1. Ruth McCullagh Physiotherapy, UCC r.mccullagh@ucc.ie
An Augmented Prescribed Exercise Programme (APEP) for frail older medical patients in the acute setting
Ruth McCullagh
Physiotherapy, UCC

2. Older medical inpatients are inactive
Median 7 days
Median 600 steps

3. Walking is associated with a shorter length of stay
6% shorter LOS
50% more walking

4. 1 day shorter length of stay
Median 7 days
1 day shorter LOS
Median 600 steps
300 to 900 steps

5. Background No effect on LOS
Patient
Nurse
Geriatrician
Physio and OT
Social worker
No effect on LOS
Small effects on physical and functional performance
Shorten LOS
Improved physical and functional performance

6. TUG – 27% unable to score at baseline
Background
Independent mobility
Patient
Nurse
Geriatrician
Physio and OT
Social worker
No effect on LOS
Small effects on physical and functional performance
TUG – 27% unable to score at baseline
LOS too short
Shorten LOS
Improved physical and functional performance

7. Aims and Objectives
To determine the effects of an Augmented Prescribed Exercise Programme (APEP) on length of stay, physical performance, quality of life and readmission rates for 3 months following discharge in frail older medical inpatients
Completed at the Mercy University Hospital, March 2015 – January 2017

8. Inclusion Criteria and Allocation Method
220 medical patients, aged ≥65 years (Mercy University Hospital, Cork)
Anticipated LOS ≥ 3 days
Premorbidly mobile
Requires assistance or walking aid (max 1 person’s aid) or recent fall
No CI to exercise
No critical care, end of life care, acute psychiatric care
Concealed allocation, randomly assigned after written consent and baseline assessment

9. Measurements Descriptors Outcome Measures Falls history and Efficacy
Hospital Utilisation
Length of stay
Readmission rates – 3 months
Physical Performance & Function
Short Physical Performance Battery
Nottingham Extended Activities of Living Scale
Quality of Life
EQ-5D-5L
Negative Outcomes
Falls
Deaths
Prolonged hospitalisation
Long-term care
Falls history and Efficacy
Falls Efficacy Scale – International
Cognition
6-Item Cognitive Impairment Test
Frailty
SHARE F-I

10. Intervention Control (sham) Intervention (apep)
Assisted twice daily (Mon – Fri) by qualified physiotherapist until discharge
Stretches and relaxation
Bed / chair based
Assisted twice daily (Mon – Fri) by qualified physiotherapist until discharge
Strength, balance, gait, transfers

11. Statistical Analysis Time to event: Length of Stay
Linear regression: Physical Performance and Quality of Life
Post hoc logistic regression: Pooled negative events
falls, prolonged hospital stay, LTC admission, death
Adjusted for age, gender, fear of falling, physical performance

12. Results Power calculations – 220
Recruited 190 (11% of screened patients)
Independently mobile (n=513)
Medically too unwell (n=163)
Chair / bedbound (n=146)
Expected hospital stay (n=137)
DC destination home unlikely (n=125)
Other (n= 538)
Declined to participate (n=17)
66 patients transferred to subacute care (33 vs 33)
Compliance
1 dropout (control group)
79 (83%) completed most APEP sessions
75 (79%) completed most sham sessions
At Discharge (control vs APEP)
6 falls (3 vs 3)
6 deaths (3 vs 3)
At Follow-up (control vs APEP)
6 remained in hospital (5 vs 1)
3 admitted to LTC (all control)
30 falls occurred (18 vs 12)
17 deaths occurred (12 vs 5)

13. Baseline Descriptors Variable Control group APEP group
Mean (±SD) or Median [IQR]
Frail / Pre-frail
74 (77%) / 18 (20%)
74 (78%) / 14 (15%)
Falls in the last 6 months
45 (46%)
46 (49%)
Aid/Assistance to walk
84 (89%)
81 (85%)
Age
81.7 (±7.3)
79.7 (±7.5)
Co-morbidity score
10 (±3.9)
10.3 (±4)
Physical Performance
3 [2 - 4]
3 [2 - 5]
Falls Self- Efficacy
3.7 [2.8 – 4.6]
3.8 [2.7 – 4.6]

14. Length of Stay Control Group APEP Group HR (time to discharge)
Total nights (n=190)
970
880
Median [IQR] (n=190)
8 [6-13]
8 [5-11]
1.11 (CI ) p=0.5
Median [IQR] (n=128)
(D/C directly home)
8 [6-11]
7 [5-10]
1.30 (CI ) p=0.1

15. Physical Performance, QoL, Negative Events
Variable
Co-ef
Unadjusted p
Adjusted
Physical Performance DC β
0.88 ( )
0.01
0.78 ( )
0.003
Physical Performance FU
0.45 ( )
0.3
0.67 ( )
0.87
QoL DC
3.96 ( )
0.1
5.10 ( )
0.9
QoL FU
0.28 ( )
0.004
0.26 ( )
0.008
Readmissions 3 months OR
1.95 ( )
0.06
2.25 (1.09 – 4.66)
0.03
Falls FU
0.60 ( )
0.2
0.57 ( )
Deaths FU
0.42 ( )
0.12
0.38 ( )
0.13
Independent mobility FU
3.64 ( )
2.47 ( )
Total negative events FU
0.50 (0.26 – 1.00)
0.05
0.47 (0.21 – 1.00)

16. Conclusion
LOS remains inconclusive - 35% transferred to sub-acute care
Median LOS = 8 days - can this be shortened any more?
Improved Physical performance, QoL and independent mobility
Reduced Negative Events (falls, deaths, LTC admissions)
Qualitative feedback
Economic Evaluation
Sub acute care

17. Acknowledgements Funding Supervisors & Mentor
Health Research Board, Ireland
Supervisors & Mentor
Dr Suzanne Timmons, Centre for Gerontology & Rehabilitation, UCC
Prof Frances Horgan, School of Physiotherapy, RCSI
Dr Rose Galvin, School of Clinical Therapies, UL
Clinical Research Facility, Cork
Mercy University Hospital, Cork