Die Problematik sedentären Verhaltens hospitalisierter Demenzpatienten – Entwicklung eines lebensstil-integrierten Bewegungsansatzes zur Steigerung der körperlichen Aktivität

Thema der vorliegenden Arbeit ist die Beschreibung sedentären Verhaltens und iatrogener Immobilität ospitalisierter, geriatrischer Patienten mit beginnender bis mittelschwerer kognitiver Einschränkung. Die Einflüsse intramuraler Strukturen sowie immobilisierender Faktoren der geriatrischen Akutstation sollen dabei untersucht werden. Darüber hinaus steht die Entwicklung eines in den Klinikalltag integrierbaren Übungsansatzes und der damit zusammenhängenden Beibehaltung der relevanten motorischen Leistungen, wie Kraft, Ausdauer und Gleichgewicht, während eines Krankenhausaufenthaltes sowie einem Aufenthalt in der stationären Rehabilitation im Fokus der Untersuchung. Die Möglichkeit der intersektoralen Fortsetzung des Trainingsprogrammes nach Entlassung ist zukünftig eine zu berücksichtigende Komponente. Manuskript 1 zeigt eine systematische Analyse der Wirksamkeit von lebensstilintegriertem funktionalem Training zur Verbesserung motorischer Funktionen bei älteren Erwachsenen und möglichen Vorteilen dieses Interventionstyps im Vergleich zu strukturierten Trainingsansätzen (Stand 2018). Während Programme, die beide Ansätze kombinieren bereits im institutionellen Umfeld mit positiven Effekten bewertet werden konnten, sind bei anderen Zielgruppen und Umfeldern kaum Erkenntnisse vorhanden. Der lebensstilintegrierte funktionelle Trainingsansatz stellt eine vielversprechende und ressourceneffiziente Alternative zu strukturiertem Training dar und kann darüber hinaus komplementär und vermutlich intersektoral nach Entlassung eingesetzt werden. Manuskript 2 stellt die erste Untersuchung eines alltagsintegrierten funktionellen Trainingsansatzes mit kognitiv eingeschränkten, geriatrischen Rehabilitationspatienten dar. Funktionelle Übungen aus dem originalen LiFE (Lifestyle-integrated functional exercise)-Programm wurden hierbei in der Zielgruppe evaluiert. Die nachgewiesenen Bodeneffekte wiesen auf einen zu hohen Schwierigkeitsgrad der Übungen hin. Dies führte zu der Entscheidung die Übungen anzupassen ehe eine weitere Testung auf der geriatrischen Akutstation mit einer noch vulnerableren Patientengruppe stattfand. Manuskript 3 ist eine systematische Analyse geriatrischer Assessments hinsichtlich ihrer Eignung zur Messung der Effekte unterschiedlicher frührehabilitativer Interventionen auf der geriatrischen Akutstation. Es zeigt, dass die Auswahl der Ergebnisparameter spezifisch mit den Interventionsinhalten in Zusammenhang gebracht werden muss, da sie einen Schlüsselfaktor für das Auffinden von Interventionseffekten der Frührehabilitation bei geriatrischen Patienten auf der Akutstation darstellt. Eine unangemessene Auswahl von Outcome-Parametern und Tests kann sonst zu inkonsistenten Ergebnissen hinsichtlich der Wirksamkeit einer frührehabilitativen Intervention führen. Manuskript 4 beinhaltet die Analyse der intramuralen Strukturen, Prozesse und häufiger iatrogener Faktoren, die eine Immobilisation der Patienten begünstigen. Mittels einer teilnehmenden Beobachtung sowie Interviews mit den auf der Station tätigen Berufsgruppen wurden Tagesroutinen und Abläufe erfasst und analysiert

Early inpatient rehabilitation for acutely hospitalized older patients: a systematic review of outcome measures

Background: Selecting appropriate outcome measures for vulnerable, multimorbid, older patients with acute and chronic impairments poses specific challenges, which may have caused inconsistent findings of previous intervention trials on early inpatient rehabilitation in acutely hospitalized older patients. The aim of this review was to describe primary outcome measures that have been used in randomized controlled trials (RCTs) on early rehabilitation in acutely hospitalized older patients, to analyze their matching, and to evaluate the effects of matching on the main findings of these RCTs. Methods: A systematic literature search was conducted in PubMed, Cochrane CENTRAL, CINAHL, and PEDro databases. Additional studies were identified through reference and citation tracking. Inclusion criteria were: RCT, patients aged ≥65 years, admission to an acute hospital medical ward (but not to an intensive medical care unit), physical exercise intervention (also as part of multidisciplinary programs), and primary outcome measure during hospitalization. Two independent reviewers extracted the data, assessed the methodological quality, and analyzed the matching of primary outcome measures to the intervention, study sample, and setting. Main study findings were related to the results of the matching procedure. Results: Twenty-eight articles reporting on 24 studies were included. A total of 33 different primary outcome measures were identified, which were grouped into six categories: functional status, mobility status, hospital outcomes, adverse clinical events, psychological status, and cognitive functioning. Outcome measures differed considerably within each category and showed a large heterogeneity in their matching to the intervention, study sample, and setting. Outcome measures that specifically matched the intervention contents were more likely to document intervention-induced benefits. Mobility instruments seemed to be the most sensitive outcome measures to reveal such benefits. Conclusions: This review highlights that the selection of outcome measures has to be highly specific to the intervention contents as this is a key factor to reveal benefits attributable to early rehabilitation in acutely hospitalized older patients. Inappropriate selection of outcome measures may represent a major cause of inconsistent findings reported on the effectiveness of early rehabilitation in this setting. Trial registration: PROSPERO CRD42017063978

Eine Pilotbeobachtungsstudie zur Analyse von (In‑)Aktivität und Gründen sedentären Verhaltens kognitiv eingeschränkter, geriatrischer Akutpatienten

Background and objective:Mobility decline and worsening of the cognitive status are all too often the result of acute hospital treatment in older patients. This is particularly pronounced in patients with pre-existing cognitive impairment. This study strived to analyze the routines of geriatric acute care and identify reasons and triggers for sedentary behavior during acute hospitalization of cognitively impaired inpatients.Methods and patients:A sample of 20 moderately cognitively impaired geriatric inpatients (average age 84 years) were recruited on an acute care ward. Information on persons attending the patient, daytime, location, context, patient’s activity behavior and difficulty of action were collected by behavioral mapping over a period of 35 1‑min timeslots and extrapolated to a period of 525 min. Routines were further analyzed via semi-structured interviews with five healthcare professionals (HCP).Results:Relevant relations between various categorical and ordinal variables, such as patients’ activity behavior, persons attending the patient, daytime, location, difficulty of action and contextual factors were found. Extrapolated data showed that patients spent 396.9 min (75%) in their room, 342.0 min (65%) were spent alone and 236.2 min (45%) lying in bed. The time patients spent alone was grossly underestimated by HCP.Conclusion:Time spent without company, lacking meaningful activities and continuous bedridden periods due to missing demands to leave the room might have led to time spent inactive and alone. These seem to be strong predictors for sedentariness. Routines of acute care should be reorganized to increase physical activity and thereby reduce sedentary behavior of this patient group.publishe

Feasibility and Effectiveness of Intervention Programmes Integrating Functional Exercise into Daily Life of Older Adults:A Systematic Review

Background: Traditionally, exercise programmes for improving functional performance and reducing falls are organised as structured sessions. An alternative approach of integrating functional exercises into everyday tasks has emerged in recent years. Objectives: Summarising the current evidence for the feasibility and effectiveness of interventions integrating functional exercise into daily life. Methods: A systematic literature search was conducted including articles based on the following criteria: (1) individuals ≥60 years; (2) intervention studies of randomised controlled trials (RCTs) and non-randomised studies (NRS); (3) using a lifestyle-integrated approach; (4) using functional exercises to improve strength, balance, or physical functioning; and (5) reporting outcomes on feasibility and/or effectiveness. Methodological quality of RCTs was evaluated using the PEDro scale. Results: Of 4,415 articles identified from 6 databases, 14 (6 RCTs) met the inclusion criteria. RCT quality was moderate to good. Intervention concepts included (1) the Lifestyle-integrated Functional Exercise (LiFE) programme integrating exercises into everyday activities and (2) combined programmes using integrated and structured training. Three RCTs evaluated LiFE in community dwellers and reported significantly improved balance, strength, and functional performance compared with controls receiving either no intervention, or low-intensity exercise, or structured exercise. Two of these RCTs reported a significant reduction in fall rate compared with controls receiving either no intervention or low-intensity exercise. Three RCTs compared combined programmes with usual care in institutionalised settings and reported improvements for some (balance, functional performance), but not all (strength, falls) outcomes. NRS showed behavioural change related to LiFE and feasibility in more impaired populations. One NRS comparing a combined home-based programme to a gym-based programme reported greater sustainability of effects in the combined programme. Conclusions: This review provides evidence for the effectiveness of integrated training for improving motor performances in older adults. Single studies suggest advantages of integrated compared with structured training. Combined programmes are positively evaluated in institutionalised settings, while little evidence exists in other populations. In summary, the approach of integrating functional exercise into daily life represents a promising alternative or complement to structured exercise programmes. However, more RCTs are needed to evaluate this concept in different target populations and the potential for inducing behavioural change.</p

The Lifestyle-integrated Functional Exercise (LiFE) program and its modifications : a narrative review

Lifestyle-integrated exercise is a promising approach to increase adherence levels of older adults compared to structured exercise programs as it saves time and effort and supports older adults in preventing falls and functional decline. The Lifestyle-integrated Functional Exercise (LiFE) program embodies this approach by integrating physical activity, balance, and strength activities into daily tasks of community-dwelling older adults aged 70+. A randomized controlled trial shows strong effectiveness of the original, resource-intensive one-on-one format of the LiFE program in terms of reducing falls, improving motor performance, and increasing physical activity. The positive effects of the original LiFE program have yet stimulated adaptions to group-based and information and communications technology-based formats, to younger seniors, for multicomponent interventions, and to populations with disabilities which resulted in 16 known studies about LiFE modifications. Evidence for the effectiveness of specific LiFE modifications exists for four programs, while seven adaptions are in the feasibility stage and one is still in the early development phase. A decade of existing LiFE research is summarized in this narrative review that, to the best of our knowledge, does not exist until now. The aim of this article is (1) to provide an overview of the number of LiFE modifications and their specifications, (2) to describe the current evidence regarding feasibility and effectiveness, and (3) to present challenges and potential of the different LiFE modifications. All adaptions of the LiFE program embody the benefits of the lifestyle-integrated approach and enable an enhancement of the successful LiFE concept.publishe