Trial lecture title: What is important to consider when developing, implementing and evaluating an intervention to maintain or increase physical function and health-related quality of life for older adults after discharge from hospital?
Ordinary opponents:
- First opponent: Professor Lars Nyber, Luleå University of Technology
- Second opponent: Associate Professor Guro Birgitte Stene, Norwegian University of Science and Technology (NTNU)
- Leader of the committee: Professor Anne Lund, OsloMet
Leader of the public defense is Associate Professor Kirsti Riiser, OsloMet.
The main supervisor is Associate Professor Therese Brovold, OsloMet and the co-supervisor is Head of Studies Karin Hesseberg, OsloMet.
Thesis abstract
Worldwide, inactivity and reduced physical function in older people during and after hospitalisation represent a substantial health burden.
Although studies have shown that many older people have declined physical function and reduced health-related quality of life (HRQOL) after discharge from hospital, knowledge about effective interventions for this population is still scarce.
Effective interventions to prevent decline in physical function and reduction in HRQOL in older people after discharge from hospital are an important contribution to healthy ageing.
Aims
The first goal of this PhD project was to describe physical performance, HRQOL and other characteristics in older people with or at risk of mobility disability after discharge from hospital. In addition, we wanted to explore the relationship between these factors.
The second goal was to evaluate the effects of a group-based multicomponent high-intensity exercise programme on physical function and HRQOL in this population, both immediately after the end of the intervention and four months later.
Methods
This thesis consists of three papers, in which two different designs are employed. The first paper presents a study with a cross-sectional observational design. In the second and third papers, a single-blinded parallel-group randomised controlled trial (RCT), including a follow-up at four months and eight months is presented.
The participants in all three studies were 89 older adults admitted at medical wards at Diakonhjemmet Hospital because of acute illness between September 2016 and May 2019. Inclusion criteria were over 65 years, risk of mobility disability (defined as: score ≤ 9 on the Short Physical Performance Battery (SPPB) while inpatient), community-dwelling, being able to walk with or without a walking aid and being able to communicate in Norwegian.
Exclusion criteria were life expectancy below eight months, a Mini-Mental State Examination score below 20, medical contraindications to exercise or participation in a structured exercise programme more than twice a week prior to admission.
The intervention group exercised to music in groups of two to 10 participants, one hour for twice a week for four months. The aim of the exercise programme was to improve endurance, strength in the lower extremities, balance and flexibility. The exercise programme was based on the Norwegian Ullevaal model and the Swedish HIFE (High-Intensity Functional Exercises) programme.
All the participants were encouraged to be physically active and exercise according to the recommendations from the World Health Organization. Assessments were carried out at baseline, at the end of the intervention at four months and at eight months (four months postintervention). The primary outcome-function was measured by the SPPB.
Physical function was also measured by the Berg Balance Scale, the six-minute walking test, grip strength and body mass index. HRQOL was measured by the Short-Form 36 Health Survey (SF-36). Background variables and information on physical activity (measured by the International Physical Activity Questionnaire - Short Form) were also collected. Attendance to the intervention was registered, in addition to harms during the intervention sessions.
Results
Eighty-nine participants (65–89 years, 49 percent female) were included. Baseline testing was conducted median 49 (25 percentile, 75 percentile) (26, 116) days after discharge.
The participants had reduced physical function and HRQOL compared with Norwegian norm values for older adults. Paper I shows that when controlled for age, gender, education and comorbidity, better physical function was associated with better physical HRQOL.
Paper II shows that there was a clinically relevant but not statistically significant difference between the groups in favour of the intervention group in the main outcome of physical function (SPPB) after the intervention.
In addition, there was a statistically significant and clinically relevant difference between the groups in favour of the intervention group in physical capacity, as measured by the six-minute walk test, as well as physical HRQOL.
Paper III shows that there was a clinically relevant difference between the groups in favour of the intervention group in SPPB after eight months (four months postintervention). This difference was not statistically significant.
Further, there was a statistically significant and clinically relevant difference between the groups in favour of the intervention group, in physical capacity and physical HRQOL. No statistically significant or clinically relevant differences between the groups were found in mental HRQOL or the other measures of physical function, either at the end of intervention or at the eight-month follow-up.
Conclusions
Patients with increased risk of functional impairment after discharge from hospital suffer a high degree of comorbidity, reduced physical function and HRQOL. In the sample, there was a significant association between physical function and physical HRQOL.
A group-based exercise programme can improve physical capacity and physical HRQOL both in the short term and longer term. There were few adverse events during the exercise sessions; hence, the programme can be assumed to be safe for this population. There is a need for more research to further develop good health services for this vulnerable group of older individuals.
