Methods

‐ RCT comparing an acute geriatric ward (AGW) with 2 usual care general medical wards (MW).
‐ randomisation in blocks of 12 patients
‐ Setting: Sweden, acute care and tertiary referral hospital.
‐ Funding: Vasterbotten County Council and Vardalstiftelsen and King Gustaf V's and Queen Victoria's Foundation.

Participants

‐ 444 older medical patients (190 AGW and 223 MW). 25 were excluded due to protocol violations.
‐ Mean age 81 years, 60% female and 16% resided in an institution prior to admission.
‐ Inclusion criteria: patients older than 70 years, acutely admitted to hospital for a medical ailment.
‐ Exclusion criteria: Admission to a specialised unit (intensive care, coronary care, acute stroke unit) or admission to a designated subspecialty unit.
‐ Main presenting symptom: chest pain (23%), dyspnoea (18%), other pain (11%), nausea/vomiting (11%), vertigo (11%), other (26%).

Interventions

‐ Acute geriatric based ward differed from the standard ward in that it provided a geriatrician, physiotherapist, occupational therapist. Interdisciplinary team work focussed on early and intensive rehabilitation and intense discharge planning.
‐ Exercise: Early start to rehabilitation. Physiotherapy and occupational therapy assessment and staffing of the ward to optimise early rehabilitation.

Outcomes

‐ Functional status (Barthel Index), cognitive status (MMSE), psychological well being, mortality, place of residence, length and cost of hospital stay, hospital readmission, healthcare costs, events after discharge, outpatient visits and personal assistance requirements.
‐ Time of outcome measure assessment: hospital discharge and 3 months after hospital discharge.

Notes

‐ Language: English
‐ PEDro score: 6
‐ Cost data converted from SEK to US$ using the conversion rates reported
by the author.
‐ Author conclusions: " A geriatric approach with greater emphasis on early rehabilitation and discharge planning in the AGW shortened the length of hospital stay and may have reduced the need for long‐term institutional living."

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Low risk

A ‐ Adequate

Methods

‐ RCT of a geriatric special care unit compared to a traditional medical or surgical ward.
‐ randomisation: "the hospital admissions office randomly assigned eligible patients."
‐ Setting: USA, acute hospital.
‐ Funding: not stated.

Participants

‐ 271 medical/surgical patients (95 treatment, 176 control).
‐ Mean age 77 years, 60% female, 10% resided in a nursing home prior to admission.
‐ Inclusion criteria: aged at least 65 years, predicted length of stay of greater than 48 hours, under the care of a participating physician.
‐ Exclusion criteria: nil reported
‐ Major diagnostic categories (ordered from most common): Respiratory, cerebrovascular, cardiac, neurological, bowel/intestinal, fractures and metastatic malignancies.

Interventions

‐ Geriatric special care unit. Registered nurses/assistants trained for project. Emphasis on maximising patient independence. Multidisciplinary team meeting twice weekly. Early discharge planning and home visit 3 weeks after discharge.
‐ Exercise intervention: patients wear their own clothes, dine in a communal area and participate in an exercise program. Supervised by nursing staff and family. Role of the physiotherapist and occupational therapist not clearly defined.

Outcomes

‐ Discharge destination, mortality, complications during hospitalisation, length and cost of hospital stay, use of physical or chemical restraints.
‐ Time of outcome measure assessment: hospital discharge.

Notes

‐ Language: English
‐ PEDro score: 5
‐ Additional information from authors: no. Attempted to contact authors regarding inconsistent sample sizes reported in tables but unable to locate, possibly due to paper having been published 20+ years ago. The authors reported the trial to be continuing but no further publications were identified.
‐ Authors conclusions: " the preliminary outcomes themselves are encouraging; they suggest that high‐quality hospital care can be delivered to the elderly for less money."

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Unclear risk

D ‐ Not used

Methods

‐ RCT of a geriatric special care unit compared to a traditional medical or surgical ward.
‐ randomisation: "the hospital admissions office randomly assigned eligible patients."
‐ Setting: USA, acute hospital.
‐ Funding: not stated.

Participants

‐ 424 medical/surgical patients (123 treatment, 301 control).
‐ Mean age 79 years, 65% female, 9% resided in a nursing home prior to admission.
‐ Inclusion criteria: aged at least 65 years, predicted length of stay of greater than 48 hours, under the care of a participating physician.
‐ Exclusion criteria: nil reported
‐ Major diagnostic categories (ordered from most common): Respiratory, cardiac, fractures, cerebrovascular, bowel/intestinal, metastatic malignancies and neurological.

Interventions

‐ Geriatric special care unit. Registered nurses/assistants trained for project. Emphasis on maximising patient independence. Multidisciplinary team meeting twice weekly. Early discharge planning and home visit 3 weeks after discharge.
‐ Exercise: patients wear their own clothes, dine in a communal area and participate in an exercise program. Supervised by nursing staff and family. Role of the physiotherapist and occupational therapist not clearly defined.

Outcomes

‐ Discharge destination, mortality, complications during hospitalisation, length and cost of hospital stay, use of physical or chemical restraints.
‐ Time of outcome measure assessment: hospital discharge.

Notes

‐ Language: English
‐ PEDro score: 5
‐ Additional information from authors: no. Attempted to contact authors regarding inconsistent sample sizes reported in tables but unable to locate, possibly due to paper having been published 20+ years ago.
The authors reported the trial to be continuing but no further publications were identified.
‐ Authors conclusions: " the preliminary outcomes themselves are encouraging; they suggest that high‐quality hospital care can be delivered to the elderly for less money."

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Unclear risk

D ‐ Not used

Methods

‐ RCT of an acute care elders unit (ACE) compared to usual care units.
‐ randomised using computer generated random numbers
‐ Setting: USA, community teaching hospital.
‐ Funding: Summa Health System Foundation.

Participants

‐ 1531 of 6609 eligible patients.
‐ Mean age 80 years, 60% female, none from institutions.
‐ Inclusion criteria: community dwelling persons aged 70 or older admitted to a medicine or family practice service.
‐ Exclusion criteria: transferred from a nursing facility or another hospital, required specialty unit admission, were admitted electively, had a length of stay of less than 2 days or had been previously enrolled in the study.
Reason for admission: acute dyspnoea or pulmonary problem (24.1%), change in mental status or neurological abnormality (20.1%), gastrointestinal (18.75%), fever, pneumonia or infection (13.98%), diabetes mellitus, failure to thrive or other problem (11.56%), congestive heart failure, chest pain or cardiac problem (11.50%).

Interventions

‐ Multidisciplinary ACE unit. Specially designed environment, patient centred care, nursing care plans for prevention of functional decline, rehabilitation, patient discharge to home and review of medical care to prevent iatrogenic illness. Daily team rounds.
Exercise: 3 times per day walk or stand. Daily ambulation to activity room for exercises and meals. Encouraged by staff. Patient or caregivers taught exercises.

Outcomes

‐ Function (ADL and IADL), mobility, mortality, discharge destination, hospital costs and LOS, satisfaction and use of at‐risk medications.
‐ Time of outcome measure assessment: hospital discharge and 1, 3, 6 and 12 months after discharge.

Notes

‐ Language: English
‐ PEDro score: 7
‐ Additional information from authors: no
‐ Author conclusions: "ACE in a community hospital improved the process of care and patient and provider satisfaction without increasing hospital length of stay or costs."

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Low risk

A ‐ Adequate

Methods

‐ see Landefeld 1995

Participants

‐ see Landefeld 1995

Interventions

‐ see Landefeld 1995

Outcomes

‐hospital length of stay and costs

Notes

‐ see Landefeld 1995
‐ Covinsky et al. provided mean cost and standard deviation data for the trial reported by Landefeld et al.
‐ Covinsky et al. also provided LOS data that included patients that died and was therefore consistent with other trials for pooling.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Unclear risk

D ‐ Not used

Methods

‐ CCT of additional exercise intervention compared to usual care.
‐Consecutive eligible patients admitted to one of two similar wards based on bed availability. The intervention ward was determined by a coin toss prior to commencement of the trial.
‐ Setting: Australia, acute public hospital.
‐Funding: Department of Medicine, Northern Health.

Participants

‐ 236 of 251 eligible patients (110 intervention, 126 usual care).
‐ Mean age 79 years, 55% female, 10% from hostel.
‐ Inclusion: general medical patients aged 65 or older, were admitted to either of the two general medical wards and were assessed within 48 hours of admission.
‐ Exclusion: admitted to hospital from a nursing home, were assessed to be nursing home level of care or palliative care, had suffered a stroke or a condition for which mobilisation was contraindicated (e.g. deep vein thrombosis or fracture), were too medically unwell to ambulate or exercise or were readmitted during the data collection period and had previously participated in the study.
Primary Diagnosis: Respiratory (30.9%), circulatory (20.8%), digestive (8.5%), genitourinary (6.8%) and other (33%).

Interventions

‐ Exercise only intervention
‐Exercise intervention was in addition to usual care physiotherapy.
‐ Individually tailored exercise intervention program prescribed by a physiotherapist and supervised by an allied health assistant. One of 4 levels of exercise program. Individually tailored. Twice per day walking and exercise program. Maximum of 10 repetitions of each exercise, 20‐30 minutes duration.

Outcomes

‐ Functional status (Barthel Index, Timed Up and Go and Functional Ambulation Classification), adverse events in hospital (mortality, falls, admission to the intensive care unit), discharge destination from hospital, hospital length of stay and readmission within 28 days of discharge.
‐ Time of outcome assessment: hospital discharge and 28 days after discharge.

Notes

‐ Language: English
‐ PEDro score: 7
‐ unpublished dataset. Manuscript is now "in press"
‐ Language: English
‐ Author conclusions: "This trial did not identify significantly improved outcomes as a result of additional exercise for acutely hospitalised older medical patients."

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Unclear risk

D ‐ Not used

Methods

‐ RCT of additional exercise intervention compared to usual care.
‐ computer generated random numbers (block randomisation).
‐ Setting: Australia, acute tertiary public hospital.
‐ Funding: Department of General Medicine, Royal Melbourne Hospital.

Participants

‐ 160 of 186 eligible patients (80 in each group).
‐ Mean age 82 years, 58% female and 18% from residence other than home prior to admission.
‐ Inclusion criteria: aged 65 years or older, admitted with a medical condition to a general medical ward.
‐Exclusion criteria: admitted from nursing home, received nursing home level of care at home, medically unstable or mobilisation was contra‐indicated by the treating medical team, admitted to the delirium management unit, non weight bearing, not assessed within 48 hours of admission, assessed to require palliative care, admitted to hospital with a diagnosis known to cause functional impairment or documented LOS of less than 48 hours.
Primary Diagnosis: not reported.

Interventions

‐ Exercise only intervention
‐Exercise intervention was in addition to usual care physiotherapy.
‐ Individually tailored exercise program during hospitalisation. One of 4 levels of exercise program. Prescribed by a physiotherapist and supervised by a physiotherapy assistant. Twice per day for 30 mins.

Outcomes

‐ Functional status (Barthel Index and TUG), adverse events (mortality, admission to ICU and falls), discharge destination from hospital, hospital length of stay and readmission within 28 days of discharge.
‐ Time of outcome measurement: hospital discharge and 28 days after discharge.

Notes

‐ Language: English
‐ PEDro score: 7
‐ Unpublished data obtained from authors from manuscript prepared for publication. Manuscript has now been published.
‐ Authors conclusions: "The intervention was effective at improving the function of hospitalised elderly general medical patients."

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Low risk

A ‐ Adequate

Methods

‐ RCT of an acute care elders (ACE) unit compared to usual care
‐ randomised by computer generated numbers
‐ Setting: USA, private, non profit teaching hospital.
‐ Funding: John A Hartford Foundation, National Institute on Ageing.

Participants

‐ 651 of 1794 eligible patients (327 intervention, 324 usual care).
‐ Mean age 80 years, 66% female and 8% from long term institutional care.
‐ Inclusion criteria: 70 years or older admitted for general medical care.
‐ Exclusion criteria: patients admitted to a specialty unit (eg. intensive care, cardiology‐telemetry or oncology).
Reason for admission: Gastrointestinal (19.1%, fever, pneumonia or other infection (18.7%), congestive heart failure (16.4%), acute dyspnoea or other pulmonary problem (16.3%), diabetes mellitus, failure to thrive or other problem (15.8%), change in mental status or other neurologic abnormality (11.7%).

Interventions

‐ Multidisciplinary ACE unit. Specially designed environment, patient centred care, nursing care plans for prevention of functional decline, rehabilitation, patient discharge to home and review of medical care to prevent iatrogenic illness. Daily team rounds.
Exercise: 3 times per day walk or stand. Daily ambulation to activity room for exercises and meals. Encouraged by staff. Patient or caregivers taught exercises.

Outcomes

‐ Function (ADL, IADL and ability to walk), mental status (subscore of MMSE), depression (Geriatric Depression Scale), overall health status, discharge destination from hospital, place or residence 3 months after discharge, acute hospital length and cost of hospital stay.
‐ Time of outcome measurement: hospital discharge and 3 months after discharge

Notes

‐ Language: English
‐ PEDro score: 5
‐ Additional information from authors: No
‐ 3 patients assumed to be lost to follow up in the intervention group for change in ADL and mobility scores.
‐ Author conclusions: "Specific changes in the provision of acute hospital care can improve the ability of a heterogenous group of acutely ill older patients to perform basic activities of daily living."

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Unclear risk

D ‐ Not used

Methods

‐ RCT of an exercise program that included a hospital component and a self‐administered 1 month home component.
‐ stratified randomisation.
‐ Setting: USA, community‐based hospital.
‐Funding: John A Hartford Foundation.

Participants

‐ 300 subjects of 2198 eligible patients (151 control, 149 intervention)
‐ Mean age 78 years, 60% female and 7% admitted from institution.
‐ Inclusion criteria: 70 years or older admitted with a medical or surgical diagnoses.
‐ Exclusion criteria: nonambulatory or living in a nursing home prior to admission, had hospital admission diagnoses known to cause functional impairment, were likely to die within 12 months according to their primary physician, admitted with primary cardiac diagnoses, could not communicate clearly, had an admission Diagnostic Related Group average length of stay of less than 5 days.
Medical Diagnostic Categories: digestive system (20%), circulatory system (7.3%), hepatobiliary system and pancreas (6.3%), male reproductive system (5.3%), skin, subcutaneous tissue or breast (4.7%), male reproductive system kidney and urinary tract (4.7%), female reproductive system (4.7%) and other (17.6%).

Interventions

‐ Exercise only intervention
‐ Exercise program during hospitalisation and 1 month after hospital discharge. 12 exercises for flexibility and strengthening and a walking program. Prescribed by a physiotherapist and supervised once per day by a physiotherapy aid and once per day unsupervised in hospital. Unsupervised for 1 month after discharge.
‐ Twice per day in hospital. Exercises 3 times per week at home. 5‐10 repetitions. Walking 5‐30mins at an intensity of 60‐80% of age adjusted maximum heart rate level and be able to talk while walking. Methods employed to encourage adherence to exercise after discharge eg. adherence cards and phone calls.

Outcomes

‐ Function (Functional Independence Measure, Locomotion Scale, frequency of leaving the neighbourhood, IADLs, National Health Interview Survey Physical Activity Scale), hospital length of stay, RAND General Health Scale, mortality.
‐ Time of outcome measurement: discharge and 1 month after discharge.

Notes

‐ Language: English
‐ PEDro scale: 8
‐ only 20% of the intervention group had a high adherence level to the hospital and home exercises.
‐ Additional information from authors: No
‐ Author conclusions: "An exercise program started during hospitalisation and continued for 1 month did not shorten length of stay but did improve functional outcome at 1 month."

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Low risk

A ‐ Adequate

Methods

‐ A CCT examining the effect of a psychogeriatric intervention group in addition to usual care compared to usual care.
‐ alternating randomisation procedure
‐ Setting: The Netherlands, teaching hospital.
‐ Funding: not stated.

Participants

‐ 237 patients enrolled (140 treatment group, 97 usual care).
‐ Mean age 83 years, 71% female and 28% from an institution.
‐ Inclusion criteria: 75 years or older, referred to the department of general medicine.
‐ Exclusion criteria: patients admitted for day treatment.
Main diagnostic groups: Congestive heart failure (41.35%), diabetes or other endocrinological problems (27.8%), gastrointestinal (18.56%), cancer (12.2%), pneumonia (11.4%) and chronic lung disease (5.97%).

Interventions

‐ Multidisciplinary joint treatment by a psychogeriatric team leader in addition to usual care. Full time physiotherapist and additional 3 nurses on intervention ward. Aim to optimise patient function. Weekly team meetings.
Exercise: Treatment for preventing functional decline and rehabilitation therapy. Supervised by a physiotherapist. Assessed daily by the physiotherapist.

Outcomes

‐ Length of stay, SIVIS dependency scales (Help index, Mobility, ADL+ continence), discharge destination, residence in a long‐term care facility
‐ Time of outcome measurement: hospital discharge.

Notes

‐ Language: English.
‐ PEDro scale: 4
‐ Additional information: No
‐ Author conclusions: "By combining elements from a psychiatric and geriatric consultation service with elements of a unit‐driven service, we were able to improve health care for the elderly in our hospital in a feasible and cost effective way."

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Unclear risk

B ‐ Unclear