J Nutr Health Aging

Volume 20, Number 7, 2016

PHYSICAL ACTIVITY AND EARLY REHABILITATION IN HOSPITALIZED

ELDERLY MEDICAL PATIENTS: SYSTEMATIC REVIEW OF RANDOMIZED
CLINICAL TRIALS
N. MARTÍNEZ-VELILLA , E.L. CADORE, Á. CASAS-HERRERO,
F. IDOATE-SARALEGUI, M. IZQUIERDO
Department of Health Sciences, Public University of Navarra (Navarra) Spain. Corresponding author: Mikel Izquierdo, PhD, Department of Health Sciences, Public University of Navarra
(Navarra) Spain, Campus of Tudela, Av. de Tarazona s/n. 31500 Tudela (Navarra) Spain, Tel.: + 34 948 417876, E-mail: mikel.izquierdo@gmail.com

Abstract: Background: To critically review the effect of interventions incorporating exercise and early
rehabilitation (physical therapy, occupational therapy, and physical activity) in the functional outcomes (i.e.,
active daily living tests, such as Barthel Index Scores, Timed-up-and go, mobility tests), and feasibility in
hospitalized elderly medical patients. Design: Systematic review of the literature. Methods: A literature search
was conducted using the following databases and medical resources from 1966 to January 2014: PubMed
(Medline), PEDro, the Cochrane Central Register of Controlled Trials and the Cochrane Database of Systematic
Reviews, Google Scholar, ClinicalTrials.gov, Clinical Evidence, SportsDiscus, EMBASE and UptoDate.
Studies must have mentioned the effects of early rehabilitation on the above mentioned functional outcomes
and feasibility. Data on the mortality, economic profile and average stay were also described. Results: From the
6564 manuscripts potentially related to exercise performance in hospitalized elderly patients, the review focused
on 1086, and 17 articles were ultimately included. Regarding functional outcomes after discharge, four studies
observed significant improvement in functional outcomes following early rehabilitation, even up to twelve
months after discharge. Eight studies directly or indirectly assessed the economic impact of exercise intervention.
Five of them did not show any increase in costs, while three concluded that the intervention was cost effective.
No adverse effect related with the interventions were mentioned. Conclusion: The introduction of an exercise
program for hospitalized elderly patients may be feasible, and may not increase costs. Importantly, early
rehabilitation may also improve the functional and healthcare.

Key words: Acute care, hospital, aged, feasibility, physical performance.

Introduction persisting at discharge in 30%. This functional impairment

The current model of care for hospitalized elderly patients
depends on a series of circumstances beyond the disease
process that causes the hospital admission, and usually
worsening the hospitalization outcome (1). Hospitalized
elderly patients are often bedridden; some studies showed
that even more than 83% of the older hospitalized patients are
bedridden versus 4% who are permitted to stand or walk (2,
3). These patients have reduced functional and physiological
reserves, rendering them more vulnerable to the effects
of been bedridden. Consequences arise at multiple levels,
particularly functional loss or cognitive impairment, longer
stays, sarcopenia secondary to immobilization, mortality and
institutionalization (4), poor mood, delirium, deconditioning,
aspirations, infections acquired on hospital, pressure ulcers and
falls (5, 6), decreased caloric intake, iatrogenia, social isolation
(7) poor quality of life, and increased use of health-related
resources (4, 8-18).
The prevalence of functional decline during hospital
admission is heterogeneous, varying from 38-80% depending
on the study (12, 19-22). In a study conducted in our
department (23), secondary functional impairment (i.e., those
impairments that occur after hospital admission) on admission
reached 80% of patients susceptible to such impairment,
Received February 24, 2015
Accepted for publication June 9, 2015
738
may progress through different possible paths according to the
population type studied and the hospitalization period (24-26).
Moreover, the consequences of hospitalization usually extend
over time, even over the long term (i.e., over than 6 months),
which exacerbates the biological changes observed during
aging such as decreases in muscle strength and power output,
muscle mass and aerobic capacity (27-29).
Alternative care models for this situation are currently being
developed, with emphasis on multidisciplinary and continuing
care units. Their main objective, other than the recovery from
the condition that caused admission (29), is the prevention
of functional decline. Many articles on functional decline
have discussed the available evidence on the effectiveness
of geriatric units (30, 31). Despite the theoretical support
for the idea that mobility improvement in the hospitalized
patient carries multiple benefits, this idea has not been fully
translated into clinical practice and some studies found
paradoxical results, such as no functional improvement of even
some adverse effects like any other health care intervention
(32). The new models include exercise as an essential part
of conventional treatment, at least when the patients are
discharged to their homes (33). Simple and basic procedures
such as increasing their walking duration by 12 minutes or
daily slow walking can reduce the average stay (34). Indeed,
J Nutr Health Aging
Volume 20, Number 7, 2016
JNHA: GERIATRIC SCIENCE
recently, it has been shown that even after long-term physical
restraint, institutionalized patients with severe disability may
improve their muscle strength, balance and gait ability by
increasing their habitual walking combined with resistance and
balance training (35).
Exercise and early rehabilitation programs are among
the mechanisms by which functional decline is prevented
during hospitalization. Although the risk factors associated
with hospitalization and functional decline after discharges
have been intensively studied, few randomized clinical trials
have studied the potential benefits of conducting standard
exercise programs for hospitalized elderly medical patients.
Nevertheless, the theoretical framework allows us to grasp the
scope of possible improvement that exists for this population
sector when such intervention is applied properly and
selectively. The benefits of exercise are clinically, biologically
and even economically confirmed (36, 37), making exercise
part of the therapeutic arsenal at our disposal.
The Cochrane review regarding exercise for acutely
hospitalized elderly medical patients included only seven
randomized controlled trials and two controlled clinical trials
out of 3138 potentially relevant articles; the effect of exercise
on measures of functional outcome was uncertain, and no
effects of intervention on adverse events were found (37,
38). There was a small reduction of stay and total hospital
costs (silver-level evidence) (38). Notwithstanding, these
reviews were published in 2007 and, therefore, there is a lack
of information regarding possible recent studies investigating
the effects of early rehabilitation for acutely hospitalized
elderly medical patients. In addition, very few studies have
explored the feasibility of conducting exercise programs for
hospitalized elderly patients (39). Because feasibility of early
rehabilitation program in acutely hospitalized elderly is a
critical question for implementing this type of intervention in
a hospital environment, it would be interesting also update the
information regarding feasibility of early rehabilitation program
including exercise interventions. Moreover, there is a need to
know what type of people will benefit from each program and
whether each program is viable before beginning any exercise
or rehabilitation program.
The main objective of the present review is to critically
review the effect of interventions incorporating exercise and
early rehabilitation (physical therapy, occupational therapy, and
physical activity) in the functional outcomes in hospitalized
elderly medical patients initiated as soon as physiological
stability is achieved and sustained during hospitalization
describing their programs and summarizing their results. The
second objective of this review is to analyze the feasibility of
physical rehabilitation programs in hospitalized elderly medical
patients. Lastly, we also aimed to describe data on mortality,
economic profile and average stay during hospitalization after
rehabilitation program of the patients who attended the included
studies.
739
Methods
Definition of terms
In order to review the effect of interventions incorporating
exercise and early rehabilitation in the functional outcomes
in hospitalized elderly medical patients, it was considered
as “functional outcomes”, any outcome related with the
capacity to perform active daily living (ADL) activities, such
as Barthel Index Scores, Lawton-Brody Questionnaire, ADL
scores (Katz index), Ability to perform 5 ADL test, Physical
Performance and Mobility Examination test, Functional
Ambulation Classification, Health-related quality of life,
Functional Independence Measure (FIM), IADL assessment,
timed-up-and-go test, sit-to-stand tests, gait ability and
mobility tests, Berg balance tests. Feasibility was defined
based on adherence and the possibility of doing the exercises
in the context of acute hospitalization. Economic profile
considered the economic impact of exercise intervention,
directly assessed when the authors presented results on
hospital costs, or indirectly assessed throughout the rate of
discharge, readmissions and length to stay. Early rehabilitation
intervention was considered as interventions including physical
therapy, occupational therapy, and physical activity performed
as soon as physiological stability is achieved by elderly patients
acutely hospitalized.
Search strategy
A systematic review of the literature was conducted using
the following databases and medical resources: PubMed
(Medline), PEDro, the Cochrane Central Register of Controlled
Trials and the Cochrane Database of Systematic Reviews,
Google Scholar, ClinicalTrials.gov, Clinical Evidence, Sports
Discus, EMBASE and UptoDate, searched from November
2013 to April 2015. The search period included from 1966 (i.e.,
date of the first article considered) to April 2015. The terms
used in the search tried to be similar to other previous studies
in an effort to permit the reproducibility, and were («aged» or
«elderly» or «geriatric») AND («hospital» or «hospitalized»)
AND («exercise» or «rehabilitation» or «ADL» or «physical
functioning» or «mobility» or «physical performance») AND
(«acute» or «acutely»): Articles about feasibility were obtained
by adding the terms «feasibility» or «feasible» or “viability” or
«adherence rate» or «safety» to the keywords above-mentioned.
During the inclusion process, the title and abstract, and the
full article if necessary, were assessed. Additional studies
were obtained by following references and citations. The
search criteria and strategy were defined and written before
performing the search. This systematic review is reported as
much as possible in accordance with the Preferred Reporting
Items for Systematic Reviews and Meta-Analysis (PRISMA)
statement (40). However, a meta-analysis was not performed
after qualitative synthesis.
J Nutr Health Aging
Volume 20, Number 7, 2016
PHYSICAL ACTIVITY AND EARLY REHABILITATION
Criteria for study consideration
Only articles reporting randomized clinical trials (RCTs) in
elderly patients older than 64 years in Spanish, Portuguese or
English were selected, except for feasibility studies which non-
randomized trials were also considered due to the small number
of studies found. The interventions examined in the articles
were required to include physical activity in the intervention
and to assess functional outcome measures related with active
daily living (mentioned above, see “Definition of Terms”).
Studies carried out in units for a specific disease (e.g., stroke)
were excluded. The same exclusion criteria applied to the
feasibility articles, except that non-randomized trials were also
included (controlled clinical trials).
Data extraction
Titles and abstracts of included articles were independently
assessed by two investigators. Reviewers were not blinded
to authors, institutions, or manuscript journals. Abstract that
did not provided enough information regarding the inclusion
and exclusion criteria were retrieved for full text assessment.
Reviewers assessed independently full text to determine
study eligibility. Data were extracted accordingly with pre-
defined informations: study design, location and patients
characteristics, methods, quality, and assessment period,
description of intervention and control, feasibility, functional
outcomes (defined above, see “Definition of Terms”) and
mortality, and economic profile and average stay. In order
to clarify some data not included in the published report, the
corresponding author of included manuscript was contacted as
needed.
Assessment of risk of bias
Study quality assessment included adequate sequence
generation, allocation concealment, blinding of outcomes
assessors, use of intention-to-treat analysis, and description
of losses and exclusions. Studies without clear descriptions
of an adequate sequence generation or how the allocation list
was concealed were considered not to have fulfilled these
criteria. Quality assessment was performed independently
by 2 unblinded reviewers and disagreements were solved by
consensus or by a third reviewer.
Results
The literature search strategy focused on 1086 articles of the
6564 potentially related to exercise performance in hospitalized
elderly patients, of which 17 articles were ultimately selected,
describing 17 studies (Figure 1). The study of Collard et
al. (41) included results of two trials performed in different
hospitals, and the articles by Landefeld et al. (42) and Covinsky
et al. (9) were generated from the same study. The search on
the feasibility of exercise for hospitalized elderly patients led
to the selection of 4 articles. These results were similar and
were added to previous systematic reviews (38, 39) bringing
740
together previous results and adding some articles that had not
previously been included (43, 44). Three studies that were not
in the Cochrane reviews were included, in which randomization
was not performed before the first three days of admission (44
-46). The collected studies were initiated in the year 1985 (41),
and the author of the first RCT reported encouraging results
and suggested the possibility of providing a higher quality of
care without increasing costs. Since that time, several studies
have been conducted, the last one in 2014 (43). Tables 1 and 2
summarize the characteristics of the studies.
Figure 1
Flowchart of search results
Quality (Risk of bias)
Among the included articles, 58.8% presented adequate
sequence generation (10 of 17) (9, 47- 55), 58.8% reported
allocation concealment (10 of 17) (43 - 51, 53, 54), 41.2% had
blinded assessment of outcomes (7 of 17),(9, 43, 45, 47, 49, 50,
52), 100% described losses to follow-up and exclusions (17 of
17) (9, 41-56) and 41.2% used the intention-to-treat principle
for statistical analyses (7 of 17) (49 - 51, 52, 53, 55, 56) (Table
4).
Locations of the studies and patient characteristics
The studies were conducted in acute geriatric units,
conventional medicine units, teaching hospitals, and tertiary
hospitals in countries that included United States, Sweden,
Spain, Germany, France, Netherlands, Norway, and Australia.
The mean age of the patients ranged from 77 to 85 years, with a
higher mean age in the most recent studies. Women accounted
highest percentage in most studies, and institutionalized
patients ranged from 7 to 28% (when institutionalization
was not an exclusion criterion for participation in the study).
Samples sizes across studies ranged from 76 (55) to 1531 (49)
patients.
Methods, quality, and assessment period
Most of the studies analyzed were RCTs, although two
controlled clinical trials (CCTs) were included. The quality
of the trials was quantified by the PRISMA recommendations
(40). According to these criteria, quality ranged from 1 to 5.

Characteristics of the included trials regarding the population and location, subjects’ age and sex, methods, intervention description in hospitalized elderly patients
Study Population and Location
Collard et al. (41) 271 medical and surgical
(Choate Hospital) patients
95 intervention and 176 control
Acute care hospital in the U.S.
Collard et al. (41) 424 medical and surgical
(Symmes Hospital) patients (123 treatment, 301
control)
Acute care hospital in the U.S
Landefeld et al. (42) 651 patients out of 1794 pos-
sible (327 intervention and 324
usual care)
Nonprofit private hospital in
the U.S.
Slaets et al. (54) 237 patients (140 intervention,
97 control)
741
Teaching hospital in the
Netherlands
Covinsky et al. (9) 651 patients out of 1794 pos-
sible (327 intervention and 324
usual care)
Nonprofit private hospital in
the U.S.
Nikolaus et al. (45) 545 patients. University Hospi-
tal and home care. Germany
Asplund et al. (48) 444 patients: 190 AGU, 223
CMU
Tertiary acute care hospital in
Sweden
Table 1
Mean Age/Females (%) Methods
≈ 77 years RCT special geriatric care
60% women ward vs. conventional medi-
10% from nursing home cal or surgical ward
≈ 79 years RCT special geriatric care
65% women ward vs. conventional medi-
9% from nursing home cal or surgical ward
≈ 80 years AGU RCT vs. conventional
66% women care
8% from nursing home
≈ 83 years CCT (alternative randomiza-
71% women tion) of the effect of adding
28% from nursing home psychogeriatric intervention
to usual care
≈ 80 years AGU RCT vs. conventional
66% women care
8% from nursing home
≈ 85 years RCT with results and costs
79% women evaluated 12 months after
62% lived alone the date of admission
≈ 81 years RCTs comparing one acute
60% women geriatric unit (AGU) with
16% from nursing home two conventional medical
units (CMU). Randomiza-
tion in blocks of 12 patients.
Intervention
AGU with assistants and
nurses. Emphasis on maxi-
mizing patient independence.
Multidisciplinary meetings
twice a week. Early discharge
and home visit 3 weeks after
discharge.
AGU with assistants and
nurses. Emphasis on maxi-
mizing patient independence.
Multidisciplinary meetings
twice a week. Plan for early
discharge and home visit 3
weeks after discharge.
AGU with special environmen-
tal measures, patient-centered
care, nursing plans to prevent
functional decline, rehabilita-
tion, patient discharged home,
and prevention of iatrogenic
complications. Daily visits.
Multidisciplinary treatment
by a psychogeriatric group in
addition to usual care. Physical
therapist and 3 full time nurses
in the intervention ward.
Objective to optimize patient
function. Weekly meetings.
AGU with special environmen-
tal measures, patient-centered
care, nursing plans to prevent
functional decline, rehabilita-
tion, patient being discharged
home, and preventing iatroge-
nic complications. Daily visits.
The patients were randomly
assigned to receive compre-
hensive geriatric assessment
(CGA) and home discharge
intervention (intervention),
CGA (assessment), or usual
care (control).
AGU with one geriatrician,
physical therapist, and occupa-
tional therapist. The interdisci-
plinary team focused on early
and intensive rehabilitation in
addition to discharge planning.
Evaluation period
On admission, at discharge, and
home visit 3 weeks after discharge
On admission, at discharge, and
home visit 3 weeks after discharge
On admission, at discharge, and
home visit 3 months after discharge
On admission, at discharge, and 6
and 12 months after discharge
On admission, at discharge, and
home visit 3 months after discharge
On admission, at discharge, and
one year after discharge
On admission, at discharge, and 3
months after discharge
Exercise Description
J Nutr Health Aging
Patients carry their own clothes,
have dinner in the common area,
Volume 20, Number 7, 2016
and participate in an exercise
program. Supervision by staff and
family. The role of the physical
therapist and occupational therapist
is clearly defined.
Patients carry their own clothes,
have dinner in the common area,
and participate in an exercise
program. Supervision by staff and
family. The role of the physical
therapist and occupational therapist
is clearly defined.
Walking or standing 3 times a day.
Daily walking to the exercise room
and for meals. Weight support,
resistance, and aerobic exercises.
Treatment for the prevention of
functional decline and rehabili-
tation.
Walking or standing 3 times a day.
JNHA: GERIATRIC SCIENCE
Daily walking to the exercise room
and for meals. Weight support,
resistance, and aerobic exercises.
Additional training such as ADL
training. At discharge, the mul-
tidisciplinary team established a
therapeutic regimen.
Early rehabilitation

Counsell et al. (49) 1531 elderly (6609 possible)
living at home, hospitalized for
acute medical illness
Teaching Hospital in the U.S.
Siebens et al. (53) 300 of 2198 possible, 151
control and 149 intervention
Tertiary hospital in the U.S.
Saltvedt et al. (44) Frail patients > 75 years ad-
mitted to Internal Medicine and
randomly assigned to a geriatric
assessment unit (n = 127) or
conventional units (n = 127)
Tertiary hospital in Norway
Jones et al. (51) 160 (of 186 possible), 80 in
each group
Public tertiary hospital in
Australia
Saltvedt et al. (46) Acutely sick, frail patients
aged >=75 years, admitted as
emergencies to the Department
742
of Internal Medicine, were ran-
domized to treatment in either
the GEMU (n = 127) or the MW
(n = 127)
De Morton et al. 236 (of 251 possible), 110 inter-
(56) vention and 126 usual care
Blanc-Bisson et 76 Patients aged > 70 years
al. (55) hospitalized at an AGU, who
walked independently three
months prior to admission.
Tertiary hospital in France
Courtney et al. (50) 124 patients (64 intervention
and 64 control)
Tertiary hospital in Australia
Table 1 (continued)
≈ 80 years RCT of multidisciplinary
60% women AGU vs. traditional care
8% from nursing home
≈ 78 years RCT of an exercise program
60% women that included a hospital
7% from nursing home component and a home-
based component performed
individually for one month
≈ 82 years RCT comparing mortality
81% women of patients admitted to a
conventional ward compared
to patients admitted to a
geriatric evaluation and
management unit
≈ 82 years RCT of an intervention
58% women involving additional exercise
18% were not living at vs. usual care
home
≈ 82 years Prospective randomized trial
≈ 81% women comparing interdisciplinary
27 - 33% were not living assessment, early rehabili-
at home tation, and comprehensive
discharge planning with
a control group receiving
treatment as usual
≈ 79 years CCT through additional
55% women exercise intervention
10% from nursing home compared with usual care.
Consecutive admission to
one of two available wards.
≈ 85 years Prospective RCT with two
72% women arms: early and intensive
rehabilitation vs. usual care
≈ 79 years RCT to assess the perfor-
62% women mance of a model of hospital
55% lived alone treatment with exercise
and home monitoring in
elderly patients at risk of
readmission
AGU with special environmen-
tal measures, patient-centered
care, nursing plans to prevent
functional decline, rehabilita-
tion, patient being discharged
home, and prevention of
iatrogenic complications. Daily
visits.
Exercise program during
hospitalization and one month
after discharge.
Multidisciplinary geriatric
evaluation and management
program including early reha-
bilitation.
Exercise program during hospi-
talization, in addition to usual
physical therapy care.
In the GEMU, the treatment
strategy emphasized compre-
hensive interdisciplinary eva-
luation of all relevant disorders,
prevention of complications
and iatrogenic conditions, early
mobilization, rehabilitation, and
discharge planning.
Exercise program during hospi-
talization, in addition to usual
physical therapy.
Exercise program during
hospitalization, and one month
after discharge.
Overall nursing and physical
therapy assessment and indivi-
dualized exercise program, with
home nursing visits and phone
follow-up begun in the hospital
and continued up to 24 weeks
after discharge.
On admission, at discharge, and 1,
3, 6, and 12 months after discharge
On admission, at discharge, and
home visit 3 weeks after discharge
On admission, 3, 6, and 12 months
after discharge
On admission, at discharge, and at
28 days
After discharge, neither group
received specific follow-up.
Activities of daily living (BADL),
instrumental BADL, cognitive
function, symptoms of depres-
sion, and general well-being were
assessed 3, 6, and 12 months after
discharge from hospital.
On admission, at discharge, and at
28 days
On admission, at the time of overall
recovery, and at one month
On admission, 4, 12, and 24 weeks
after discharge
Walking or standing 3 times a day.
Daily walking to the exercise room
and for meals. Weight support,
J Nutr Health Aging
resistance, and aerobic exercises.
Volume 20, Number 7, 2016
12 flexibility and strengthening
exercises, walking program
Emphasis on interdisciplinary eva-
luation and of all relevant diseases,
prevention of complications and
iatrogenic conditions, mobiliza-
tion and early rehabilitation, and
discharge planning.
One of 4 possible levels of an exer-
cise program. Individually taught.
Early mobilization and rehabi-
litation, with encouragement to
participate in ADLs. No systematic
physical activity program descri-
bed.
One of 4 possible levels of an exer-
cise program. Individually taught.
Early transfer to chair, from 1-2
PHYSICAL ACTIVITY AND EARLY REHABILITATION
days, walking, a program of phy-
sical therapy. All patients received
nutritional supplements.
The intervention group received an
additional intervention following a
protocol developed by the authors.
The prescribed regimen included
4 components: muscle stretching,
balance, walking for endurance,
and muscle stretching exercises
using resistance. The intervention
continued at home with home visits
and phone calls by a nurse.

Abizanda et al. (47) 400 patients admitted to AGU.
198 occupational therapy inter-
vention and 202 to conventional
treatment
Hospital in Spain
Laver et al. (52) 44 of 235 possible (22 control
and 22 intervention)
Geriatric rehabilitation unit in
an acute care public hospital of
Australia
Tibaek et al. (43) 71 patients (35 control and 36
intervention). 15 dropped out (8
control and 7 intervention).
Department of Geriatric rehabi-
litation at Copenhagen Univer-
sity Hospital in Denmark
RCT: Randomized clinical trial; QA: Quality assurance; GEML: Geriatric evaluation and medical unit; BADL: Basic activities of daily living; CCT: controlled clinical trial; CGA: Comprehensive geriatric assessment; MW:
Medical ward.
743
Characteristics of the included trials regarding the program oversight, exercise program features, environmental modifications, quality, cost and conclusion in
Study Program Oversight
Collard et al. (41) (Choate Hospital Nursing staff and family
and Symmes Hospital)
Landefeld et al. (42) Encouraged by staff. Exercises are
taught to the patient or caregiver.
Table 1 (continued)
≈ 84 years RCT in three groups of
56% women patients: cardiovascular
disease, stroke, and other
situations. Additional
brief occupational therapy
intervention compared to
standard therapy.
≈ 85 years RCT. Participants were
79% women randomly assigned to a phy-
62% lived alone sical therapy program with
interactive games (Wii -Fit)
or conventional physical
therapy.
80 ± 6.5 years (inter- RCT. Participants were
vention), 79 ± 7.5 years randomly assigned to a pro-
control gressive resistance training
58% women in addition to standard care
62% lived alone or standard care.
Table 2
hospitalized elderly patients
Exercise program features
Not described. An attempt was
made to contact the authors to
complete the data, but it was unsuc-
cessful (> 20 years study).
3 times per day
Daily activities in the fitness room
and at meals
Multidisciplinary geriatric
assessment and management
program with a protocol of ear-
ly occupational therapy added
to conventional management.
The conventional treatment
group had mobility maximiza-
tion, walking sessions, trans-
fers, steps, balance, stretching,
and flexibility vs. Wii Fit in the
intervention group.
The standard treatment group
received supervised phy-
siotherapy and the treatment
group performed resistance
training along with supervised
resistance training.
Environmental modifications
Ward with 10 beds and a common
dining area
Unit with 14 beds Clear pas-
sageways, clocks and calendars,
extra spaces with light, colors, pri-
vacy in the rooms, and a room for
light exercise and social interaction.
On admission and at discharge
On admission and at discharge
On admission and at discharge
Costs results
The authors claimed lower costs.
Average stays and hospital charges
were similar in both groups
Session of 45 minutes daily from
Monday to Friday with an average
of 5 sessions during hospitalization
J Nutr Health Aging
Day 1: CGA and preparation of
individual therapeutic plan
Volume 20, Number 7, 2016
Day 2: 45-minute sessions. Co-
gnitive stimulation, instructing the
family, BADL training
Day of discharge: Additional
session of 30 minutes with recom-
mendations for ADL.
Participants in the Wii Fit group
had activities selected by the
physical therapist according to
individual skills and therapeutic
needs, including tasks that focused
on balance, strength, or aerobic
capacity development.
Participants in the treatment group
performed progressive resistance
training supervised by physiothe-
rapists who supervised the control
group.
JNHA: GERIATRIC SCIENCE
Functional outcomes results and
conclusions
No significant differences between
intervention and control groups for
use of restraints, medical compli-
cations and and self-rated mobility.
Initial results are encouraging: they
suggest that high-quality hospital
care can be provided to elderly
patients for less money.
At discharge, intervention group
had a higher level of functional in
the basic ADL. Specific changes
in the provision of acute hospital
care can improve the ability of a
heterogeneous group of acutely
hospitalized elderly patients to
perform ADL.

Slaets et al. (54) Physical therapist
Covinsky et al. (9) Encouraged by staff. Exercises are
taught to the patient or caregiver.
Daily activities in the fitness room
and board
Nikolaus et al. (45) Physician, 3 nurses, one physical
therapist, one occupational thera-
pist, social worker, and secretary.
744
Asplund et al. (48) Physical therapist and occupational
therapist
Counsell et al. (49) Encouraged by staff. Exercises are
taught to the patient or caregiver.
Siebens et al. (53) Prescribed by physical therapist.
Once daily monitored and once
daily without supervision. One
month at home unsupervised.
Table 2 (continued)
Daily evaluation by physical
therapist
3 times per day
Not described
3 times per day
Daily activities in the fitness room
and meals
Twice daily in-hospital exercises
and 3 times per week at home,
5 - 10 repetitions. Walking 5-30
minutes. Intensity: 60-80% of
HRmax. Ability to speak while
exercising.
No
Unit with 14 beds. Clear pas-
sageways, clocks and calendars,
extra spaces with light, colors, pri-
vacy in the rooms, and a room for
light exercise and social interaction.
No
No
Unit with 34 beds. Clear pas-
sageways, clocks and calendars,
extra spaces with light, colors, pri-
vacy in the rooms, and a room for
light exercise and social interaction.
None
The average stay was 5 days less,
with 30% fewer readmissions and
9% institutionalization in the inter-
vention group. They claim they can
improve care cost-effectively.
Daily cost was slightly higher in
the intervention group (US $876 vs.
US $847, P =.076). However, the
average stay was lower in the in-
tervention group (7.5 vs. 8.4 days,
P =.449). The final cost was thus
lower in the intervention group (US
$6,608 intervention vs. US $7,240
control, P =.926).
Direct costs were lower in the in-
tervention group, about (US $4000)
person/year. Intervention reduced
length of stay and readmissions.
In the geriatric unit, there were 7%
more home discharges (relative
risk 1.17, 95% CI, 0.93-1.49), and
the average stay was shorter (mean
5.9 vs. 7.3, P =.002). Costs were
similar.
There was no significant difference
in length of stay, costs, readmis-
sions, or home visits.
Average stay similar in both groups
Patients in the intervention
group were more independent on
discharge measured by the ADL.
J Nutr Health Aging
By combining elements of geriatric
and psychogeriatric consultation
Volume 20, Number 7, 2016
driven by the service of the unit,
health care for the elderly could
be improved in our hospital in a
feasible and cost-effective way
Intervention and usual-care patients
were similar in independence in
ADLs. An intervention designed
to improve functional outcomes in
elderly patients was less expensive
than conventional hospital care.
Intervention and control groups
had similar functional status at
discharge. CGA in combination
with a home-based intervention
after discharge does not improve
survival, but may reduce length of
stay and readmissions. It can also
reduce institutionalization and the
direct costs of hospitalized patients.
No differences in the Barthel Index
between groups at discharge. A
geriatric approach with great em-
phasis on early rehabilitation and
discharge planning in AGU reduces
the average stay and may decrease
admission to nursing homes.
The ADL outcome decline
from baseline or nursing home
placement was less frequent in the
intervention group after discharge
PHYSICAL ACTIVITY AND EARLY REHABILITATION
and during the year following
hospitalization (P<0.05). An AGU
in a tertiary hospital improved the
process of care and satisfaction of
patients and care personnel, without
increasing the cost or length of stay.
Intervention was associated with
better function in instrumental ADL
at 1 month. An exercise program
started during hospitalization and
continued for a month did not
shorten the stay, but improved
functional outcomes at one month.

Saltvedt et al. (44) Geriatrician, physical therapist,
nurse, occupational therapist.
Jones et al. (51) Prescribed by physical therapist
and supervised by an assistant.
Saltvedt et al. (46) Physiotherapy and occupational
therapy were prescribed by the
doctor and supervised by physical
and occupational therapists.
De Morton et al. (56) Prescribed by physical therapist
and supervised by an assistant.
745
Blanc-Bisson et al. (55) Physical therapist
Courtney et al. (50) Physical therapist and nurse
Table 2 (continued)
Not described
Twice daily, 30 minutes
Physical therapy and rehabilitation
not described.
Twice daily; maximum of 10
repetitions of each exercise for
20-30 minutes
Twice daily, 5 days a week for 30
minutes and physical therapy at
home for 1 month. Crural biceps:
10 repetitions of dynamic work
against the foot of the bed. When
plantar flexor and extensor muscles
could be lifted, they were exercised
in the standing position. Lower
extremity: alternate hip flexion to
45 ° for 3-5 seconds, 10 repetitions
with 10 seconds rest. Pelvis: knee
flexed 30°, moving pelvis to the
right and left 10 times.
Muscle stretching: before and after
resistance training and walking
program.
Balance: daily, including
body rocking, standing on heels,
balance with eyes closed, and
walking a line.
Walking: to increase aerobic capa-
city and mobility. Start slowly 3-5
minutes with progressive increase
to 5 to 10 minutes. Initially 2-3
times a week, then 3-4 times a
Special room for exercise and Not described Barthel Index and IADL did not
meals differ between groups during
follow-up. Treating frail elderly
J Nutr Health Aging
patients in a specific geriatric
evaluation and management unit
Volume 20, Number 7, 2016
substantially reduced mortality.
None The intervention group had a lower When admission Barthel Index
average stay scores were low, there was a greater
(Hazard ratio (HR) 1.46 (95% CI improvement in these scores in
1.04–2.05); P = 0.026). the intervention compared with
control group. The intervention was
effective in improving the function
of hospitalized elderly medical
patients.
Not described Not described Treatment in the GEMU had no
measurable beneficial impact on
function, mood or symptoms of
depression. Considering the pre-
viously shown mortality reduction,
an additional effect on function
was less likely, and the overall
treatment effect was considered to
be positive
No No significant differences, although There were no significant functio-
the average stay was one day less nal improvement in the Barthel In-
in the intervention group. dex, timed up and go and functional
ambulation classification. This trial
did not identify a significant impro-
vement in outcomes as a result of
additional exercise in hospitalized
elderly medical patients.
None Not described No significant changes were
JNHA: GERIATRIC SCIENCE
observed between intervention and
control groups in the had grip stren-
gth and ADL scores (Katz index).
None Intervention group had 25% fewer Intervention group presented signi-
urgent readmissions and 45% ficant greater health-related quality
fewer urgent visits to the family of life. Premature introduction of a
physician. program of individual exercise and
long-term follow-up by phone can
reduce the use of emergency health
services and improve the quality
of life of elderly patients at risk of
hospital readmission.
 Table 2 (continued)

week. Resistance exercises for

upper and lower body with resis-
tance bands 2-3 times per week
J Nutr Health Aging

increasing to 3-4 times per week.

Contractions held 3-5 seconds, re-
Volume 20, Number 7, 2016

peated 5 times for both extremities

Abizanda et al. (47)
Laver et al. (52)
Geriatrician and occupational
therapist
Nursing staff and physical therapist
and increasing to 2-3 blocks of 10
repetitions.
Cognitive stimulation and pre-
vention of delirium: 10 minutes;
instructions to families to prevent
complications: 5 minutes; BADL
retraining: 30 minutes; bed
mobility; sit and stand; dressing,
bathing, personal hygiene, and
toilet use
Balance: weight change on table
Strength: exercises for the lower
extremities. 25 minutes a day, 5
days a week. Close supervision by
physical therapists.
No
Treatment was carried out in a
gymnasium equipped with parallel
bars, treadmill, and small weights.
Not described Although there were no overall
significant differences, patients
with cardiopulmonary illness and/
or patients classified in the group of
pathologies without stroke admitted
to an AGU may benefit from a brief
occupational therapy intervention.
Not described No significant differences between
Wii Fit group and conventional
therapy were observed in the TUG,
SPPB, functional independence
measure and balance scores. In
this feasibility study, using an inte-
ractive game program by physical
therapists with hospitalized elderly
patients was safe, and adherence
levels were comparable to conven-

746
Tibaek et al. (43) Prescribed and supervised by expe- Progressive resistance training
rienced physiotherapists. composed by three sets of 12-15
repetitions with an intensity of
60-70% of one maximum repetition
(1 RM). Progression load was
assessed from the participant’s
perceived effort using a specific
scale (easy to moderate). Sessions
lasted 50 minutes.
Treatment was carried out in at the
Department of Geriatric Rehabili-
tation, using sand bag) in backpack
and by an elastic band of different
resistances.
tional treatment. Preliminary
results suggest exploring these new
therapeutic strategies.
Not described Participants of the treatment group
improved the performance in the
10-m walk test and the Barthel
Index (walking). There was a trend
toward significant differences
between groups at post-test in the
Barthel Index (stairs).
PHYSICAL ACTIVITY AND EARLY REHABILITATION

RCT: Randomized clinical trial; QA: Quality assurance; GEML: Geriatric evaluation and medical unit; BADL: Basic activities of daily living; CCT: controlled clinical trial; CGA: Comprehensive geriatric assessment; MW: Medical
ward.
 Table 3
Characteristics of included trials for feasibility of exercise in elderly hospitalized

Study Population Mean Age / Female (%) Intervention Feasibility Conclusion

J Nutr Health Aging

Brown et al. (62) 9 patients (7 intervention and 2 ≈ 85 years / 0% Twice a week. At discharge 20-30 From 605 patients admitted, 76 This study demonstrates the diffi-
control) minutes walk every day and were included in study, and 66 culties in recruiting patients during
Volume 20, Number 7, 2016

Mallery et al. (60) 39 patients (19 intervention and 20
control)
Nolan et al. (61) 220 patients (196 intervention and
24 control)
1021 admitted, included in study
strength training every two days vs
usual care (which included physio-
therapist assessment if requested.
≈ 82 years / 59% Usual care and resistance exercises
3 times per week, 30-40 minutes
assisted by physical therapist.
In control group usual care and
passive training 3 times per week,
30-40 minutes assisted by physical
therapist.
≈ 84 years / 67% Participation in the Maintenance
Functional Exercise Program, 6
times per week, 30 minutes vs
usual care with physiotherapist.
It is feasible to identify hospitalized
refused to participate.
395 admitted, 39 included.
Intervention group: participation
71%, 63% adherence. In the control
group: 96% participation and 95%
adherence. Reasons for exclusion
included: expected short stay,
cardiac syndromes, medical exemp-
tion, impossibility to walk, pysician
or patients refusion.
hospitalization and suggests that an
exercise program during this period
may not be feasible. Patients usual-
ly were sick or did not feel able to
exercise during hospitalization. A
home exercise program 2-4 weeks
after discharge can have greater
chances of success.
Using a program of simple and
standardized exercises, the hospi-
talized elderly are capable of per-
forming resistance exercise. These
exercises may prevent functional
deterioration during hospitalization.

747
220, 33 resigned. elderly who can benefit from an
exercise program to maintain func-
tional abilities, and the program
can begin even at 48 hours after
admission.
JNHA: GERIATRIC SCIENCE

Laver et al. (50) 44 patients (22 intervention and 22 ≈ 85 years / 79% Individual Program Interactive 235 admitted, 44 included, 90% The use of an interactive game pro-
control) Video (Wii Fit), 25 minutes a day, adherence in the intervention group gram assisted by physiotherapists
5 days a week, supervised by a and 91% in control group. in older hospitalized patients is
physiotherapist. safe, and the adherence levels were
comparable to those of conventio-
nal treatment.
J Nutr Health Aging
Volume 20, Number 7, 2016

PHYSICAL ACTIVITY AND EARLY REHABILITATION

Table 4
Assessment of risk of bias

Study
Collard et al. (57) (Choate
Hospital and Symmes
Hospital)
Landefeld et al. (49)
Slaets et al. (52)
Covinsky et al. (9)
Nikolaus et al. (53)
Asplund et al. (45)
Counsell et al. (46)
Siebens et al. (51)
Saltvedt et al. (54)
Jones et al. (48)
Saltvedt et al. (55)
De Morton et al. (58)
Blanc-Bisson et al. (56)
Courtney et al. (47)
Abizanda et al. (44)
Laver et al. (50)
Tibaek et al. (2014)
Items are marked as either present (1) or absent (0).
Adequate sequence Reported allocation Blinded assessment of Described losses to fol- Intention-to-treat
generation concealment outcomes low-up and exclusions principle for statistical
analyses
0 0 0 1 0
1 0 1 1 0
1 0 0 1 0
1 0 1 1 0
0 1 1 1 0
1 1 0 1 0
1 1 1 1 1
1 1 0 1 1
0 1 0 1 0
1 1 0 1 1
0 1 0 1 0
0 0 0 1 1
0 0 0 1 1
1 1 1 1 1
1 1 1 1 0
1 1 1 1 1
0 1 1 1 0

The Abizanda et al. (47) study stands out also for its quality
because no patient who entered the study (acute geriatric unit)
was excluded, so their results can be extrapolated to the reality
of conventional medical units. Some studies were limited to
the period of hospitalization (41, 51), while others conducted
variable follow-up, ranging from 28 days (51, 56) to 12 months
(45, 49, 54). The studies whose interventions extended to some
degree over time had better outcomes than the others (45, 50,
53, 55). Only one of the studies that provided no continuity
after admission showed any improvement at three months (44).
Description of the intervention
Interventions could be basically divided into two types:
multidisciplinary programs with an exercise component and
cases in which an exercise program was added to the usual
care (45, 47, 50-53, 55, 56). The description of the exercises
included weekly frequencies from 2 to 5 times per week,
including strength, balance, and mobility exercises types. The
intensity, frequency, and duration of the exercises increased
progressively. An interactive game was used in one study with
an instrument called Wii Fit (52). Multidisciplinary teams
included geriatricians, nurses, social workers, occupational
therapists, and physical therapists (9, 41, 42, 44, 48, 49, 54). In
this group, the exercise intervention was minimally described
(walking, stimulation of independence), so comparison and
extrapolation to other studies is very difficult. In some cases,
environmental measures were added, such as common areas
for conducting exercise and main meals (9, 42, 49). When
follow-up of patient progress occurred, it was conducted by
home visits, phone calls, and the provision of educational
material (49, 50). Exercise programs were usually supervised
by physical therapists, occupational therapists, nurses, or staff
trained for that purpose.
Feasibility
Table 3 shows the feasibility characteristics of the analyzed
trials. As in a recent review (39), we only found four studies
after the search, three of which demonstrated the feasibility of
conducting an early exercise program in hospitalized elderly
patients (52, 57, 58), and one had significant difficulties in
recruiting patients (only 2% of eligible patients were recruited)
and did not address the feasibility of the exercise program
(59). Some of the issues examined in these studies included
recruitment, adherence, and adverse effects. The adherence
rates ranged from 60% to 90%, and the most common causes
for leaving the studies were early discharge, admission to
the intensive care unit (ICU) or palliative care unit, clinical
instability, and death. Most studies included in the review
reported few adverse effects, such as fall or injury, without
finding any significant differences in the adverse effects
compared with the control group. No adverse effects related
with early rehabilitation intervention were mentioned in the

748
J Nutr Health Aging
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JNHA: GERIATRIC SCIENCE
studies.
Functional outcomes and mortality
Four of the studies assessing basic activities of daily living
at the time of discharge found significant improvements in
the functional capacity (42, 43, 51, 54). The improvements
observed exclusively in the intervention group included
increases in the Barthel Index score, 10-meters walking test and
others tests related with mobility and with the capacity active
daily living (42, 43, 51, 54). Regarding functional outcome
after discharge, only the studies that standardized exercise
with follow-up at discharge found improvement, even up to
twelve months after discharge (45, 50, 53, 55); however, one
study that did not provide measures of exercise at discharge
found a positive effect of the intervention at three months (45).
Seven studies assessed physical performance (43, 49-51, 53,
54, 56), but the results were contradictory because, while some
studies showed that the intervention improved or prevented
the worsening of physical performance (43, 49, 51, 54), others
failed to show such a result. During follow-up, the results on
physical performance were also mixed (45). Finally, one study
did not show lower mortality (45), while another found that the
management of patients in a geriatric unit did reduce mortality
(44).
Economic profile and average stay
Eight studies directly or indirectly assessed the economic
impact of exercise intervention. Five of them did not show any
increase in costs (9, 48, 49, 56), while three concluded that the
intervention was cost effective (45, 54, 56). When the average
stay was analyzed, four studies demonstrated a significantly
shorter hospital stay (45, 48, 54), and three studies showed a
higher number of patients reintegrated into the community (44,
45, 48, 54).
Discussion
The first objective of this review was to assess the effect
of a physical activity program in hospitalized elderly medical
patients. Seventeen articles from 17 studies were assessed,
complementing the previous evidence from the medical
literature, which was reflected in three systematic reviews
(37-39). This review shows that exercise programs can be
beneficial if continued after discharge by helping to prevent
functional decline in this context and encourages allowing the
implementation of exercise and rehabilitation programs that
have proved to be feasible and, in some cases, cost effective
(45, 54, 56). In multidisciplinary interventions, the average
stay and institutionalization were reduced (9, 48, 51, 54).
The primary objective of adding exercise to conventional
management focused mainly on functional measures, and
indeed some of the studies showed functional improvements
(42, 43, 51, 54). It is very difficult to comprehensively assess
the interventions performed, as in many cases they were
749
described very superficially and were very heterogeneous.
Moreover, interpretation of the intervention can be hindered in
cases where the control group was routinely offered appropriate
physical therapy measures (56). The type of scale chosen to
assess functional outcomes is very important, as the Barthel
Index showed a ceiling effect, while the Katz index showed a
floor effect (51, 56). Regarding physical performance, the same
phenomenon occurs because the selection of measurement
scales is complex, as in the case of the Timed-up-and-go test,
which demonstrated a floor effect in some cases (52). Few
studies showed functional differences between intervention
and control groups at discharge (42, 54), although when the
intervention was prolonged, some studies showed benefits
even over the long term at the functional and Basic activities of
daily living (BADL) levels (46). This result suggests the need
to maintain continuing care for exercise, either in person or by
other means like by phone.
Although several studies in this systematic review did not
shown improvement on functional outcomes, there still may
be a potential role of exercise intervention as an effective
way to reduce the functional loss, institutionalization and
mortality in elderly patients as a hospitalization outcome (42,
43, 51, 54). Along with the studies included in the present
systematic review, the role of exercise in the hospitalized
elderly may be suggested because recent studies have been
shown that multicomponent exercise intervention composed
by resistance, balance and walking exercises may improve the
muscle strength, power output, muscle size and quality, as well
as functional capacity in institutionalized elderly patients at
very poor physical condition (35, 60, 61).
The implementation of our suggestions in the real world of
busy hospital staff is mainly restricted by economical issues
because it is necessary to rely on an additional physiotherapist.
When we address patients enrollment, patients’ adherence and
safety in the context of what is suggested above, it has been
shown by previous studies a very high adherence rate, with
very few drop outs as well as scarce side effects (60, 61). In
order to implement the exercise program in early rehabilitation,
it is also very important to convey the necessary knowledge
to the staff. Although its implementation is a challenge, some
studies have shown feasibility (52, 57, 58) and others have
shown functional improvements (42, 43, 51, 54), which make
the early rehabilitation an interesting possibility in order to
avoid a severe functional decline in acutely elderly patients.
This study has limitations: Data extraction was unblinded,
which is a potential source of bias. Additionally, high
heterogeneity was identified in the studies especially in the
structured interventions incorporating exercise and early
rehabilitation. To address this issues, data quality assessment
was performed independently by 2 unblinded reviewers.
Moreover, the absence of reliability data of the outcomes
measurements of included studies, as well as imbalances
between intervention and control groups may affects their
results, and consequently, the conclusions of this review.
J Nutr Health Aging
Volume 20, Number 7, 2016
PHYSICAL ACTIVITY AND EARLY REHABILITATION
In summary, the introduction of an exercise program for
hospitalized elderly patients may be feasible and may not
increase costs. In addition, it may also have a positive effect in
the healthcare and functional parameters. There are difficulties
in selecting the most appropriate scales and the most suitable
type of intervention. Geriatric units are the agents of innovation
and development for RCT, and the importance has been
demonstrated of changing from the disease-centered view to
the patient-centered view, optimizing traditionally neglected
aspects such as functional recovery after hospitalization.
Taking together recent evidences regarding exercise
interventions in acutely hospitalized elderly medical patients
as well as regarding exercise interventions in institutionalized
elderly at greater risk of disability, some key-points to exercise
prescription may be suggested in order to improve functional
outcomes in hospitalized elderly patients, which include the
following:
• The patients should begin a short daily walk inside the
hospital, along routes normally traveled in a wheelchair as
soon as the medical condition is stabilized; for example, going
to the dining room, bathroom, or walking along the corridors
of the hospital. In addition, the participants can walk using
canes and walker devices, if necessary, with the assistance of a
physical therapist. Moreover, the patients must be encouraged
to increase the distance walked and to try to walk without aid.
The distance must be gradually increased according to the
physical ability of the participants. It´s extremely important to
prevent any kind of injuries like falls or exacerbations of the
medical conditions.
• Balance and gait retraining exercises that progressed
in difficulty must be also implemented: semi-tandem foot
standing, line walking, stepping practice, walking with small
obstacles, proprioceptive exercises on unstable surfaces, and
altering the base of support, and weight transfer from one leg to
the other.
• Exercises for executive and cognitive functions should also
performed individually and in groups; these exercises should
address stimuli for eating and dressing, space-time orientation,
reasoning, memory, language, attention and perception in order
to achieve at least the basal situation
• Resistance-training programs should be performed starting
with light loads (i.e., 20-30% of patients’ maximal load) and
progressing to moderate to heavier loads (60-80% of patients’
maximal load). Resistance training prescription should include
explosive mode contractions into the strength training program,
as skeletal muscle power has been strongly associated with the
functional capacity in elderly populations.
• To optimize the functional capacity of individuals,
resistance training programs should include exercises in which
daily activities are simulated, such as the sit-to-stand exercise.
Future studies should advance the knowledge regarding
the most effective exercise intervention type in hospitalized
elderly patients before and after their discharge in order to
avoid their muscle strength and power losses, as well as their
750
cardiorespiratory decline. Importantly, these benefits would
allow the patients to maintain their functional capacity and
quality of life.
Acknowledgements: This work was supported in part by the Spanish Department of
Health and Institute Carlos III of the Government of Spain [Spanish Net on Aging and
frailty; (RETICEF)], Department of Health of the Government of Navarre and Economy
and Competitivity Department of the Government of Spain, under grants numbered
RD12/043/0002, 87/2010, and DEP2011-24105, respectively. This project is also funded in
part by the European Commision (FP7-Health, Project reference: 278803).
Conflict of interest: The authors do not have any conflict of interest to disclose.
Ethical Standards: The authors declare that the study procedures comply with the
current ethical standards for investigation involving human participants in Spain.
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