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Project

IMPROVING FUNCTIONAL PERFORMANCE AND DAILY ACTIVITY OF THE HOSPITALIZED GERIATRIC REHABILITATION PATIENT

Background:

Worldwide people are living longer and all countries face major organizational and socio-economic challenges in healthy ageing. Independent living is an important health issue and even more challenging for the geriatric patient. The geriatric patient is characterized by multimorbidity and a clinically recognizable state of increased vulnerability termed frailty: an aging-associated decline in reserve and function across multiple physiologic systems.

Independent living is compromised by hospitalization in older persons as it mostly results in functional decline. A geriatric rehabilitation ward aims at restoring functional independence. Patients are admitted with different pathological conditions such as stroke, fractures, post-operative functional decline. Functional decline within hospitalization can be explained by a diminished capacity to perform activities of daily living (ADL), like sit to stand, transferring in and out of bed, and walking. ADL’s are multicomponent activities requiring strength and power, balance and also speed and endurance.

Literature provides information on how to train single aspects of functional performance, like strength or balance. However little is known about the effect of multicomponent exercise programs for geriatric inpatients with (multi)pathologies on functional performance in a rehabilitation settings.
On our geriatric rehabilitation ward an intensive multicomponent physical therapy week program with the aim to improve functional performance of the geriatric inpatient has been implemented: the Geriatric Activation Program Pellenberg (GAPP). We developed GAPP since 2015 based on clinical guidelines and recent scientific literature and GAPP consists of exercises to increase muscle strength and power, balance, (gait)speed, functional training and group sessions with all components.

Even with a structured multicomponent exercise program, therapy time spent with patients is limited and a vast amount of rehabilitation time and possibilities is lost on the rehabilitation ward. Evidence suggests that a caregiver might play a key role in maintaining functional performance in discharged patients or in decreasing the readmission rate for older adults due to inactivity. Caregiver involvement in exercise programs might also be beneficial during hospitalization.

However 17% of the Flemish people live alone, of which 40% is 65 or older. Consequently other means to increase activity need to be explored when no care-giver is available. Exergaming devices are increasingly popular and their health benefits have been explored in literature, even in the frail population. The SilverFit is one example of an exergaming device designed specifically for use by older people, with a choice of physical and cognitive exercise. The exercises can be accommodated to suit both the physical and cognitive level, even for patients with a very low level. 

Aims:

Aim one: to study the patient related factors that increase functional performance of geriatric inpatients within the GAPP, in an observational study.
Aim two: a systematic literature review on caregiver involvement in rehabilitation programs and the effect on functional performance of older adults. And a scoping review of the components of exergaming devices for geriatric inpatients and comparing of these findings with the components available within SilverFit.
Aim three: feasibility of the intervention with the caregiver (GAPP+CARE) and the intervention with the exergaming device (GAPP+SILVERFIT).
Aim four: to study the additional effect of caregiver involvement or an exergaming device on functional performance of geriatric inpatients within the GAPP, in a randomized controlled trial.

Methodology:

Aim one:
1.1 Observational study of the effect of four weeks of GAPP on functional performance of geriatric inpatients (March 2017 – March 2019). Geriatric inpatients campus Pellenberg who are able to walk 10m with support, are medically stable and have a probable stay of at least four weeks, will be included. The intervention (four weeks GAPP) will be provided by the physical therapists of the ward, including myself (PTs). Functional performance will be measured by standard outcome measures including the basic-ADL or Katz-scale, the Berg Balance Scale (BBS) and the 10mwalk test (10MWT). These outcome measures will be obtained by the PTs and master thesis students of KU Leuven (MTSs): at baseline, two and four weeks. Ethical approval has been obtained of the Medical Ethics Committee of the Leuven University Hospitals.
1.2 Through data analysis we will: 1) examine if there are significant and clinical important improvements of functional performance, 2) examine what the characteristics (like cognitive state, comorbidities, functional performance level at the start of GAPP) are of responders and non-responders (based on clinical important improvements in functional performance), and 3) construct a prediction model for successful rehabilitation, in collaboration with biomedical statistics department.

Aim two:  
2.1 Conduct a systematic literature review of caregivers involvement in rehabilitation programs and the effect on functional performance of older adults. J Vreven and myself will conduct a thorough search in PubMed, Cochrane, Cinahl, Web of Sciences, Embase. Narrative synthesis and meta-analysis of the data is planned. Work on this review started in January 2018 and the review protocol has been registered in the International Prospective Register of Systematic Reviews: PROSPERO 2018 CRD42018091798.
2.2 Conduct a scoping literature review of the components of commercially available exergaming devices for geriatric inpatients and comparing of these findings with the components available within SilverFit.

Aim three:
3.1 Development of GAPP+CARE. Develop a program that includes education and involvement of caregivers in the GAPP. This program will be developed based on the insights from the review above and a consensus by caregivers, patients and experts in geriatric rehabilitation.
3.2 Development of GAPP+SILVERFIT. Develop a program that includes an exergaming device (SilverFit) in the GAPP. This program will be developed based on the insights from the literature search above and a consensus by caregivers, patients and experts in geriatric rehabilitation.
3.3 Design a clinical trial according to Medical Research Council framework for the development and evaluation of complex interventions and in consensus with experts in geriatric rehabilitation medicine.
3.4 Pilot study of GAPP+CARE and GAPP+SILVERFIT. A mixed-methods evaluation study will be conducted in order to see if the two programs are feasible and acceptable by the patients, caregivers and healthcare staff of the ward.

Aim four:
Prospective randomized controlled trial with mixed methods evaluation and with three arms: GAPP, GAPP+CARE and GAPP+SILVERFIT. Geriatric inpatients of campus Pellenberg who are able to walk 10m with support and who are medically stable will be included. Based on a sample size calculation using the variance of the Berg Balance Scale (BBS) of the preliminary results of the observational study, a predicted difference in mean BBS of 6 between GAPP and GAPP+CARE, and dropout rate of 25%, we aim to include 28 participants in each group. The Intervention will be either GAPP, GAPP+CARE or GAPP+SILVERFIT.
4.1 Outcome measures will be obtained by a blinded assessor, at baseline, before discharge, 1 month and 3 months after discharge.
4.2 Factors contributing on acceptance of GAPP+CARE and GAPP+SILVERFIT programs will be investigated through a structured interview of the participants, their caregivers and healthcare staff of the ward.

Conclusion:
This PhD project aims to investigate if GAPP is beneficial in improving functional performance in geriatric patients with different pathologies while hospitalized. Additionally, we want to study the effect on functional performance of caregiver involvement in the exercise program during and after hospitalization. For patients without a caregiver we want to study whether the SilverFit has an additional effect on functional performance and if this is comparable with the effect of caregiver involvement.

Date:24 May 2018 →  2 May 2022
Keywords:functional performance, geriatric patient, exercise program
Disciplines:Gerontology and geriatrics, Nursing, Education curriculum
Project type:PhD project