jfa journal

AND option

OR option

COULD A TAILORED EXERCISE INTERVENTION FOR HOSPITALISED OLDER ADULTS HAVE A ROLE IN THE RESOLUTION OF DELIRIUM? SECONDARY ANALYSIS OF A RANDOMISED CLINICAL TRIAL

 

N. Martinez Velilla1,2, L. Lozano-Vicario1, M.L. Sáez de Asteasu1,2, F. Zambom-Ferraresi1,2, A. Galbete1, M. Sanchez-Latorre1, M. Izquierdo1,2

 

1. Navarrabiomed, Hospital Universitario de Navarra (HUN), Universidad Pública de Navarra (UPNA), IdiSNA, Pamplona, Spain; 2. CIBER of Frailty and Healthy Aging (CIBERFES), Instituto de Salud Carlos III, Madrid, Spain.

Corresponding Author: Nicolas Martinez Velilla, Navarrabiomed, Complejo Hospitalario de Navarra (CHN), Universidad Pública de Navarra (UPNA), IdiSNA, Pamplona, Spain, nicolas.martinez.velilla@navarra.es

J Frailty Aging 2022;in press
Published online October 16, 2022, http://dx.doi.org/10.14283/jfa.2022.60

 


Abstract

Delirium is a transient neurocognitive disorder. Nonpharmacological measures can be efficient in reducing the incidence and intensity of delirium, but there is a paucity of evidence when using a physical exercise program exclusively. This was a secondary analysis of a randomised clinical trial that provided evidence on the functional and cognitive benefits of an individualised exercise intervention in hospitalised older adults. Of the 370 patients who participated in the trial, 17.1% in the intervention group had delirium and 12.1% in the control group. After the exercise intervention, 84.6% of the patients in the intervention group showed improvement in delirium compared to 68.4% of patients in the control group. Despite the fluctuating nature of delirium,we show that it is feasible to establish individualised exercise interventions in hospitalised geriatric patients in the periods when patients are able to cooperate. Baseline functional status, measured by the Barthel Index, is a clinical marker that could help to identify those who will benefit most.

Key words: Delirium, exercise, geriatric, hospital.


 

Introduction

Delirium is a transient neurocognitive disorder characterised by an acute onset and fluctuating course, inattention, cognitive dysfunction, and behavioural abnormalities (1), with a prevalence ranging from 15–75%, depending on the clinical setting, although discharge data underreport the occurrence of delirium (2). The short- and long-term consequences have a high impact in older adults and are associated with poorer clinical outcomes and utilisation of health-related resources. This population, especially those who are frail, is particularly vulnerable to the development of delirium and its consequences (3).
Numerous pharmacological and nonpharmacological alternatives have been explored, and despite the failure to demonstrate the efficacy of drugs in the management of delirium, nonpharmacological measures such as those implemented by the multicomponent Hospital Elder Life Program (HELP) appear to be more efficient and reduce the incidence of delirium by 43% compared to usual care (4, 5). One element of these multicomponent strategies is to encourage physical activity in both medical and surgical patients. However, there is a paucity of evidence when using a physical exercise program exclusively.
This type of intervention is a real challenge, despite the theoretical benefits. Implementing exercise in patients with hyperactive delirium is very difficult in the acute phase of delirium, but as it is a fluctuating phenomenon, it is feasible that in periods when the patient can actively or passively collaborate, individualised interventions could add synergistic benefits even more intensively than just promoting physical activity.
Previously, our team developed a randomised clinical trial in which we showed the important functional and cognitive benefits of this type of strategy in hospitalised patients, but we failed to demonstrate any benefit in the course of delirium, probably due to a selection bias, since the patients had to collaborate and understand the instructions (5). However, our subjective perception was that exercise could be beneficial. We therefore specifically explored what effects exercise alone had on patients in the intervention group to explore the theoretical possibilities.

 

Methods

This was a secondary analysis of a randomised clinical trial (NCT02300896) that provided evidence on the functional and cognitive benefits of an individualised exercise intervention in hospitalised older adults (5). We initially analysed the patients in the intervention group who improved delirium with those who did not, and posteriorly explored the associated baseline characteristics and clinical courses of those patients whose delirium improved in both groups.

 

Results

Of the 370 patients who participated in the trial, 17.1% in the intervention group had delirium and 12.1% in the control group. After the exercise intervention, 84.6% of the patients in the intervention group showed improvement compared to 68.4% of patients in the control group, with no statistically significant differences in the baseline characteristics of these patients. When we compared the patients with delirium who improved in both groups, we found no obvious phenotypic differences, except that those patients for whom exercise had a beneficial effect on delirium had a better Barthel index (82.6 vs. 70.8). Additionally, those patients who showed an improvement in delirium also showed improvements in the Short Performance Physical Battery, Yesavage Depression Scale and Quality of Life scale (Table 1).

Table 1. Changes in outcomes within patients that improve Delirium

1. Mann-Whitney U test; QoL: Quality of Life; SPPB: Short Physical Performance Battery

 

Discussion

Despite the fluctuating nature of delirium, it is feasible to establish individualised exercise interventions in hospitalised geriatric patients in the periods when patients are able to cooperate. Baseline functional status, measured by the Barthel Index, is a clinical marker that could help to identify those who will benefit most, which may also suggest that the degree of frailty is a decisive factor in reversing not only functional status but also delirium. The improvement of delirium in those patients who participated in the intervention group brought additional parallel benefits that should be considered within the broader framework of the role of physical activity as a fundamental tool in the nonpharmacological management of numerous diseases and clinical situations.
Nonpharmacological interventions in patients with delirium can be individualised according to the baseline profile, and the impact of delirium improvement in patients receiving an exercise intervention occurs in parallel with functional, affective and quality of life improvements. The type of delirium also determines the response; in our case most of the cases were hypoactive.
To the best of our knowledge, there is no previous medical literature applying this type of intervention. There are pre-habilitation programs for surgical patients or intensive care patients, and the results are in line with ours (6). This sub-analysis has numerous limitations, such as the small number of included patients and the secondary nature of the analysis. However, we believe that it is important to consider such individualised strategies given the potential benefits, despite the very difficult challenges that such interventions may pose for geriatric medical or surgical hospitalised patients with any type of delirium. Given the great impact of non-pharmacological measures in the management of delirium, it is necessary to explore the possibility of customising specific programs through individualised exercise in the same way as other aspects of personalised medicine are being developed.

 

Conflicts of Interest: All authors declare no Conflicts of Interest related to this manuscript.

Ethical standard: The study followed the principles of the Declaration of Helsinki and was approved by the Complejo Hospitalario de Navarra Clinical Research Ethics Committee. All patients or their legal representatives provided written informed consent. There was no financial compensation.

Funding: NM-V received funding from “la Caixa” Foundation (ID 100010434), under agreement LCF/PR/PR15/51100006.

 

References

1. Slooter AJC, Otte WM, Devlin JW, et al. Updated nomenclature of delirium and acute encephalopathy: statement of ten Societies. Intensive Care Med 2020 465. 2020;46(5):1020-1022. doi:10.1007/S00134-019-05907-4.
2. Casey P, Cross W, Mart MWS, Baldwin C, Riddell K, Dārziņš P. Hospital discharge data under-reports delirium occurrence: results from a point prevalence survey of delirium in a major Australian health service. Intern Med J. 2019;49(3):338-344. doi:10.1111/IMJ.14066.
3. Inouye SK, Bogardus S. T. J, Charpentier PA, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med. 1999;340(9):669-676. doi:10.1056/NEJM199903043400901.
4. Burton JK, Craig LE, Yong SQ, et al. Non-pharmacological interventions for preventing delirium in hospitalised non-ICU patients. Cochrane Database Syst Rev. 2021;2021(7). doi:10.1002/14651858.CD013307.PUB2/MEDIA/CDSR/CD013307/REL0002/CD013307/IMAGE_N/NCD013307-CMP-008.01.SVG.
5. N Martinez-Velilla, A Casas-Herrero, F Zambom-Ferraresi, et al. Effect of Exercise Intervention on Functional Decline in Very Elderly Patients During Acute Hospitalization: A Randomized Clinical Trial. JAMA Intern Med. 2019;179(1):28-36. doi:10.1001/JAMAINTERNMED.2018.4869.
6. Gual N, García-Salmones M, Brítez L, et al. The role of physical exercise and rehabilitation in delirium. Eur Geriatr Med. 2020;11(1):83. doi:10.1007/S41999-020-00290-6.

© Serdi 2022