Читать книгу Pathy's Principles and Practice of Geriatric Medicine - Группа авторов - Страница 201

The traditional model of care for acute hospitalised older patients depends on a series of circumstances beyond the disease process that caused the hospital admission and usually worsens the hospitalisation outcome.^178‐180 Hospitalised older patients are often bedridden.^181,182 resulting in reduced functional and physiological reserves. Consequences arise at multiple levels, including functional loss, cognitive impairment, increased length of hospital stay, sarcopenia secondary to immobilisation, falls, frailty, institutionalisation, and mortality.^181,183,184 Although the typical patient profile has changed dramatically over the past century and is currently characterised by frailty, disability, multimorbidity, and polypharmacy in chronic patients, the hospital care model remains embedded in the previous century, which increases the risk of patients developing avoidable complications associated with hospitalisation. Exercise and early rehabilitation programmes are among the interventions through which functional decline is likely to be best prevented in older patients during hospitalisation.^185‐187

Healthcare systems are still poorly adapted to the needs of elderly patients, and low in‐hospital mobility is directly associated with functional deterioration at discharge and, even more so, at follow‐up.^188,189 In this context, physical exercise can play an essential role in preventing functional and cognitive decline during hospitalisation in the elderly.^5,190 The benefits of exercise have been clinically, biologically, and even economically confirmed,^179,190 making exercise a valuable addition to the therapeutic arsenal. Although only a few RCTs have examined the potential benefits of exercise training for acutely hospitalised elderly patients, the effects of in‐hospital exercise intervention on functional outcomes are promising.^{179,180,190‐192} Recently, Martínez‐Velilla et al.¹⁷⁹ and Saez de Asteasu et al.¹⁸⁰ showed that oldest‐old frail people improved overall functional capacity and cognition during acute hospitalisation when compared with usual care after an individualised multicomponent exercise training programme. The usual‐care group received habitual hospital care, which included physical rehabilitation when needed. For the intervention group, exercise training was programmed in two daily sessions (morning and evening) of 20 minutes duration over 5–7 consecutive days (including weekends), supervised by a qualified fitness specialist. Each session was performed in a room equipped ad hoc in the acute care of elderly (ACE) unit. Exercises were adapted from the Vivifrail multicomponent physical exercise programme to prevent weakness and falls^143‐145 (www.vivifrail.com). The resistance exercises were tailored to the individual’s functional capacity using variable resistance training machines aiming at 2 to 3 sets of 8 to 10 repetitions with a load equivalent to 30 to 60% of the 1‐repetition maximum. Participants performed three exercises involving mainly lower‐limb muscles (squats rising from a chair, leg press, and bilateral knee extension) and one involving the upper‐body musculature.¹³⁶ This contrasts with an earlier RCT showing no significant benefit of a simple in‐hospital mobility programme and a behavioural strategy to encourage mobility in older patients and their ability to perform ADLs after acute hospitalisation.¹⁸¹ These findings suggest that interventions beyond walking stimulation are needed to preserve or increase functional capacity in older patients during acute hospitalisation. This is likely because muscle mass tends to decrease in the elderly during hospitalisation, and muscle strength and muscle mass are associated with disability, morbidity, and mortality.¹⁹³ Therefore, an individualised physical exercise intervention including low‐moderate intensity progressive resistance training is an effective therapy to counteract the loss of muscle strength and mass that frequently occurs during hospitalisation.^179,180,194 Once discharged, however, progression to moderate‐high intensity resistance training is required to achieve the benefits shown in many of the randomised controlled trials referred to above,^{7,70,74,75,195,196} given the well‐described dose‐response effects related to intensity and adaptations to anabolic exercise.