay the onset of progressive disability.20 Research has shown that endurance, strength, and muscle power training can prevent disability in frail elderly people.54 In a hospital setting, a Cochrane report55 found that multidisciplinary interventions involving exercise reduced hospital length of stay, cost of hospital stay, and increased proportion of patients discharged directly home compared with usual care. Further, a meta-analysis56 showed that extra physical therapy had beneficial effects, such as improved mobility, physical activity, and quality of life, compared with a standard physical therapy program in hospitalized patients with acute or subacute conditions. The studied CGA units work by a structured early- rehabilitation strategy, which involves physical therapy and occupational therapy initiated immediately upon achieving physiologic stability, which continues throughout the hospital stay. Research on early rehabilitation has shown improved physical function and the intervention has been described as feasible and safe to execute.57 Many factors within the CGA concept probably influence, when it comes to preserving physical fitness. There may be several critical differences compared to conventional care, which may interact, and benefit frail elderly patients. However, the early-rehabilitation perspective including assessment, care, and educational efforts could be regarded as crucial for the prevention of functional decline. Consequently, more time was spent on physical training in these units. Good access to assistive Table 2 Baseline characteristics of the population Variable Intervention group (CGA, unit) N Control group (conventional care) N p-value Age, years, mean (sD) 206 85.7 (5.3) 202 85.6 (5.4) 0.850 gender, female, n (%) 206 122 (59) 202 108 (53) 0.241 Frailty screening score, mean (sD) 206 3.5 (0.9) 202 3.4 (0.9) 0.149 Charlson’s index score, mean (sD) 206 7.4 (2.1) 202 6.2 (1.5) ,0.001 living alone, n (%) 206 139 (67) 202 132 (65) 0.649 Own living without home-help service, n (%) 206 60 (29) 202 77 (38) 0.055 handgrip strength (kg), mean (sD) 184 18.8 (7.2) 153 18.0 (7.9) 0.330 6-MWT (m), mean (sD) 147 146 (103.4) 95 160 (100.0) 0.287 TUg (sec), mean (sD) 153 30.0 (23.2) 120 37.4 (28.6) 0.020 reported reasons for admission, n (%) Dyspnea 206 67 (32) 202 65 (32) Worsened general condition/tiredness 206 48 (23) 202 43 (21) Pain 206 29 (14) 202 24 (12) Fever/infection 206 28 (14) 202 40 (20) Vertigo/falling 206 27 (13) 202 30 (15) Others 206 52 (25) 202 35 (17) Notes: The baseline characteristics of the population divided by group, intervention group, and control group, and the main reasons that led to admission. Continuous data are presented as the mean ±1 sD. nominal data are presented as number (%). Copyright © 2017. Dove Medical Press. Adapted from ekerstad n, Karlson BW, Dahlin Ivanoff s, et al. Is the acute care of frail elderly patients in a comprehensive geriatric assessment unit superior to conventional acute medical care? Clin Interv Aging. 2017;12:1–9.40 Abbreviations: CgA, Comprehensive geriatric Assessment; sD, standard deviation; 6-MWT, 6-minute walk test; TUg, timed up-and-go test. Clinical Interventions in Aging 2017:12submit your manuscript | www.dovepress.com Dovepress Dovepress 1938 Åhlund et al in terms of preserving physical fitness measured as HS, submaximal aerobic capacity, and functional mobility at 3 months follow-up. In the acute care of frail elderly patients, more atten- tion should focus on interdisciplinary teamwork with the emphasis on preserving physical fitness and encouraging ambulation and autonomy. Clinical implications This study shows that it is possible to improve physical fitness in severely frail, hospitalized patients. The CGA concept, with its focus on early rehabilitation, has been shown to benefit these patients in terms of submaximal aerobic capacity and HS. By showing there is still rehabilitation potential, targeted interventions suitable for these patients may be implemented in clinical health care, such as interdisciplinary teamwork including individualized physical therapist assess- ment and treatment. CGA management in hospital care may positively influence outcomes of great importance for the patients, such as walking ability and independence. Acknowledgments The authors wish to thank the NU Hospital Group, Depart- ment of Research and Development, for financing research time and all the coworkers within the study group for their assistance with data collection. Disclosure The authors report no conflicts of interest in this work. References 1. 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