Can in-hospital or post discharge caregiver involvement increase functional performance of older patients? A systematic review

Functional decline including reduced abilities of self-care are common consequences of hospitalization among older adults [1]. Up to 39% of patients 75 years or older admitted to geriatric, medical and surgical wards experience functional decline [2, 3]. The frequency of functional decline increases with age and is associated with the failure to recover to the basic activities of daily living (ADL) level during hospitalization [3]. Inactivity, immobility, suboptimal continence care, and poor nutrition during hospitalization have been suggested as the main reasons for functional decline [1, 4].

Physical therapy (PT) has proven to be effective in improving functional performance in older hospitalized patients [5]. A systematic review by Kosse et al. indicated that early physical therapy and rehabilitation can be safely executed and leads to better performance of ADL, shorter length of stay, and higher proportion of discharge home in hospitalized older adults [6]. Geriatric rehabilitation is best seen as a holistic treatment with a functional and multidisciplinary approach as well as long term health promotion [7‐9]. Since increased physical activity is associated with arresting or reversing declines in functional performance, patients should be guided to seek opportunities and use available tools to achieve an active lifestyle [8, 9].

New hospital acquired ADL disability, is associated with the inability to regain pre-hospital functioning [10‐12]. Only between 30 to 50% of the older patients regain pre-hospitalization activity levels and 25% of older adults treated in an inpatient rehabilitation facility are readmitted soon after discharge [13]. Limited time of PT, lack of patient activity outside therapy and detraining (deterioration of the acquired level of performance) when therapy has stopped are all reasons for functional decline, both during hospitalization and after discharge [14‐17]. Extra PT time improves functional outcome and shortens length of stay, but consequently increases healthcare costs [18]. Even when PT meets the WHO activity guideline of 300 min of activity at moderate intensity per week, it still is insufficient to change sedentary behavior [19, 20]. At the same time, it is often difficult for hospitalized older patients to be active on their own, due to, among others, their dependency of healthcare workers (HCW) for transfers and walking. In addition, patients are discharged as soon as a basic level of functional performance is met, like getting in and out of bed [21]. Consequently, at the moment of discharge the patient’s functional performance level is lower than their pre-hospital level. This in turn, makes patients and caregivers cautious about taking up normal activities or even continuing exercises.

Informal caregivers play an important role in care of older people in Europe as no care system will ever be able to completely cover all long-term care needs by professional health care services [22]. A meta-analysis by Sörensen et al. shows that different interventions with caregivers are effective in lowering caregiver burden, depression, care receiver symptoms, and in improving subjective well-being, perceived caregiver satisfaction and ability/knowledge [23]. Although several studies evaluated the effect of caregiver involvement on functional performance in older adults, no systematic review on this subject has been undertaken.

The aims of this systematic review are:

The review protocol was registered in PROSPERO (CRD42018091798) and the PRISMA reporting guidelines were used. (www.​prisma-statement.​org).

This review summarizes the evidence of in-hospital and post discharge caregiver involvement in increasing functional performance in older adults. Furthermore, we looked at the influence on psychological well-being, healthcare utilization, discharge destination and mortality. Based on the main caregiver intervention we distinguished three groups, a care pathway [26], education and bed-side handling skills [27, 29, 32, 33], and caregiver mediated exercises [28, 30, 34]. The influence of caregiver involvement on functional performance, as well as on the other outcomes varied widely between the eight included studies. Positive results were mainly evident at the end of the intervention and in the following 3 months.

The findings of this review suggest that involvement of caregivers in the rehabilitation of older adults leads to better functional performance up to 3 months after initiation. Three different types of caregiver involvement showed positive results for functional performance up to 3 months after initiation, but evidence is low. Sessions on education and handling skills practice seem effective to improve functional performance and psychological well-being, and decrease length of stay. Caregiver-mediated exercises seem to be more effective when baseline functional performance is lower. However, further research is needed on the generalizability of and contributing factors to, these improvements as programs involving caregivers are so far heterogeneous, predominantly investigated post stroke and show a variable effect on outcomes.