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Original Study| Volume 22, ISSUE 12, P2432-2439.e1, December 2021

Geriatric Rehabilitation Inpatients Roam at Home! A Matched Cohort Study of Objectively Measured Physical Activity and Sedentary Behavior in Home-Based and Hospital-Based Settings

  • Keenan A. Ramsey
    Affiliations
    Department of Human Movement Sciences, @AgeAmsterdam, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands
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  • Paula Loveland
    Affiliations
    Department of Medicine and Aged Care, @AgeMelbourne, The Royal Melbourne Hospital, Parkville, Victoria, Australia
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  • Anna G.M. Rojer
    Affiliations
    Department of Human Movement Sciences, @AgeAmsterdam, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands
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  • Linda Denehy
    Affiliations
    Department of Physiotherapy, Melbourne School of Health Sciences, The University of Melbourne, Victoria, Australia
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  • Rose Goonan
    Affiliations
    Department of Medicine and Aged Care, @AgeMelbourne, The Royal Melbourne Hospital, Parkville, Victoria, Australia
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  • Celia Marston
    Affiliations
    Department of Medicine and Aged Care, @AgeMelbourne, The Royal Melbourne Hospital, Parkville, Victoria, Australia
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  • Jacqueline E. Kay
    Affiliations
    Department of Medicine and Aged Care, @AgeMelbourne, The Royal Melbourne Hospital, Parkville, Victoria, Australia
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  • Jacinta Brenan
    Affiliations
    Department of Medicine and Aged Care, @AgeMelbourne, The Royal Melbourne Hospital, Parkville, Victoria, Australia
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  • Marijke C. Trappenburg
    Affiliations
    Department of Internal Medicine, Amstelland Hospital, Amstelveen, the Netherlands

    Department of Internal Medicine, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands
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  • Wen Kwang Lim
    Affiliations
    Department of Medicine and Aged Care, @AgeMelbourne, The Royal Melbourne Hospital, Parkville, Victoria, Australia
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  • Esmee M. Reijnierse
    Affiliations
    Department of Medicine and Aged Care, @AgeMelbourne, The Royal Melbourne Hospital, Parkville, Victoria, Australia

    Department of Rehabilitation Medicine, Amsterdam UMC, VU University Medical Center, Amsterdam Movement Sciences, Amsterdam, the Netherlands
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  • Carel G.M. Meskers
    Affiliations
    Department of Human Movement Sciences, @AgeAmsterdam, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands

    Department of Rehabilitation Medicine, Amsterdam UMC, VU University Medical Center, Amsterdam Movement Sciences, Amsterdam, the Netherlands
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  • Andrea B. Maier
    Correspondence
    Address correspondence to Andrea B. Maier, MD, PhD, @Age, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, van der Boechorststraat 7, 1081 BT Amsterdam, the Netherlands.
    Affiliations
    Department of Human Movement Sciences, @AgeAmsterdam, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands

    Department of Medicine and Aged Care, @AgeMelbourne, The Royal Melbourne Hospital, Parkville, Victoria, Australia

    Healthy Longevity Translational Research Program, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Centre for Healthy Longevity, National University Health System, Singapore
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Open AccessPublished:May 19, 2021DOI:https://doi.org/10.1016/j.jamda.2021.04.018

      Abstract

      Objectives

      This study aimed to describe objectively measured physical activity and sedentary behavior in geriatric rehabilitation patients receiving care in the home-based compared to the hospital-based setting.

      Design

      Observational matched cohort study.

      Setting and Participants

      Home-based (patient's home) or hospital-based (ward) geriatric rehabilitation was delivered to inpatients within the REStORing health of acutely unwell adulTs (RESORT) observational, longitudinal cohort of the Royal Melbourne Hospital (Melbourne, Victoria, Australia).

      Methods

      Patients were asked to wear ActivPAL4 accelerometers for 1 week and were assessed by a comprehensive geriatric assessment at admission, discharge, and followed up after 3 months. Hospital-based patients were matched to home-based patients for sex and baseline physical function [Short Physical Performance Battery (SPPB), activities (instrumental) of daily living, and Clinical Frailty Scale]. Differences in patient characteristics and physical activity (total, standing and walking durations, number of steps and sit-to stand transitions) and sedentary behavior (total, sitting and lying durations) were assessed.

      Results

      A total of 159 patients were included: 18 home-based [mean age: 81.9 ± 8.6 years, 38.9% female, median (interquartile range [IQR]) SPPB: 7.0 (5.0-9.0)] and 141 hospital-based [mean age: 82.9 ± 7.8 years, 57.4% female, median (IQR) SPPB: 1.0 (0.0-4.0)] patients, of whom 18 were matched [mean age: 80.1 ± 7.4 years, 38.9% female, median (IQR) SPPB: 6.5 (4.8-10.0)]. Median physical activity measures were consistently higher in home-based patients compared to the total group of hospital-based patients. After matching, physical activity measures remained >2.4 times higher and were significantly different for all measures (total physical activity, standing and walking durations, and steps) except for sit-to-stand transitions. Sedentary behaviors were similar with home-based patients spending non-significantly more time sitting but significantly less time lying than hospital-based patients (matched and total).

      Conclusions and Implications

      Home-based inpatients are more physically active than hospital-based inpatients independent of matching for sex and baseline physical function, which supports home-based geriatric rehabilitation.

      Keywords

      Despite the goals of geriatric inpatient rehabilitation being to improve function, independence, and prevent adverse outcomes,
      • Bachmann S.
      • Finger C.
      • Huss A.
      • et al.
      Inpatient rehabilitation specifically designed for geriatric patients: Systematic review and meta-analysis of randomised controlled trials.
      low physical activity and high sedentary behavior are often the norm for hospitalized patients, independent of their mobility capacities.
      • Meesters J.
      • Conijn D.
      • Vermeulen H.M.
      • Vliet Vlieland T.P.M.
      Physical activity during hospitalization: Activities and preferences of adults versus older adults.
      • Brown C.J.
      • Redden D.T.
      • Flood K.L.
      • Allman R.M.
      The underrecognized epidemic of low mobility during hospitalization of older adults.
      • Fisher S.R.
      • Goodwin J.S.
      • Protas E.J.
      • et al.
      Ambulatory activity of older adults hospitalized with acute medical illness.
      Consequences may include hospital-associated functional decline, higher medical complications, and increased mortality.
      • Brown C.J.
      • Friedkin R.J.
      • Inouye S.K.
      Prevalence and outcomes of low mobility in hospitalized older patients.
      ,
      • Kortebein P.
      • Symons T.B.
      • Ferrando A.
      • et al.
      Functional impact of 10 days of bed rest in healthy older adults.
      Interventions to combat sedentary behavior often include early mobilization and the promotion of physical activity during hospitalization.
      • Peate I.
      Putting an end to pyjama paralysis: The benefits.
      ,
      • Scheerman K.
      • Raaijmakers K.
      • Otten R.H.J.
      • et al.
      Effect of physical interventions on physical performance and physical activity in older patients during hospitalization: A systematic review.
      However, perceptions of clinicians about tasks and responsibilities in physical activity promotion
      • Scheerman K.
      • Mesters J.W.
      • Borger J.N.
      • et al.
      Tasks and responsibilities in physical activity promotion of older patients during hospitalization: A nurse perspective.
      and the hospital environment and design itself (including serving meals in beds, presence of other patients, lack of destinations to walk to, and safety concerns) may physically and psychologically limit the participation in physical activity and encourage sedentary behavior.
      • Brown C.J.
      • Williams B.R.
      • Woodby L.L.
      • et al.
      Barriers to mobility during hospitalization from the perspectives of older patients and their nurses and physicians.
      Negative effects of hospitalization on physical activity
      • Shepperd S.
      • Doll H.
      • Angus R.M.
      • et al.
      Avoiding hospital admission through provision of hospital care at home: A systematic review and meta-analysis of individual patient data.
      may be mitigated through the delivery of hospital-equivalent care by multidisciplinary teams in the patient's own home instead, which is increasingly being employed by hospitals and is associated with higher patient satisfaction, lower costs, and fewer medical complications.
      • Caplan G.A.
      • Sulaiman N.S.
      • Mangin D.A.
      • et al.
      A meta-analysis of “hospital in the home.”.
      • Leff B.
      • Burton L.
      • Mader S.L.
      • et al.
      Comparison of functional outcomes associated with hospital at home care and traditional acute hospital care.
      • Leff B.
      • Burton L.
      • Mader S.L.
      • et al.
      Hospital at home: Feasibility and outcomes of a program to provide hospital-level care at home for acutely III older patients.
      Home-based care may also provide more opportunities and incentives (and may even require) for individuals to engage in more physical activity compared to the traditional hospital-based setting, such as engaging in household chores. A recent study provided evidence for higher physical activity and lower sedentary behavior in acute inpatients receiving home-based care than those receiving hospital-based care.
      • Levine D.M.
      • Ouchi K.
      • Blanchfield B.
      • et al.
      Hospital-level care at home for acutely ill adults.
      As physical activity is low in geriatric rehabilitation inpatients,
      • Klenk J.
      • Wekenmann S.
      • Schwickert L.
      • et al.
      Change of objectively-measured physical activity during geriatric rehabilitation.
      recovering from acute illness with added provisions of interventions such as physiotherapy and occupational therapy may further enhance the effects of home-based care.
      This observational matched cohort study aimed to compare objectively measured physical activity and sedentary behavior in geriatric rehabilitation inpatients receiving care in the home-based setting vs the hospital-based setting.

      Methods

      Setting and Participants

      “REStOring health of acutely unwell adulTs” (RESORT) is an observational longitudinal cohort of patients admitted to the Royal Melbourne Hospital (Victoria, Australia) for geriatric rehabilitation (commenced October 16, 2017). Next to the traditional hospital-based care provided in 4 wards, the Royal Melbourne Hospital offers a home-based inpatient rehabilitation program [Royal Melbourne [email protected] ([email protected])], which provides bed-substitution care that is replicative of the hospital-based setting via a multidisciplinary team, including physicians, nurses, and allied health professionals, for patients living within 30 minutes’ driving distance from the Royal Melbourne Hospital and operated at a 15-bed capacity at the time of investigation. Patients, who would have otherwise received hospital-based care, are deemed suitable for home-based care by physicians to ensure medical stability, ability to independently transfer and use the toilet safely, and adequate cognitive capacity.
      • Lim S.M.
      • Island L.
      • Horsburgh A.
      • Maier A.B.
      Home First! Identification of hospitalized patients for home-based models of care.
      Patients in both settings were assessed by a Comprehensive Geriatric Assessment
      • Parker S.G.
      • McCue P.
      • Phelps K.
      • et al.
      What is Comprehensive Geriatric Assessment (CGA)? An umbrella review.
      by physicians, nurses, occupational therapists and physiotherapists within 48 hours of admission and discharge and followed up at 3 months via phone interviews. This study was approved by the Melbourne Health Human Research Ethics Committee (no. HREC/17/MH/103), with all ethical guidelines followed according to the Declaration of Helsinki.
      World Medical Association Declaration of Helsinki
      Ethical principles for medical research involving human subjects.
      Written informed consent was obtained from all patients or their legal proxies. Inability to provide informed consent and/or receiving palliative care at admission were exclusion criteria.

      Patient Characteristics

      Demographics included age, sex, marital status, living situation, and smoking status and were self-reported or extracted from medical records. Reason for hospital admissions and number of medications were obtained from medical records. Disease burden was assessed by the Charlson Comorbidity Index (0-36 points), where a higher score indicates greater burden.
      • Charlson M.E.
      • Pompei P.
      • Ales K.L.
      • MacKenzie C.R.
      A new method of classifying prognostic comorbidity in longitudinal studies: Development and validation.
      Frailty was assessed using the Clinical Frailty Scale (CFS), which classifies frailty from 1 to 9 points representing very fit to terminally ill.
      • Church S.
      • Rogers E.
      • Rockwood K.
      • Theou O.
      A scoping review of the Clinical Frailty Scale.
      Malnutrition was assessed by the Malnutrition Screening Tool (0-5 points) where higher scores indicate greater risk of malnutrition.
      • Ferguson M.
      • Capra S.
      • Bauer J.
      • Banks M.
      Development of a valid and reliable malnutrition screening tool for adult acute hospital patients.
      History of falls in the past year was ascertained by self-report or medical records. Length of stay was extracted from medical records. Cognition was assessed by the standardized Mini-Mental State Examination (0-30 points), where lower scores reflect worse cognition,
      • Vertesi A.
      • Lever J.A.
      • Molloy D.W.
      • et al.
      Standardized Mini-Mental State Examination. Use and interpretation.
      cognitive impairment was defined as previously described,
      • Chan C.H.
      • Maddison C.
      • Reijnierse E.M.
      • et al.
      The association of comorbidity measures and mortality in geriatric rehabilitation inpatients by cancer status: RESORT.
      and delirium was assessed with the Short Confusion Assessment Method.
      • Inouye S.K.
      • Van Dyck C.H.
      • Alessi C.A.
      • et al.
      Clarifying confusion: The confusion assessment method: A new method for detection of delirium.
      Height (centimeters) was assessed using a stadiometer and for those who could not stand, height was calculated from knee height using the Chumlea equation for Caucasians.
      • Chumlea W.C.
      • Guo S.
      Equations for predicting stature in white and black elderly individuals.
      Depending on ambulatory status, weight (kilograms) was assessed by either a standing or seated scale, or a weighted hoist. Body mass index was calculated by weight divided by height squared (kg/m2).

      Physical Function

      The Functional Ambulation Classification was used by physicians to assess ambulation status, with scores ranging from 0 (non-functional) to 5 (independent).
      • Viosca E.
      • Martínez J.L.
      • Almagro P.L.
      • et al.
      Proposal and validation of a new functional ambulation classification scale for clinical use.
      Ability to walk, use of a walking aid, difficulty walking 100 m, and difficulty climbing stairs were dichotomous (yes/no) self-reported data assessed at preadmission (retrospectively at admission), admission, and 3-month follow-up, and were obtained from patient surveys or extracted from medical records. Activities of daily living were assessed by occupational therapists at admission, discharge, and 3-month follow-up by the Katz Index of Activities of Daily Living (ADL)
      • Katz S.
      • Ford A.B.
      • Moskowitz R.W.
      • et al.
      Studies of illness in the aged: The index of ADL: A standardized measure of biological and psychosocial function.
      and the Lawton and Brody Instrumental ADL (IADL)
      • Lawton M.P.
      • Brody E.M.
      Assessment of older people: Self-maintaining and instrumental activities of daily living.
      where higher scores indicate greater ability to complete tasks, respectively. The Short Physical Performance Battery (SPPB), made up of balance tests (0-4 points), a 4-m walk test (0-4 points), and a chair stand test (0-4 points), was assessed by physiotherapists with higher scores indicating better physical performance (0-12 points).
      • Guralnik J.M.
      • Simonsick E.M.
      • Ferrucci L.
      • et al.
      A Short Physical Performance Battery assessing lower extremity function: Association with self-reported disability and prediction of mortality and nursing home admission.
      Maximum hand grip strength was measured by physiotherapists from 3 attempts with each hand using a handheld dynamometer (JAMAR hand dynamometer; Sammons Preston, Inc, Bolingbrook, IL).
      • Reijnierse E.M.
      • de Jong N.
      • Trappenburg M.C.
      • et al.
      Assessment of maximal handgrip strength: How many attempts are needed?.

      Objectively Measured Physical Activity and Sedentary Behavior

      From October 22, 2019, to March 29, 2020, patients on their fifth (range 2-7) day of hospital admission were asked to wear an ActivPAL4 triaxial accelerometer (PAL Technologies Ltd, Glasgow, Scotland, UK) on their right thigh for 7 days to objectively assess daily physical activity and sedentary behavior. The ActivPAL is an inertial sensor that uses static acceleration (range ±4g) and inclination to directly measure and quantify an individual's postural allocation and partition these behaviors into time spent upright including standing and walking vs time spent non-upright including sitting and lying [inclination approximately > or < 20° from horizontal (0°)] and it additionally counts number of steps and sit-to-stand transitions.
      • Steeves J.A.
      • Bowles H.R.
      • McClain J.J.
      • et al.
      Ability of thigh-worn ActiGraph and activPAL monitors to classify posture and motion.
      Data were collected in 15-second epochs with a sampling frequency of 20 Hz and analyzed in 60-second epochs. A valid day was defined as at least 20 out of 24 hours of wear, and patients were required to complete ≥1 valid day to be included. Total wear time was expressed as days per week and other duration variables as minutes per day. Total physical activity duration was defined as the mean time spent upright over valid days and was the sum of standing and walking durations. Steps and sit-to-stand transitions were defined as the mean number or count over valid days. Sedentary duration was defined as the mean time spent non-upright over valid days and was the sum of sitting and lying durations.

      Statistical Analysis

      As patients were not randomized to care settings, selection bias was anticipated, particularly for physical function. Subsequently, post hoc nearest-neighbor one-to-one matching techniques were employed. Each home-based patient was matched to a hospital-based patient by sex and physical function measured by SPPB score. If the SPPB score was missing or there was more than 1 match, ADL score, IADL score, Functional Ambulation Classification score, Clinical Frailty Scale score, and age were progressively evaluated until a match was identified.
      Descriptive statistics for patient characteristics, physical activity and sedentary behavior were reported as means ± standard deviations and compared with independent samples t tests (continuous variables, normally distributed), medians with interquartile ranges, and compared with Mann-Whitney U tests (continuous variables, skewed), or numbers (n) with percentages (%) and compared with either chi-square or Fisher exact tests (categorical variables). Statistical significance was set at α = 0.05. All analyses were performed using the Statistical Package for the Social Sciences software (IBM SPSS Statistics, version 25.0; IBM Corp, Armonk, NY). Physical activity over the 24-hour day was visualized by multiple series line graphs using Microsoft Excel (version 16.16.22) by plotting the median (solid lines) and interquartile range (dotted lines) of each group's mean physical activity over valid days, respectively, for each 30-minute period. To demonstrate the clinical relevance of physical activity during geriatric inpatient rehabilitation, physical function over time was summarized in box plots using Plotly (Plotly Technologies Inc, Montreal, Québec, Canada) for ADL and IADL scores and reported in tables as n (%) for dichotomous physical function variables.

      Results

      Inclusion

      A total of 159 inpatients participated in accelerometry data collection: 18 home-based and 145 hospital-based patients. Four patients participated in accelerometry in both settings and were subsequently included as home-based patients to avoid double-counting; comparisons of their physical activity and sedentary behavior in each setting are in Supplementary Figure 1.

      Patient Characteristics

      Of the 18 home-based patients, 7 were female (mean age 81.9 ± 8.6 years), and of the total 141 hospital-based patients, 57.4% were female (mean age 82.9 ± 7.8 years) (Table 1). A greater proportion of hospital-based patients lived alone; they were significantly more frail and at a greater risk for malnutrition compared with home-based patients. Physical function expressed by Functional Ambulation Classification, ADL, IADL, SPPB (including its subtests), and hand grip strength were significantly lower in the group of hospital-based compared to home-based patients. Matching of hospital-based to home-based patients resulted in a sex and physical function matched hospital-based group of 18 patients including 7 women (mean age 80.1 ± 7.4 years). SPPB scores were not statistically different between home-based and matched hospital-based patients. After matching, more matched hospital-based patients lived alone and had worse ADL and IADL scores compared with home-based patients.
      Table 1Patient Characteristics of Geriatric Rehabilitation Inpatients at Admission Receiving Care in the Home-Based vs Hospital-Based Setting (Matched and Total, Respectively)
      Home-BasedHospital-Based
      Total (n = 18)Matched (n = 18)Total (n = 141)
      n
      Number of patients for which data were available.
      Valuen
      Number of patients for which data were available.
      ValueP
      P values are based on the difference of patients characteristic for the home-based group compared with the matched hospital-based group and total hospital-based group, respectively, using the following tests: independent samples t test for normally distributed variables, Mann-Whitney U test for non-normally distributed (skewed) variables, chi-square test for categorical variables when the expected values in each group were >5, and Fisher exact test for categorical variables when expected values in each group were <5. P values <.05 are presented in bold.
      n
      Number of patients for which data were available.
      ValueP
      P values are based on the difference of patients characteristic for the home-based group compared with the matched hospital-based group and total hospital-based group, respectively, using the following tests: independent samples t test for normally distributed variables, Mann-Whitney U test for non-normally distributed (skewed) variables, chi-square test for categorical variables when the expected values in each group were >5, and Fisher exact test for categorical variables when expected values in each group were <5. P values <.05 are presented in bold.
      Demographics
       Age, y, mean ± SD1881.9 ± 8.61880.1 ± 7.4.51614182.9 ± 7.8.63
       Female, n (%)187 (38.9)187 (38.9)>.9914181 (57.4).14
       Married, n (%)179 (52.9)186 (33.3).24114153 (37.6).22
       Living situation, n (%)
      Living alone184 (22.2)1811 (61.1).01814171 (50.4).024
      With partner189 (50.0)186 (33.3).31014145 (31.9).13
      With children184 (22.2)181 (5.6).3414123 (16.3).51
      With roommates181 (5.6)180 (0.0)>.991410 (0.0).11
      Other180 (0.0)180 (0.0)>.991412 (1.4)>.99
       Institutionalized, n (%)180 (0.0)180 (0.0)>.991411 (0.7)>.99
       Current smoker, n (%)180 (0.0)182 (11.1).491336 (4.3)>.99
      Clinical characteristics
       Primary reason for hospital admission, n (%)
      Musculoskeletal187 (38.9)1811 (61.1).1814168 (48.2).46
      Neurologic184 (22.2)182 (11.1).6614120 (14.2).48
      Infection182 (11.1)180 (0.0).491414 (2.8).14
      Cardiac181 (5.6)180 (0.0)>.991419 (6.4)>.99
      Respiratory181 (5.6)181 (5.6)>.9914111 (7.8)>.99
      Metabolic181 (5.6)181 (5.6)>.991413 (2.1)>.99
      Gastrointestinal181 (5.6)180 (0.0)>.9914111 (7.8)>.99
      Hematology181 (5.6)180 (0.0)>.991411 (0.7).21
      Psychiatry180 (0.0)183 (16.7).231419 (6.4).60
      Urology180 (0.0)180 (0.0)>.991414 (2.8)>.99
      Ophthalmology180 (0.0)180 (0.0)>.991411 (0.7)>.99
       CCI score, points (0-36)182.1 [0.0-3.3]181.5 [0.8-3.0].861412.0 [1.0-4.0].21
       CFS score, points (0-90)185.0 [4.0-5.3]154.0 [3.0-5.0].331266.0 [5.0-7.0].012
       MST score, points (0-90)180.0 [0.0-0.0]180.0 [0.0-0.5].781380.0 [0.0-2.0].032
       Fall in the past year, n (%)1814 (77.8)1813 (72.2)>.99139105 (77.5)>.99
       LOS in acute, d185.5 [3.8-7.8]186.7 [3.8-10.4].531335.6 [2.8-10.8].95
       LOS in hospital-based geriatric rehab, d1016.0 [7.0-31.0]1812.7 [11.0-20.9]>.9914116.9 [11.8-28.9].38
       LOS in home-based geriatric rehab, d1812.0 [10.0-12.0]N/AN/A
       LOS in acute, d185.5 [3.8-7.8]186.7 [3.8-10.4].541335.6 [2.8-10.8].11
      Cognition and psychological
       Cognitive impairment, n (%)186 (33.3)189 (50.0).3114186 (61.0).025
       sMMSE score, points (0-30)623.0 [21.8-27.3]1523.0 [19.0-27.0].7312522.0 [16.5-26.2].39
       Delirium (short CAM), n (%)185 (27.8)183 (16.7).6914125 (17.7).34
      Anthropometry
       Weight (kg)1875.4 [59.3-85.8]1884.4 [66.0-93.6].3614170.9 [59.4-84.6].70
       Height (cm)11158.7 [154.0-177.0]18163.8 [155.0-173.2].95137161.0 [156.0-169.3].87
       BMI1126.8 [23.7-30.0]1829.1 [24.6-36.0].2813727.2 [23.1-31.5].88
      Physical function
       FAC score, points (0-5)174.0 [3.5-4.5]183.0 [3.0-4.0].091363.0 [1.0-3.0]<.001
       Able to walk, n (%)1818 (100)1817 (94.4)>.99141127 (90.1).37
       Use of a walking aid, n (%)1811 (61.1)188 (44.4).3214096 (68.6).52
       Difficulty walking 100m, n (%)178 (47.1)155 (33.3).4312367 (54.5).57
       ADL score, points (0-6)185.0 [4.0-6.0]183.0 [2.0-4.0].0011412.0 [1.0-3.0]<.001
       IADL score, points (0-8)183.0 [2.0-5.0]181.0 [1.0-2.0]<.0011411.0 [0.0-2.0]<.001
       SPPB score, points (0-12)157.0 [5.0-9.0]186.5 [4.8-10.0].931321.0 [0.0-4.0]<.001
      Balance score, points (0-4)173.0 [2.0-4.0]183.0 [2.0-4.0].991340.0 [0.0-2.0]<.001
      Gait speed score, points (0-4)163.0 [2.0-3.0]182.0 [1.8-3.3].621361.0 [0.0-2.0]<.001
      Chair stand test score, points (0-4)151.9 [0.0-2.0]181.0 [0.0-3.0].551340.0 [0.0-0.0]<.001
      Hand grip strength, kg, mean ± SD1625.7 ± 9.81822.5 ± 7.7.3112016.9 ± 7.5.003
      ADL, Activities of Daily Living; CCI, Charlson Comorbidity Index; CFS, Clinical Frailty Scale; d, days; LOS, length of stay; MST, Malnutrition Screening Tool; short CAM, Short Confusion Assessment Method; BMI, body mass index; FAC, Functional Ambulation Classification; IADL, Instrumental Activities of Daily Living; kg, kilograms; M, meters; SD, standard deviation; sMMSE, Standardized Mini Mental State Examination; SPPB, Short Physical Performance Battery; y, year.
      Variables are presented as median [interquartile range] unless otherwise indicated.
      Number of patients for which data were available.
      P values are based on the difference of patients characteristic for the home-based group compared with the matched hospital-based group and total hospital-based group, respectively, using the following tests: independent samples t test for normally distributed variables, Mann-Whitney U test for non-normally distributed (skewed) variables, chi-square test for categorical variables when the expected values in each group were >5, and Fisher exact test for categorical variables when expected values in each group were <5. P values <.05 are presented in bold.

      Physical Activity and Sedentary Behavior During Geriatric Inpatient Rehabilitation

      Median physical activity was significantly higher and median sedentary behavior was significantly lower in home-based patients compared with total hospital-based patients for all measures (all P < .001), with the exception of sitting duration, which was non-significantly higher in home-based patients (P = .11) (Table 2). Differences between home- and hospital-based patients persisted after matching; home-based patients were >2.4 times more active than matched hospital-based patients for all physical activity measures with the exception of sit-to-stand transitions. Comparing medians and interquartile ranges of home-based patients to matched hospital-based patients more time was spent physically active (P = .011), including both a longer time standing (P = .012) and walking (P = .002). Home-based patients took significantly more steps than matched hospital-based patients (P = .004) and sit-to-stand transitions, but differences for sit-to-stands were non-significant (P = .10). Sedentary behavior was significantly lower for home-based patients compared with matched hospital-based patients (P = .011). Of sedentary time, home-based patients spent more time than matched hospital-based patients sitting (P = .09) and spent significantly less time lying (P = .020).
      Table 2Accelerometry Measures of Physical Activity and Sedentary Behaviors of Geriatric Rehabilitation Inpatients Receiving Care in the Home-Based vs Hospital-Based Setting (Matched and Total, Respectively)
      Home-BasedHospital-Based
      Total (n = 18)Matched (n = 18)Total (n = 141)
      n
      Number of patients for which data were available.
      Valuen
      Number of patients for which data were available.
      ValueP
      P values are based on the difference of patients characteristic for the home-based group compared with the matched hospital-based group and total hospital-based group, respectively using the following tests: independent samples t test for normally distributed variables, Mann-Whitney U test for non-normally distributed (skewed) variables, chi-square test for categorical variables when expected values in each group were >5, and Fisher exact test for categorical variables when expected values in each group were <5. P values <.05 are presented in bold.
      n
      Number of patients for which data were available.
      ValueP
      P values are based on the difference of patients characteristic for the home-based group compared with the matched hospital-based group and total hospital-based group, respectively using the following tests: independent samples t test for normally distributed variables, Mann-Whitney U test for non-normally distributed (skewed) variables, chi-square test for categorical variables when expected values in each group were >5, and Fisher exact test for categorical variables when expected values in each group were <5. P values <.05 are presented in bold.
      Wear time, d186 [5-6]186 [6-6]>.991456 [5-6]>.99
      Physical activity duration, min/d18316.27 [160.12-374.60]18122.81 [54.28-219.36].01114558.42 [25.61-120.54]<.001
       Standing duration18263.01 [132.16-307.68]18104.52 [36.46-177.14].01214546.83 [22.87-101.99]<.001
       Walking duration1849.46 [30.43-67.58]1820.75 [10.30-32.76].0021457.44 [1.54-14.54]<.001
      Steps per day182968.10 [1641.90-4752.86]181236.17 [701.33-2359.92].004145401.67 [65.26-898.67]<.001
      Sit-to-stands per day1839.08 [29.71-53.63]1824.50 [13.14-46.75].1014520.33 [9.50-30.00]<.001
      Sedentary duration, min/d181123.73 [1065.40-1279.88]181317.19 [1220.64-1385.72].0111451381.58 [1319.46-1413.97]<.001
       Sitting duration18612.17 [486.00-679.27]18532.75 [140.13-651.98].09145550.90 [152.25-694.15].11
       Lying duration18564.48 [472.78-661.71]18708.74 [549.50-1235.54].020145771.53 [602.33-1230.44]<.001
      All variables are presented as median [interquartile range].
      Number of patients for which data were available.
      P values are based on the difference of patients characteristic for the home-based group compared with the matched hospital-based group and total hospital-based group, respectively using the following tests: independent samples t test for normally distributed variables, Mann-Whitney U test for non-normally distributed (skewed) variables, chi-square test for categorical variables when expected values in each group were >5, and Fisher exact test for categorical variables when expected values in each group were <5. P values <.05 are presented in bold.
      Over the course of the day, physical activity in both groups was highest from 8 am to 3 pm and began tapering from 6 to 9 pm (Figure 1). The home-based group exhibited clear and consistent patterns of higher physical activity compared to the total hospital-based group; with the 25th percentiles for steps and standing duration of the home-based group being higher than the 75th percentiles of the total hospital-based group. Measures of sedentary behavior exhibited similar patterns in both groups, with the home-based participants spending more of their sedentary time sitting and the hospital-based patients spending more time lying. Patients who wore the ActivPAL in both the home-based and hospital-based settings exhibited similar patterns in both settings, with higher physical activity in the home-based setting present in patients with longer times between accelerometry measurements (Supplementary Figure 1).
      Figure thumbnail gr1
      Fig. 1Physical activity and sedentary behavior per 30-minute period of the 24-hour day cycle in geriatric rehabilitation inpatients receiving care in the home-based vs hospital-based setting (matched and total groups, respectively) . For each 30-minute period, group medians (50th percentile) are represented by points connected by solid lines and upper (75th percentile) and lower (25th percentile) limits of interquartile ranges are represented by dotted lines.

      Physical Function Over Time

      Descriptive analysis showed that both median ADL and IADL increased from admission to discharge in all groups with larger gains in the hospital-based groups. ADL and IADL remained stable (equal medians) from discharge to 3-month follow-up in all groups (Figure 2). The proportion of patients reporting the use of a walking aid, difficulty walking 100 m, or difficulty climbing stairs either declined or remained stable from preadmission to 3-month follow-up in hospital-based patients, and 1 additional home-based patient reported the use of a walking aid and difficulty climbing stairs, respectively. At 3 month follow-up, 1 of 18 home-based patients fell, whereas 3 of 12 matched and 27 of 92 total hospital-based patients fell (Table 3).
      Figure thumbnail gr2
      Fig. 2(A) Activities of daily living (ADL) and (B) instrumental activities of daily living (IADL) at admission, discharge, and 3-month follow-up in geriatric rehabilitation inpatients receiving care in the home-based vs hospital-based setting (matched and total groups, respectively). Points represent individuals. Medians (50th percentile) are represented in within boxes by horizontal lines, and upper (75th percentile) lower (25th percentile) limits of the interquartile range are represented by the top and bottom box borders, respectively.
      Table 3Physical Function Assessed at Preadmission, Admission, and 3-Month Follow-up in Geriatric Rehabilitation Inpatients Receiving Care in the Home-Based vs Hospital-Based Setting (Matched and Total, Respectively)
      Home-BasedHospital-Based
      Total (n = 18)Matched (n = 18)Total (n = 141)
      Preadmission, n (%)Admission n (%)3-mo Follow-Up, n (%)Preadmission, n (%)Admission, n (%)3-mo Follow-Up, n (%)Preadmission, n (%)Admission, n (%)3-mo Follow-Up, n (%)
      Use of a walking aid11 (61.1)13 (72.2)12 (66.7)8 (44.4)7 (38.9)7 (53.6)88 (72.1)99 (81.8)77 (84.6)
      Difficulty walking 100 m8 (47.1)9 (50.0)8 (47.1)5 (33.3)8 (53.3)3 (23.1)62 (57.4)101 (91.8)53 (55.8)
      Difficulty climbing stairs10 (55.6)9 (52.9)11 (64.7)9 (60.0)9 (60.0)5 (41.7)81 (75.7)100 (90.1)77 (83.7)
      Had a fall14 (77.8)N/A1 (5.1)13 (72.2)N/A3 (23.1)92 (76.6)N/A27 (29.3)
      All variables are presented as the number of patients with variable present (n) and percentage of total (%).

      Discussion

      Geriatric inpatient rehabilitation delivered in the home-based setting is associated with higher physical activity than in the hospital-based setting; however, time spent sedentary was similar. Matching confirmed results and demonstrated that these findings are independent of sex and baseline physical function.
      Daily physical activity was more than 2.4 times higher in home-based patients compared with matched hospital-based patients for all measures except for sit-to-stand transitions, which is clinically relevant given that greater physical activity is associated with numerous positive health outcomes including better physical function and reduced mortality.
      • Rojer A.G.M.
      • Ramsey K.A.
      • Trappenburg M.C.
      • et al.
      Instrumented measures of sedentary behaviour and physical activity are associated with mortality in community-dwelling older adults: A systematic review, meta-analysis and meta-regression analysis.
      • Hall K.S.
      • Hyde E.T.
      • Bassett D.R.
      • et al.
      Systematic review of the prospective association of daily step counts with risk of mortality, cardiovascular disease, and dysglycemia.
      • Ramsey K.A.
      • Rojer A.G.M.
      • D’Andrea L.
      • et al.
      The association of objectively measured physical activity and sedentary behavior with skeletal muscle strength and muscle power in older adults: a systematic review and meta-analysis.
      • Tolley A.
      • Ramsey K.A.
      • Rojer A.G.M.
      • et al.
      The association of objectively measured physical activity and sedentary behaviour with frailty in community-dwelling older adults: a systematic review.
      Partitioning sedentary behavior into sitting and lying duration, time allocation was similar between patients in the home-based and hospital-based settings. This was an unexpected finding that reflects high sedentary behavior in geriatric rehabilitation inpatients is independent of setting and from physical activity,
      • Panahi S.
      • Tremblay A.
      Sedentariness and health: Is sedentary behavior more than just physical inactivity?.
      which is in line with recent recommendations to focus on both ends of the activity spectrum by creating a physical environment to increase physical activity and additionally emphasizing reducing sedentary behavior.
      • Baldwin C.E.
      • Phillips A.C.
      • Edney S.M.
      • Lewis L.K.
      Recommendations for older adults’ physical activity and sedentary behaviour during hospitalisation for an acute medical illness: an international Delphi study.
      Our results are corroborated by a recent pilot study for a randomized controlled trial comparing 9 home-based and 11 hospital-based acutely admitted patients using a skin patch (physIQ or VitalConnect) to assess physical activity.
      • Levine D.M.
      • Ouchi K.
      • Blanchfield B.
      • et al.
      Hospital-level care at home for acutely ill adults.
      ,
      • Levine D.M.
      • Ouchi K.
      • Blanchfield B.
      • et al.
      Hospital-level care at home for acutely ill adults: A pilot randomized controlled trial.
      The median physical activity duration [209 (90) vs 78 (44) minutes/d, P < .01], steps [1820 (3300) vs 159 (508) per day, P < .06], and standing duration [4.8 (1.4) vs 2.7 (1.8) hours/d, P < .01] were all higher in the home- vs the hospital-based group.
      • Levine D.M.
      • Ouchi K.
      • Blanchfield B.
      • et al.
      Hospital-level care at home for acutely ill adults: A pilot randomized controlled trial.
      The subsequent randomized controlled trial of 43 home-based and 48 hospital-based acutely admitted inpatients assessed sedentary and lying duration, which was, respectively, 11% and 37% higher in hospital vs home-based patients.
      • Levine D.M.
      • Ouchi K.
      • Blanchfield B.
      • et al.
      Hospital-level care at home for acutely ill adults.
      Smaller differences between groups are likely explained by the acute setting, rather than the rehabilitation setting in the current study; although there are many benefits to home-based hospitalization, it is likely insufficient to impede the systemic effects of acute illness on functional ability and subsequent engagement in physical activity. Furthermore, although their median age was comparable to the current study, anyone >18 years was eligible for inclusion, which may also explain these differences. A recent systematic review seeking to investigate if geriatric inpatients >60 years old receiving acute care in a home-based setting are more active than hospital-based patients identified that there was a complete absence of studies designed to answer this question.
      • Scott J.
      • Abaraogu U.O.
      • Ellis G.
      • et al.
      A systematic review of the physical activity levels of acutely ill older adults in Hospital At Home settings: An under-researched field.
      The present study, although in the rehabilitation setting, is the first to provide evidence for higher physical activity in home-based geriatric inpatients and thus gives incentive for future research in a larger sample.
      Our findings suggest that receiving care in the home-based setting may facilitate physical activity by overcoming institutional and cultural restrictive barriers and allowing more opportunity for engagement in physical activities.
      • Scheerman K.
      • Schoenmakers A.H.C.
      • Meskers C.G.M.
      • Maier A.B.
      Physical, motivational and environmental factors influencing physical activity promotion during hospitalization: older patients’ perspective.
      Safety concerns, specifically, avoiding falls, is commonly cited as a concern by clinicians against increasing physical activity in hospitalized patients; however, this is not supported by research and has led to a pervasive implementation of falls prevention measures that have little efficacy in preventing falls, but present substantial consequences by inhibiting mobility.
      • Growdon M.E.
      • Shorr R.I.
      • Inouye S.K.
      The tension between promoting mobility and preventing falls in the hospital.
      Another common misconception of clinicians is that hospitalized patients lack the motivation to be mobilized or initiate physical activity themselves.
      • Scheerman K.
      • Schoenmakers A.H.C.
      • Meskers C.G.M.
      • Maier A.B.
      Physical, motivational and environmental factors influencing physical activity promotion during hospitalization: older patients’ perspective.
      ,
      • Kirk J.W.
      • Bodilsen A.C.
      • Sivertsen D.M.
      • et al.
      Disentangling the complexity of mobility of older medical patients in routine practice: An ethnographic study in Denmark.
      Previous qualitative research identified a willingness and even desire of hospitalized patients to have more opportunity and autonomy in out-of-bed activity.
      • Brown C.J.
      • Williams B.R.
      • Woodby L.L.
      • et al.
      Barriers to mobility during hospitalization from the perspectives of older patients and their nurses and physicians.
      The present study supports these ethnographic findings by showing that patients outside of the hospital environment choose to engage in more physical activity. Furthermore, the absence of a difference in the number of sit-to-stand transitions between the home-based and hospital-based settings show that the frequency of activity bouts was similar; however, the duration of physical activity after transitioning from sitting to standing was significantly and consistently (throughout the day) shorter in hospital-based patients, suggesting that once a patient is activated there should be adequate opportunity for them to remain active.
      Changes in ADL and IADL over time showed that on the group level there is improvement from admission to and stability from discharge to 3-month follow-up in all groups. The larger improvements in physical function identified in the hospital-based group were likely because of the clear presence of a ceiling effect for both ADL and IADL. We subsequently did not expect that the short duration and likely low intensity of physical activity during geriatric rehabilitation would correspond with short-term changes in ADL and IADL in this cohort; rather, these changes were more likely due to disease burden and subsequent treatment response,
      • Laurent M.
      • Oubaya N.
      • David J.P.
      • et al.
      Functional decline in geriatric rehabilitation ward; is it ascribable to hospital acquired infection? A prospective cohort study.
      which we were unable to control for given the small sample. Furthermore, physical activity assessed postdischarge is likely a better determinant of future ADL and IADL trajectories as it is free of the previously mentioned hospital-associated barriers. Therefore, future studies should incorporate physical activity and sedentary behavior assessment postdischarge, as is being highlighted using data of the Hospital-ADL cohort of acute patients,
      • Kolk D.
      • Aarden J.J.
      • MacNeil-Vroomen J.L.
      • et al.
      Factors associated with step numbers in acutely hospitalized older adults: The Hospital–Activities of Daily Living Study.
      and include more distant follow-up to evaluate the long-term role of physical activity during and post-hospitalization.
      To our knowledge, this is the first study using accelerometry in home-based rehabilitation inpatients and subsequently the first to compare levels of physical activity and sedentary behavior with hospital-based patients. Recruitment was from a large metropolitan hospital, inclusion for accelerometry was random, and exclusion criteria were minimal; thus, increasing the generalizability of our findings. Randomization to home-based care is particularly challenging in geriatric inpatients populations
      • Crotty M.
      • Kittel A.
      • Hayball N.
      Home rehabilitation for older adults with fractured hips: How many will take part?.
      and selection bias was anticipated in this study, which was minimized through matching; however, the differences in ADL and IADL between groups were unable to be ameliorated, which represents a limitation. Furthermore, this study is limited by the small sample size of patients included in the home-based group, as data collection was stopped early due to the COVID-19 pandemic and the home-based service only operated with 15 beds at the time of accelerometry data collection, which has since been expanded because of successful implementation and increasing demand.
      • Lim S.M.
      • Island L.
      • Horsburgh A.
      • Maier A.B.
      Home First! Identification of hospitalized patients for home-based models of care.
      However, we confirmed that sample sizes were large enough to perform the analyses presented.
      • Jenkins D.G.
      • Quintana-Ascencio P.F.
      A solution to minimum sample size for regressions.

      Conclusions and Implications

      Home-based geriatric inpatient rehabilitation is associated with greater physical activity compared with the hospital-based setting even after matching for sex and physical function and therefore promotes rehabilitation goals of mobilization. This adds to the emerging body of literature that provides benefits of home-based care. Future research should confirm findings in a larger sample, identify unique enablers of physical activity in the home setting at the individual and environmental levels that could be implemented into hospital settings, and assess long-term impacts of higher physical activity during home-based care.

      Acknowledgments

      The authors would like to thank the Royal Melbourne Hospital at Home ([email protected]) team with special thanks to the nursing staff for help with implementation of accelerometers. Furthermore, the authors thank the multidisciplinary team members of the Royal Melbourne Hospital, Royal Park Campus, involved in the RESORT cohort for their clinical work and the @Age team for their role in the data collection and processing.

      Supplementary Data

      Figure thumbnail fx1
      Supplementary Fig. 1Mean physical activity and sedentary behavior per 30-minute period of the 24-hour day cycle of 4 geriatric inpatients patients who wore ActivPALs in both the hospital-based and home-based settings. Accelerometry measurements were taken on 2 different occasions; the left and right arrows in the legend indicate the number of days in between accelerometry measurements.

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