Deconditioning and rehabilitation

Introduction 

Malaysia is transitioning from an ageing to an aged nation. According to the Department of Statistics Malaysia (DOSM), 7.4% of Malaysia's population was aged 65 years or older in 2023, projected to exceed 15% by 2030. Frailty is increasingly prevalent, affecting 11% of adults aged 50–59 years and escalating to 51% among those aged 90 years or older, based on global data. A local pilot study in March 2024 in general medical wards highlighted common frailty-related issues, including deconditioning (36%), delirium (17%), and a 12-month readmission rate of 46%. 

Objectives 

To introduce a user-friendly, standardized frailty care bundle to support non-geriatric-trained healthcare personnel in detecting common issues related to frailty syndrome early and implementing appropriate interventions. 

Methods 

A multidisciplinary team comprising geriatricians, medical practitioners, pharmacists, nurses, therapists, dieticians, and medical social workers developed a care bundle focusing on three key components: (1) screening tools for identifying acute functional decline, sarcopenia, and delirium; (2) protocolized management pathways; and (3) a discharge planning checklist. The bundle is designed for ease of use in general medical wards by non-geriatric-trained personnel. 

Results 

The care bundle will be piloted in 2025 across general medical wards. Nurses and doctors will screen patients aged 65 and older for deconditioning and delirium upon admission, notifying geriatrician as needed. Early physiotherapist referrals will address deconditioning, and a structured delirium checklist will guide targeted management. The discharge checklist includes caregiver identification, discharge planning, medication reconciliation, equipment assessment, and welfare support. 

Conclusion 

Frailty amidst an ageing population poses significant clinical and economic burdens, including higher readmission rates and healthcare costs. A standardized frailty care bundle offers a systematic approach to optimizing elderly care, improving outcomes, and addressing ageing challenges. Future audits will assess its effectiveness in reducing readmissions, functional decline, and healthcare costs.

Background  

University Hospital Southampton (UHS) partnered with Saints Foundation (SF), to test the feasibility and acceptability of a non-registered Exercise Practitioner (EP) to work alongside the therapy team to promote physical activity (PA) of hospitalised older people. Our aim was to collect trust level data to review the impact the EP had on outcomes such as length of stay (LOS) and discharge destination (DD) and identify and address any additional challenges that arose. 

Methods  

The EP delivered twice weekly gym-based group interventions as well as regular 1:1 rehabilitation and education sessions to hospitalised older patients. Interventions were ward based or within the acute therapy gym.  

Results  

Between June and August 2023 the EP reviewed 82 patients, mean age of 88 years. 15 (18%) patients underwent 1:1 rehabilitation whereas 67 (82%) patients underwent gym-based rehabilitation sessions. Median LOS for patients reviewed by the EP was 15 days compared with average departmental LOS of 8 days. 53 (65%) patients were able to either maintain or improve their predicted to actual discharge destination, compared with 10 (12%) patients whose physical capability declined. Of those remaining, 1 patient died and 18 others had not yet been discharged. High patient satisfaction levels continued to be reported.  

Conclusion  

Intervention by a non-registered EP appears to have an impact on patients’ ability to maintain or improve level of function and physical dependency during acute hospital stay.  Factors such as outbreaks of infectious illness and staffing challenges prevented more frequent EP led intervention. Next steps include introducing daily class-based interventions. Participants will be encouraged to attend at least three classes. Anticipated benefits include improvement in patients’ functional levels and reductions in physical dependency on discharge.  Additional data will be collected on fear of falling and confidence in function as well as uptake of post discharge activity and readmission. 

Introduction: Hospital-Associated Deconditioning Syndrome (HADS) can lead to prolonged length of stay (LOS). Evidence indicates that early intervention may reduce HADS and LOS. (British Geriatrics Society, Deconditioning, Healthy Ageing, 11 May 2017, Dr Amit Arora, NHS England, 24 January 2017, Time to Move). The Acute Frailty Team (AFT) at Eastbourne District General Hospital piloted a Frailty Early Discharge Scheme (FEDS) in the Frailty Unit for 8 weeks between May-June 2023 with the aim of providing early mobilisation and discharge planning to reduce LOS.

Methods: Patients were admitted to either FEDS or Non-FEDS (NFEDS) beds depending on the bed availability. FEDS patients were provided with additional early assessments and interventions including discharge plans from day 1 after admission, offering early, continuous and active mobilisation by a trained FEDS team of a registered Nurse and Health Care Assistant. The FEDS team worked in conjunction with the medical team to actively promote discharge planning while patients were still receiving acute medical treatment, before patients becoming medically fit for discharge (MFFD). NFEDS followed the standard care plan, usually initiated after patients were declared MFFD. Data was collected for all patients, comparing FEDS 12 beds with NFEDS 12 beds.

Results: 83 patients were enrolled 45 FEDS, 38 NFEDS Discharged within 48hrs FEDS 11.11%, NFEDS 2.63% Discharged within 7 days FEDS 44.44%, NFEDS 28.94% LOS 8.07 days FEDS, 11.36 days NFEDS (30 day trim point).

Conclusions: 1. Increased rate of discharge within 48 hrs and 7 days. 2. Reduced LOS within 30 days. 3. The benefit is mostly noticed within the first 7 days indicating the need to apply the intervention early 4. The adoption of a FEDS-project in all frailty wards could be beneficial for elderly patients.

Introduction:

As awareness of hospital-associated deconditioning increases, services to prevent hospital admissions and provide discharge support for older adults are expanding, aiming to reduce admissions and the risks associated with prolonged hospital stays. A Welsh Government IQS titled “Older People and People Living with Frailty” published in January 2024 identifies a need to shift our health and social care system from prioritising reactive crisis management to a ‘place-based’, community-focused approach that emphasises proactive identification and management of frailty. The CTMUHB @Home Service (AHS) was instituted in 2017 to provide domiciliary and community-based care to patients at risk of hospital admission, covering Rhondda, Cynon, Taff Ely and Merthyr Tydfil.

Methods:

A retrospective review of patients discharged from the AHS between February and May 2024 was completed (n=345). Reasons for referral, diagnostic journey details, and patient outcomes were recorded. Alongside this, the IV Antibiotics Service register for the same period was analysed (n=48) to calculate the number of Bed Days saved and its associated cost effectiveness.

Results:

57% of referrals are related to patients’ risk of or recent falls, followed by 16% of patients with increased frailty who are approaching crisis. 8% of patients have been referred for the specialised services of the AHS, such as COPD reviews, discharge support, pharmacological optimisation, or follow-up blood tests. Most referrals originate from GPs, with other sources including facilitated discharges or WAST. Bed day costs saved from the IV Antibiotics Service are estimated to be £358,000.

Conclusion:

We now have a better understanding of the AHS’ monthly patient in and outflow. Although the substantial cost savings seem positive, it is still uncertain whether this conclusively measures the AHS’ cost-effectiveness. This understanding will help pave the next steps towards increasing awareness about the functions of the AHS as a hospital avoidance team focused on frailty.

Introduction: Femoral fragility fractures (FFFs) are a significant healthcare concern, with the incidence predicted to rise to 100,000 annually in the UK by 2033. Current secondary preventative strategies focus on the patient’s physical state – overlooking Hospital-associated Deconditioning (HAD), the decline in patient wellbeing post-admission. To prevent HAD, a ‘Games Area’ (GA) was introduced in December 2023 as a service improvement. This study evaluates the GA’s effectiveness in preventing HAD, by assessing patient satisfaction.

Method: We evaluated all patients aged 65yrs or more during their post-operative rehabilitation for their FFF who were deemed fully weight-bearing and medically ready for discharge. The control group received the standard care provided by the ward’s multidisciplinary team, while the GA group also had access to the GA, where patients were encouraged to participate in activities with fellow inpatients. Activities included colouring, jigsaw puzzles and wordsearches. Data were collected via weekly questionnaires and medical records.

Results: Overall, 75 patients participated (38 in the control group, and 37 in the GA group). Patients in the GA group reported higher satisfaction ratings, with a mean score of 3.01 (SD = 0.406) out of 5, while the control group’s mean was 1.83 (SD = 0.279).

Conclusion: The GA acts as a simple, cost-effective intervention that can mitigate HAD by enriching the ward environment – hence, enhancing patient experience, and may improve patients’ physical, mental, and emotional health.

Background: Older adults are the fastest-growing and most sedentary group in society. With sedentary behaviour associated with deleterious health outcomes, reducing sedentary time may improve overall well-being. Adults aged ≥75 years are underrepresented in sedentary behaviour research, and tailored strategies to reduce sedentary time may be warranted for this subset of older adults. The development of an intervention to reduce sedentary behaviour in adults aged ≥75 years using co-production and behaviour change theory is reported.

Methods: Four co-production workshops with community-dwelling older adults aged ≥75 years were held between October-December 2022. The intervention development process was informed by the Behaviour Change Wheel (BCW) and Theoretical Domains Framework (TDF). Audio recordings and workshop notes were iteratively analysed, with findings used to inform subsequent workshops.

Results: The co-production group consisted of six community-dwelling older adults aged ≥75 years and two researchers. The developed intervention consists of four components (activity monitoring, educational material, group sessions and researcher follow-up), maps to 24 behaviour change techniques and targets barriers to reducing sedentary time. Participants were receptive of the co-production process.

Conclusions: Integrating co-production with the BCW can provide several benefits, with the BCW providing structure to the intervention development process, and co-production increasing the likelihood of the developed intervention being viewed as feasible by older adults. Furthermore, coding intervention components to the BCW may further our understanding of what approaches are successful or unsuccessful at influencing behavioural change. Transparent reporting of the intervention development process may benefit researchers developing interventions with older adults. Future research will pilot the co-produced intervention.

Introduction:

The Older Person's Assessment Unit (OPAU) Physiotherapy team have been collaborating with Breathe Arts Health Research (BAHR) to provide ‘Dance for Strength and Balance’ (DSAB) classes for Older Adults as an alternative to traditional, long-established Strength and Balance Group (SABG). Previous preliminary data established DSAB to be safe and effective in falls risk reduction for participants.

The primary aim of this service evaluation was to determine if DSAB is at least as effective as SABG for improving outcomes and reducing falls risk for OPAU patients.

Methods:

46 DSAB patients were cross-matched to 46 SABG patients over a 3-year period (10^th October 2019 – 24^th November 2022). Only those with full data sets and at least 80% class adherence were included. Participants were matched by age, gender, ethnicity and functional level at class entry, including their Timed Up and Go (TUAG) scores. 

Intervention effect was measured by change in performance of outcome measures including TUAG, Gait Speed (GS), Sit to Stands in 1 minute (STS), Turn 180 and Falls Efficacy Scale (FES-I).

Data was analysed using two-tailed t-tests.

Results:

Median age of participants was 79.5 years (48-95).

DSAB and SABG were beneficial to participants, with falls risk reduction demonstrated across the range of outcome measures.

There was no significant difference between groups for changes in TUAG, Gait Speed, Turn 180 and FES-I, with p-values >0.05 for all.

There was a significant difference in STS 1min (DSAB 0.63, SD 5.17; SABG 7, SD 6.72); t=-5.1, p=0.00

Conclusion:

DSAB classes were as effective as traditional SABG in targeting outcomes known to impact falls risk. The difference in STS 1min between groups is likely due to repetition of this as an exercise in SABG, and worth incorporating into DSAB. DSAB should remain an option for older adults aiming to reduce falls risk.

Background: The role of rehabilitation medicine in treating post-acute COVID-19 survivors is currently ill-defined. Recently developed evidence-based initiatives, such as Cochrane REH-COVER, aim to describe the management of COVID-19 patients, but the variance and overlap in intervention types result in clinical uncertainty.

Objective: To provide a summary of delivered rehabilitation services for COVID-19 patients during the pandemic.

Methods: We collected evidence from the full set of REH-COVER Rapid living Systematic Reviews between March 2020 and February 2022 using the supplementary tables. We included studies that reported treatments in rehabilitation care within hospital and community settings. We collected additional information on the intervention type, multidisciplinary care, use of routine data and length of rehabilitation to define our outcomes.

Results: Out of 580 REH-COVER studies, 63 met the inclusion criteria. In-hospital interventions were present in 43 (68%) of cases, 14 (22%) were performed in community or home settings, and 6 (10%) were not explicitly defined. 83% of studies were conducted during the initial wave of COVID-19 in the first half of 2020. Among the intervention categories, pulmonary rehabilitation (N=41, 65%) and physical therapy (N=38, 60%) were the most common. Multidisciplinary interventions were described in 33 (52%) of studies where the median rehabilitation time was 21 (14; 26) days compared to 10 (5; 15) days for single specialisms (p=0.005). However, 27 (43%) studies did not report these data. Works that utilised routine data reported a slightly extended treatment (20 [12; 33]) compared to those that did not (14 [7; 22] days).

Conclusions: There is currently a wide variation in descriptions of rehabilitation interventions for COVID-19 patients. The limited number of papers clearly describing the content and length of rehabilitation programmes reduce the ability to share best practices. Harmonising therapy descriptions could improve the quality and standardisation of research in COVID-19 rehabilitation.

Introduction

Older adults with multimorbidity can experience poor health-related quality of life (HRQOL). Yoga has the potential to improve HRQOL. The British Wheel of Yoga’s Gentle Years Yoga© (GYY) programme was developed for older adults with chronic conditions. We investigated the effectiveness and cost-effectiveness of the GYY programme in older adults with multimorbidity.

Method

This was a multi-site, individually randomised, open, superiority trial with embedded economic and process evaluations. Community-dwelling adults aged ≥65 years with ≥2 chronic conditions were recruited from general practices. All participants continued with usual care. Intervention participants were offered a 12-week GYY programme, which changed from face-to-face to online delivery during COVID-19. Most outcomes were participant reported. The primary outcome and endpoint was health-related utility measured using the EQ-5D-5L over 12 months. Secondary outcomes were HRQOL, depression, anxiety, loneliness, falls, adverse events and healthcare resource use.

Results

The mean age of the 454 participants was 73.5 years, 60.6% were female, and the median number of conditions was three. The primary analysis (n=422) showed no statistically or clinically significant difference in the EQ-5D-5L utility score over 12 months (adjusted mean difference of 0.020 favouring intervention; 95% CI -0.006 to 0.045, p=0.14). No statistically significant differences were observed in key secondary outcomes. No serious, related adverse events were reported. The intervention cost £80.85 more per participant (95% CI £76.73 to £84.97) than usual care, generated an additional 0.0178 quality-adjusted life years (QALYs) per participant (95% CI 0.0175 to 0.0180), and had a 79% probability of being cost-effective at a willingness-to-pay threshold of £20,000 per QALY gained.

Conclusion

The GYY programme showed no statistically significant benefits in terms of HRQOL, mental health, loneliness or falls. However, the intervention was safe, acceptable to most participants, and highly valued by some. The economic evaluation suggests that the intervention could be cost-effective.

Introduction

The health benefits of physical activity for older people are well recognised and include reduction in falls, improvement in frailty status and physical function. Nonetheless, physical inactivity remains a significant problem among older adults. This study aimed to determine the feasibility and acceptability of implementing online volunteer-led group exercise for community-dwelling older adults.

Methods

This pre-post mixed methods study was conducted among older adults attending community social clubs. Eligible participants were aged ≥ 65 years, able to walk independently, and able to provide written consent. The intervention consisted of a once weekly volunteer-led online group chair-based exercise. The primary outcomes were the feasibility and acceptability of the intervention. Secondary outcomes included physical activity levels measured using the Community Health Model Activities Program for Seniors (CHAMPS) questionnaire, functional status (Barthel Index), and health-related quality of life (EQ-5D-5L). Outcomes were measured at baseline and at 6 months.  Trials registration: NCT04672200.

Results

Nineteen volunteers were recruited, 15 completed training and 9 were retained (mean age 68 years, 7 female). Thirty participants (mean age 77 years, 27 female) received the intervention and attended 54% (IQR 37-67) of exercise sessions. One minor adverse event was reported. Participants had no significant changes in secondary outcome measures, with a trend towards improvement in physical activity levels. The intervention was acceptable to volunteers, participants, and staff. The seated exercises were perceived as safe, manageable and enjoyable. Volunteers were relatable role models providing positive vicarious experiences that improved participants confidence to exercise within a friendly, non-judgmental environment. Technological issues, or reluctance to learn how to use technology were barriers to the intervention. The social interactions and sense of belonging motivated participation. 

Conclusions

Trained volunteers can safely deliver online group exercise for community-dwelling older adults and the intervention was feasible and acceptable to older adults, volunteers and club staff.