Key messages
There may be a benefit in some exercise treatments for older adults during an unplanned hospital stay, but we cannot be certain. Exercise interventions probably do not cause harm; we found no increase in the risk of falling for older adults when they were in hospital.
What is the problem?
Older adults often lose the ability to carry out their usual day-to-day activities following an unplanned hospital admission. One reason for this is that people are less active in hospital than they would normally be at home when well. Being inactive in hospital may also contribute to other problems, such as a greater risk of becoming confused, difficulty moving about and a reduced quality of life when discharged from hospital.
What did we want to find out?
Does helping older people to exercise whilst in hospital improve their recovery and ability to manage their usual day-to-day activities when they are discharged?
What did we do?
We searched medical databases for studies that compared exercise programmes to usual care (with or without a sham (fake) intervention). Usual care was the treatment that would normally be given to patients who were not part of the research studies. Two studies used sham interventions in addition to usual care. The sham interventions were not designed to impact the patients' recovery, but to add a level of trustworthiness to the research studies.
What did we find?
We found 24 studies with 7511 participants, of whom 58% were women. The average ages of participants in the studies ranged from 73 to 88 years. Thirteen studies were from Europe, six from Oceania, four from North America and one from South America. Participants were admitted to hospital with a wide range of illnesses or medical conditions such as infections, heart failure, kidney failure, bleeding in the stomach or gut, and vertigo.
The types of exercise treatments and the amount of exercise that people were asked to do varied considerably. Nine studies classified the exercise treatment as rehabilitation-related activities (treatments designed to increase physical activity, but that did not follow a specific exercise programme). Six studies consisted of structured exercise (a specific exercise programme that every person in the treatment group performed). The exercise may have varied depending on the individual person's ability, but the treatment did not involve progressive strength training. With progressive strength training people exercise their muscles against some type of resistance that is progressively increased as their strength improves. Nine studies provided an element of progressive resistance training.
Main findings
Exercise programmes may result in little to no difference compared to usual care in people's ability to carry out usual day-to-day activities (scoring 1.8% better, ranging from 0.43% worse to 4.12% better).
Compared to usual care (with or without sham treatments), exercise treatment resulted in 6.5% better (0.2% better to 13.1% better) scores in the ability to walk and move around. However, due to the quality of evidence we are very uncertain as to the true effect of exercise programmes.
Ten per cent fewer people (42% fewer to 41% more) who received exercise programmes compared to those who received usual care experienced new confusion during hospitalisation, but we are uncertain about the results.
No studies measured whether the people who took part in the research thought that the exercise treatment was successful.
Exercise programmes may not clinically improve quality of life at discharge from hospital compared to usual care (6.0% better, ranging from 0.9% better to 15.5% better).
Exercise programmes probably make little difference to the number of people who fall during hospitalisation compared to usual care (1% fewer people, ranging from 41% fewer to 65% more).
Two per cent more people (38% fewer to 68% more) who received exercise programmes became more unwell during hospitalisation compared to those who received usual care. However, due to the quality of evidence, we are very uncertain as to the true effect of exercise programmes.
We remain uncertain if any particular type of exercise provides more benefit than another.
What are the limitations of the evidence?
The quality of evidence was generally low or very low for most of the outcomes that we included in this review. Some studies were designed in a way that reduced the trustworthiness of their results, but there were also important differences between the findings of different studies and much uncertainty as to the true effect of the exercise treatments.
How up to date is the evidence?
This Cochrane Review is current to May 2021.
Exercise may make little difference to independence in activities of daily living or QoL, but probably does not result in more falls in older medical inpatients. We are uncertain about the effect of exercise on functional mobility, incidence of delirium and medical deterioration. Certainty of evidence was limited by risk of bias and inconsistency. Future primary research on the effect of exercise on acute hospitalisation could focus on more consistent and uniform reporting of participant's characteristics including their baseline level of functional ability, as well as exercise dose, intensity and adherence that may provide an insight into the reasons for the observed inconsistencies in findings.
Approximately 30% of hospitalised older adults experience hospital-associated functional decline. Exercise interventions that promote in-hospital activity may prevent deconditioning and thereby maintain physical function during hospitalisation. This is an update of a Cochrane Review first published in 2007.
To evaluate the benefits and harms of exercise interventions for acutely hospitalised older medical inpatients on functional ability, quality of life (QoL), participant global assessment of success and adverse events compared to usual care or a sham-control intervention.
We used standard, extensive Cochrane search methods. The latest search date was May 2021.
We included randomised or quasi-randomised controlled trials evaluating an in-hospital exercise intervention in people aged 65 years or older admitted to hospital with a general medical condition. We excluded people admitted for elective reasons or surgery.
We used standard Cochrane methods. Our major outcomes were 1. independence with activities of daily living; 2. functional mobility; 3. new incidence of delirium during hospitalisation; 4. QoL; 5. number of falls during hospitalisation; 6. medical deterioration during hospitalisation and 7. participant global assessment of success. Our minor outcomes were 8. death during hospitalisation; 9. musculoskeletal injuries during hospitalisation; 10. hospital length of stay; 11. new institutionalisation at hospital discharge; 12. hospital readmission and 13. walking performance. We used GRADE to assess certainty of evidence for each major outcome.
We categorised exercise interventions as: rehabilitation-related activities (interventions designed to increase physical activity or functional recovery, but did not follow a specified exercise protocol); structured exercise (interventions that included an exercise intervention protocol but did not include progressive resistance training); and progressive resistance exercise (interventions that included an element of progressive resistance training).
We included 24 studies (nine rehabilitation-related activity interventions, six structured exercise interventions and nine progressive resistance exercise interventions) with 7511 participants. All studies compared exercise interventions to usual care; two studies, in addition to usual care, used sham interventions. Mean ages ranged from 73 to 88 years, and 58% of participants were women.
Several studies were at high risk of bias. The most common domain assessed at high risk of bias was measurement of the outcome, and five studies (21%) were at high risk of bias arising from the randomisation process.
Exercise may have no clinically important effect on independence in activities of daily living at discharge from hospital compared to controls (16 studies, 5174 participants; low-certainty evidence). Five studies used the Barthel Index (scale: 0 to 100, higher scores representing greater independence). Mean scores at discharge in the control groups ranged from 42 to 96 points, and independence in activities of daily living was 1.8 points better (0.43 worse to 4.12 better) with exercise compared to controls. The minimally clinical important difference (MCID) is estimated to be 11 points.
We are uncertain regarding the effect of exercise on functional mobility at discharge from the hospital compared to controls (8 studies, 2369 participants; very low-certainty evidence). Three studies used the Short Physical Performance Battery (SPPB) (scale: 0 to 12, higher scores representing better function) to measure functional mobility. Mean scores at discharge in the control groups ranged from 3.7 to 4.9 points on the SPPB, and the estimated effect of the exercise interventions was 0.78 points better (0.02 worse to 1.57 better). A change of 1 point on the SPPB represents an MCID.
We are uncertain regarding the effect of exercise on the incidence of delirium during hospitalisation compared to controls (7 trials, 2088 participants; very low-certainty evidence). The incidence of delirium during hospitalisation was 88/1091 (81 per 1000) in the control group compared with 70/997 (73 per 1000; range 47 to 114) in the exercise group (RR 0.90, 95% CI 0.58 to 1.41).
Exercise interventions may result in a small clinically unimportant improvement in QoL at discharge from the hospital compared to controls (4 studies, 875 participants; low-certainty evidence). Mean QoL on the EuroQol 5 Dimensions (EQ-5D) visual analogue scale (VAS) (scale: 0 to 100, higher scores representing better QoL) ranged between 48.9 and 64.7 in the control group at discharge from the hospital, and QoL was 6.04 points better (0.9 better to 11.18 better) with exercise. A change of 10 points on the EQ-5D VAS represents an MCID.
No studies measured participant global assessment of success.
Exercise interventions did not affect the risk of falls during hospitalisation (moderate-certainty evidence). The incidence of falls was 31/899 (34 per 1000) in the control group compared with 31/888 (34 per 1000; range 20 to 57) in the exercise group (RR 0.99, 95% CI 0.59 to 1.65).
We are uncertain regarding the effect of exercise on the incidence of medical deterioration during hospitalisation (very low-certainty evidence). The incidence of medical deterioration in the control group was 101/1417 (71 per 1000) compared with 96/1313 (73 per 1000; range 44 to 120) in the exercise group (RR 1.02, 95% CI 0.62 to 1.68).
Subgroup analyses by different intervention categories and by the use of a sham intervention were not meaningfully different from the main analyses.