Comparison of hospitalisation settings and exercise interventions in acute care: a systematic review and meta-analysis

Abstract

Background

Inpatient hospitalisation is associated with adverse outcomes in older adults, including hospital-associated deconditioning. The hospital-at-home (HaH) model may promote physical activity. This systematic review and meta-analysis compares functional outcomes between inpatient and HaH settings and evaluates the efficacy of exercise interventions in both settings.

Methods

Systematic searches of PubMed, Scopus, Web of Science and ScienceDirect were conducted on 27 April 2024. Three distinct searches were performed: (i) studies comparing HaH and inpatient hospitalisation, (ii) trials evaluating inpatient exercise interventions and (iii) research on HaH exercise interventions. Two reviewers independently selected studies published from 2014 onwards using the PICOS framework and they assessed quality using PEDro scale. A meta-analysis was performed using a random effects model to analyse exercise interventions. This systematic review with meta-analysis was conducted according to PRISMA 2020 guidelines and was registered on PROSPERO (CRD42024598286).

Results

Among the 9470 studies identified, nine studies comparing acute-care settings and 21 studies on exercise interventions (one in HaH) were included. Findings suggest that HaH may positively affect functional and cognitive outcomes. Inpatient exercise interventions significantly improved physical performance [standardised mean difference (SMD) = 0.42, 95% confidence interval (CI) = 0.12–0.72] and functional independence (SMD = 0.45, 95% CI = 0.14–0.77) at discharge.

Conclusion

HaH may contribute to preserving physical and cognitive status. Supervised exercise interventions during inpatient hospitalisation are safe and effective for improving older adults’ functional status, although further research in the HaH model is needed.

Key Points

• Hospital-at-home may contribute to preserving physical and cognitive status.

• Multicomponent exercise programs enhance functional status in hospital inpatients.

• Further research on exercise programs within the hospital-at-home model is needed.

Introduction

Hospitals are frequently associated with several adverse events, such as an increased risk of healthcare-acquired infections, pressure ulcers and falls [1]. Hospital-associated deconditioning is particularly concerning, affecting 30% of older inpatients [2]. Hospital-associated deconditioning is defined as a whole-body syndrome that affects cognitive and physical function, often leading to a reduced ability to perform activities of daily living (ADL) [3, 4]. This condition is linked to an elevated risk of institutionalisation, hospital readmission and mortality [5, 6].

Prolonged bed rest is key to developing hospital-associated deconditioning [7]. A meta-analysis by Fanzio et al. [8] indicated that medical patients are primarily sedentary during their hospital stays, engaging in physical activity for only 4.9% of the daytime hours. This high level of sedentarism has sparked growing interest in the potential of exercise interventions to reverse functional decline and cognitive impairment among hospitalised older adults [9, 10].

Despite advancements in exercise programs, hospital-associated deconditioning and inactivity among inpatients remains high [11, 12]. Environmental and social factors, such as tethering to medical devices, bed-centred care, reliance on beds or wheelchairs for transportation, inappropriate bed rest orders, fear of injury and small and cluttered hallways, may limit physical activity [13]. Consequently, managing patients in a less restrictive home environment may help overcome these barriers, promote physical activity and reduce the risk of functional decline [14].

In this context, the hospital-at-home (HaH) model represents a promising alternative for promoting physical activity while alleviating resource strain [15]. HaH provides acute hospital-level care in a patient’s home for a limited period, treating conditions that would typically necessitate inpatient care [16]. The model comprises two main approaches: early supported discharge (ESD) and admission avoidance (AA). ESD facilitates the early discharge of inpatients, while AA allows direct admission to HaH, effectively replacing inpatient hospitalisation [14]. HaH services are highly heterogeneous, including a broad range of procedures such as continuous monitoring, diagnostic testing (e.g. laboratory tests, electrocardiograms and radiography) and treatment (e.g. intravenous medication) [16].

Recent interest in HaH interventions has surged due to their potential to optimise patient flow, reduce unnecessary hospitalisations and enhance hospital capacity while lowering healthcare costs [15]. Furthermore, HaH has been associated with improved patient satisfaction and lower rates of nosocomial infections without an associated increase in readmission or mortality [14, 17]. HaH may also provide a more conducive environment for maintaining or increasing physical activity [18], although current research remains limited and inconclusive [19]. Some studies suggest that HaH might mitigate the risk of functional decline and cognitive impairment compared to inpatient care, but definitive evidence is lacking [14, 20].

While the efficacy of in-hospital exercise interventions has been extensively studied in acutely hospitalised older adults [10], evidence regarding their implementation in HaH settings for acute medical illnesses has been understudied. Given HaH’s potential to impact key health outcomes such as physical activity, functional status and cognitive health, a review is imperative to consolidate evidence, address inconsistencies and guide future research [19, 21]. This systematic review has three aims: (i) to compare the effects of HaH and hospital-based care on physical activity, functional status and cognitive health, (ii) to assess the effectiveness of exercise interventions in inpatient hospitalisation and (iii) to assess the effectiveness of exercise interventions in HaH.

Methods

Study design

This systematic review with meta-analysis used a triple approach. First, it comprised studies that compare the effects of HaH versus inpatient hospitalisation on physical activity levels, functional decline and cognitive impairment. Second, it included studies evaluating exercise interventions in hospital settings. Finally, we explored the effects of exercise interventions in the HaH context. The review adhered to the guidelines outlined in the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement [22]. This systematic review and meta-analysis was registered on PROSPERO (CRD42024598286).

Search strategy

The three searches performed in this systematic review were conducted on 27 April 2024. Articles were gathered from Medline (PubMed), Web of Science, Scopus and ScienceDirect. Two authors (PE-U and MLSA) independently performed the systematic searches and disagreements were resolved through discussion with a third author (MI). We established a methodological search filter to extract only the results published from 2014 onwards. There were no language filters. The entire search strategy is available in Appendix 1 in the Supplementary Data section.

Selection criteria

The PICOS model defined the inclusion criteria (Appendix 1 in the Supplementary Data section) [23]. We did not include reviews, meeting abstracts, conference proceedings or editorials. Additionally, trials were excluded if acutely ill patients were omitted. We also excluded programs that combined exercise with nutritional or psychological interventions, as this approach may interfere with analysing the effects of exercise itself.

Screening

The search strategy combined all results from the four databases and eliminated duplicates. The identified articles were appraised by reading their titles and abstracts. The selected articles were read, and articles that did not meet the inclusion criteria were excluded.

Data extraction

Two authors (PE-U and MLSA) independently extracted summary estimates data based on key observations. In studies comparing the effects of inpatient hospitalisation and HaH, we recorded the study information (e.g. author name, year of publication and location), population (e.g. age, sex and number of participants), intervention (e.g. type of HaH), measurement methods and outcomes (e.g. physical activity, functional decline and cognitive impairment).

For studies that included exercise interventions, the following information was reviewed: study information (e.g. author name), population demographics (e.g. age and number of participants), exercise intervention (e.g. frequency, volume and type of exercise), measurement methods and outcomes (e.g. functional and cognitive decline).

Risk of bias assessment

Two authors (PE-U and MLSA) independently evaluated the risk of bias for each included trial using the PEDro Scale. According to Maher et al. [24], PEDro is a reliable 11-item scale for measuring the methodological quality of randomised controlled trials (RCTs). Including RCTs was a requirement that was applied exclusively to studies assessing inpatient exercise interventions. Therefore, given that there were no RCTs among the selected studies in the other two searches, we only evaluated the methodological quality of studies analysing exercise interventions during inpatient rehabilitation. We illustrated the results of the PEDro Scale using Review Manager (RevMan) 5.3 software [25].

Statistical analysis

A meta-analysis was conducted when at least three RCTs compared the effects of exercise with a control group for a specific endpoint. If multiple studies from the same RCT assessed the same endpoint, only primary analyses were included and ancillary analyses were excluded to avoid redundancy. Heterogeneity across studies was evaluated using Cochran’s Q test and Higgins I² statistic [26, 27]. Depending on the level of heterogeneity observed, we applied a random-effects model using the Empirical Bayes method [28]. The pooled standardised mean difference (SMD) and 95% confidence intervals (CI) for the interventions were calculated. Publication bias was assessed using selection models and Egger’s test. Sensitivity analyses were conducted by adjusting for bias through selection models [29]. A significance level of 0.05 was set for all statistical tests. Statistical analyses were performed using JASP software, version 0.18.3 (2024).

Results

Study selection

Figure 1 shows the three flow diagrams of the database search process. After identifying 9470 studies, 27 were selected for the qualitative analysis, of which 10 were subsequently included in the meta-analysis. Six studies compared inpatient hospitalisation with HaH, while the remaining 21 studies analysed the effects of exercise interventions (20 in inpatient settings and one in HaH).

Figure 1.

Flow diagram. n, number of studies.

The search of studies comparing HaH and inpatient hospitalisation yielded a total of 2899 studies, all of them obtained from Scopus (n = 1026), Web of Science (n = 810), PubMed (n = 730) and ScienceDirect (n = 333). After removing 1580 duplicates, 1319 articles were screened for titles and abstracts. Among the 46 full-read articles, 40 were excluded based on the previously established inclusion and exclusion criteria. Consequently, the final selection for qualitative analysis consisted of six articles.

The search process for studies examining the effects of exercise interventions during inpatient hospitalisation identified 5161 records from four databases: Scopus (n = 1927), ScienceDirect (n = 1121), Web of Science (n = 1116), and PubMed (n = 997). Additionally, four records were identified from the reference lists, resulting in 5165. After removing duplicates, 3052 records were screened by title and abstract. Of these, 66 full-text articles were assessed for their eligibility. Ultimately, 20 studies were included in this qualitative analysis, with 10 of these further included in the meta-analysis.

The search process for studies investigating the effects of exercise interventions in HaH settings yielded 1410 records from four databases: PubMed (321), Web of Science (355), Scopus (453) and ScienceDirect (281). After removing duplicates, 776 records were screened by their titles and abstracts. Of these, 46 full-text articles were assessed for eligibility. Only one study was included in this qualitative analysis, which prevented us from performing a meta-analysis.

Risk of bias

Figures 1 and 2 in Appendix 1 in the Supplementary Data section summarise the risk of bias across RCTs that assessed exercise interventions during inpatient hospitalisation. Overall, the articles analysed had high methodological quality.

Figure 2.

Forest plot of physical performance in inpatient settings. CI, confidence intervals. n, number of subjects in each group. N, total subjects of the study. SMD, standardised mean difference.

Studies comparing inpatient hospitalisation and HaH

Table 1 presents the characteristics of the six selected studies that compared inpatient hospitalisation with HaH. These studies included 2910 acutely hospitalised older patients of both sexes with medical conditions that required hospital-level care. The predominant type of HaH studied was AA [30–34], with only one study examining ESD combined with AA [35].

Table 1.

Qualitative analysis of studies comparing HaH and inpatient hospitalisation.

	Design	Patient characteristics	HaH type	Analysed variables	Measurement methods	Outcome
Arai et al. [30] 2020 Japan	Retrospective case–control study	N (M/F): 61 (27/34) Mean age (SD): 84.76 (5.19) HaH/inpatients: 40/21	AA and condition-specific	Functional status Cognitive status	DILE-disability DILE-dementia	In comparison with HaH patients, hospital inpatients group had a higher proportion of patients whose disability had worsened (P = 0.16) and a significantly higher proportion of patients whose dementia had worsened (P = 0.03).
Arai et al. [31] 2023 Japan	Prospective case–control study	N (M/F): 45 (20/25) Mean age (SD): 88.03 (5.33) HaH/inpatients: 30/15	AA and condition-specific	Functional status Cognitive status	DILE-disability DILE-dementia	There were no significant between-group differences in disability (P = 0.06), whereas dementia significantly worsened in hospital inpatients compared to HaH patients (P = 0.02).
Mas et al. [35] 2017 Spain	Quasi-experimental longitudinal study	N (M/F): 849 (238/611) Mean age (SD): 83.23 (7.32) HaH/inpatients: 244/605	AA/ESD and frailty centric	Functional resolution	Barthel Index	There were no significant between-group differences in functional resolution (P = 0.247).
Mas et al. [32] 2018 Spain	Quasi-experimental longitudinal study	N (M/F): 171 (70/101) Mean age (SD): 86.1 (6.8) HaH/inpatients: 57/114	AA and frailty centric	Relative functional gain at discharge	Barthel Index	Relative functional gain was significantly higher in the HaH group compared to hospital inpatients (P = 0.01).
Shepperd et al. [33] 2021 United Kingdom	Randomised trial	N (M/F): 1032 (407/625) Mean age (SD): 83.3 (7) HaH/inpatients: 687/345	AA and frailty centric	Functional status	Barthel Index	The number of HaH patients with a score ≥15 in BI was increased by 9.5%. The number of hospital inpatients with a score ≥15 in BI was increased by 10.7%.
Tierney et al. [34] 2021 United Kingdom	Retrospective observational study	N (M/F): 505 (182/323) Mean age (SD): 83.76 (6.47) HaH/inpatients: 314/191	AA and frailty centric	Mobility function	Categorisation	A significantly higher number of hospital inpatients had worsened mobility in comparison with HaH patients (P = 0.008).

ADL, Activities of Daily Living. DILE-dementia, Degree of independent living for older people with dementia. DILE-disability, Degree of independent living for older adults with disabilities. IADL, Instrumental Activities of Daily Living. IQR, interquartile range. N (M/F), number of participants (male participants/female participants). RCT, randomised controlled trial. SD, standard deviation.

Of the studies included, none compared physical activity levels between inpatient hospitalisation and HaH. Five studies evaluated functional decline: two found significant differences [32, 34], whereas three did not [30, 31, 35]. The measurement methods used for the functional decline included the Barthel Index [32, 33, 35], Degree of Independent Living for the Elderly with Disability (DILE-disability) [30, 31], Lawton-Brody’s Index [18, 36], and categorisation of mobility function [34]. Only two studies have assessed cognitive decline. Both used the Degree of Independent Living for the Elderly with Dementia (DILE-dementia) and found that a higher proportion of dementia worsened among hospital inpatients than among HaH patients [30, 31].

Studies assessing exercise interventions in acute care

Table 2 presents 20 RCTs that assessed the impact of exercise interventions in acutely ill older inpatients (further details in Appendix 1 in the Supplementary Data section) [36–55]. Of these, nine were secondary analyses [38, 44–46, 49–53]. All studies included older adults, some focusing exclusively on those aged 75 years and above [38, 41–46, 48–53, 55], whereas others included participants aged 65 years and older [36, 37, 39, 40, 47, 54].

Table 2.

Qualitative analysis of studies analysing the effects of exercise interventions in inpatient settings.

	Population	Intervention characteristics	Measurement methods	Outcome (between-group differences)
Braun et al. [36]	N (EG/CG): 35 (9/26) Age: 80.9 (7.7)	EG: 4–5 sessions/week (20–30′) of strength, balance and walking. CG: usual care.	DEMMI, HABAM,TUG, FAC, gait speed and 6MWD	There were no significant differences in any of the outcomes (P > 0.05).
Brown et al. [37]	N (EG/CG): 100 (50/50) Age: 73.9 (6.96)	EG: 2 daily sessions (15–20′) of strength and walking. CG: usual care.	Katz Index	There were no significant differences in ADL function (P = 0.67).
Cadore et al. [38]	N (EG/CG): 90 (44/46) Age: 87.73 (4.84)	EG: 2 daily sessions (20′) of strength, gait and balance. CG: usual care.	1RM in leg press and bench press and power at ≤30% and 55% of 1RM	EG significant improved 1RM (leg press and bench press) and power (P < 0.05).
Gazineo et al. [39]	N (EG/CG): 387 (193/194) Age: 86.46 (6.98)	EG: 1 daily session (20–30′) of assisted walking. CG: usual care.	BAS	EG significantly improved walking ability (P < 0.001).
Hu et al. [40]	N (EG/CG): 100 (50/50) Age: 76.63 (7.12)	EG: 30′ daily session of walking and balance exercises. CG: usual care.	Katz Index, TUG and handgrip	There were no significant differences in any of the outcomes (P > 0.05).
Lozano-Vicario et al. [41]	N (EG/CG): 36 (18/18) Age: 87.4 (6.7)	EG: 30′ daily session of strength, balance and walking. CG: usual care.	SPPB, HABAM, BI, handgrip and 1RM	EG significantly improved HABAM (P = 0.015). There were no significant differences for other outcomes (P > 0.05).
Martínez-Velilla et al. [42]	N (EG/CG): 200 (97/103) Age: 86.5 (4.4)	EG: 2 daily sessions (20′ each) of strength, gait and balance. CG: usual care.	SPPB, BI, handgrip and MMSE	EG significantly improved SPPB and handgrip (P < 0.05), with no significant differences in BI or MMSE (P > 0.05).
Martínez-Velilla et al. [43]	N (EG/CG): 370 (185/185) Age: 87.3 (4.9)	EG: 2 daily sessions (20′ each) of strength, gait and balance. CG: usual care.	SPPB, BI, handgrip and MMSE	EG significantly improved SPPB, ADL function, MMSE and handgrip (P < 0.001).
Martínez-Velilla et al. [44]	N (EG/CG): 35 (22/13) Age: ≥75	Same as above.	SPPB, BI, handgrip and MMSE	EG significantly improved SPPB (P = 0.01), with no significant differences for the rest of the outcomes (P > 0.05).
Martínez-Velilla et al. [45]	N (EG/CG): 297 (148/149) Age: 87.3 (4.9)	Same as above.	BI	EG significantly improved all ADL functions (P < 0.05), except feeding and bowel control (P > 0.05).
Martínez-Velilla et al. [46]	N (EG/CG): 103 (54/49) Age: 86.52 (4.51)	Same as above.	SPPB, BI, handgrip and MMSE	EG significantly improved SPPB, ADL function, handgrip and MMSE (all of them P ≤ 0.001).
McCullagh et al. [47]	N (EG/CG): 190 (95/95) Age: 80 (7.47)	EG: 2 sessions of strength, balance and gait, 5 days/week. CG: stretching exercises.	SPPB	EG significantly improved SPPB compared to CG (P = 0.01).
Ortiz-Alonso et al. [48]	N (EG/CG): 268 (143/125) Age: 88 (5)	EG: 1–3 sessions of strength and walking 5 days per week. CG: usual care.	Katz index, SPPB and FAC	There were no significant differences in ADL function, walking ability and SPPB (P > 0.05).
Pérez-Zepeda et al. [49]	N (EG/CG): 370 (163/160) Age: 87.3 (4.9)	EG: 2 daily sessions (20′) of strength, balance and walking CG: usual care.	FI	EG significantly improved frailty (P < 0.05).
Sáez de Asteasu et al. [50]	N (EG/CG): 370 (185/185) Age: 87.3 (4.9)	Same as above.	GVT, TMT-A, verbal fluency test and MMSE	EG significantly improved verbal and arithmetic GVT, MMSE, verbal fluency test and TMT-A (P < 0.001).
Saez de Asteasu et al. [51]	Same as above.	Same as above.	Prevalence of responders, non-responders and adverse responders.	In EG a significantly higher number of responders was found in all the endpoints (all P < 0.001).
Sáez de Asteasu et al. [52]	N (EG/CG): 130 (65/65) Age: 87 (4.62)	Same as above.	SPPB, 6-metre GVT, GVT, 1RM leg press and power at 50% of 1RM	EG significantly improved SPPB, 6-metre GVT, GVT, leg press 1RM and leg power at 50% of 1RM (P < 0.05).
Sáez de Asteasu et al. [53]	N (EG/CG): 370 (185/185) Age: 87.3 (4.9)	Same as above.	Maximal isometric strength, 1RM and peak of power at various percentages of 1RM	EG significantly improved isometric strength, 1RM and peak of power at 30%–75% of 1RM (P < 0.001).
Torres-Sánchez et al. [54]	N (EG/CG): 58 (29/29) Age: 73.89 (7.44)	EG: daily incremental cycling exercise in a pedal exerciser. CG: usual care.	30STS, OLS test, lower limb strength and number of steps	EG significantly improved strength, steps and balance (P < 0.05), with no significant differences for other outcomes (P < 0.05).
Tor-Roca et al. [55]	N (EG/CG): 109 (63/46) Age: 87 (5)	EG: 2 daily sessions (30′) of strength, balance and walking. CG: usual care.	BI	EG significantly improved ADL function (P < 0.05).

6MWD, 6-metre walking distance. BAS, Braden Activity Subscale. BI, Barthel Index. CST, chair stand test. DEMMI, De Morton Mobility Index. FAC, Functional Ambulatory Categories. FI, frailty index. GVT, dual-task (verbal and arithmetic) Gait Velocity Test. HABAM, Hierarchical Assessment of Balance and Mobility. MMSE, Mini-Mental State Examination. N, number of participants. OLS, one-leg stance. RM, repetition maximum. RPE, rate of perceived exertion. SPPB, Short Physical Performance Battery. STS, sit-to-stand. TMT-A, Trail Making Test Part A. TUG, Timed Up and Go test.

Several interventions have been supervised [36, 37, 39–42, 47, 48, 54, 55], whereas others have combined supervised and unsupervised sessions [43–46]. Most studies implemented a multicomponent exercise intervention [36, 41–47, 55]; although some focused solely on walking programs [37, 39, 40, 48]. The control group received usual care in all studies except one in which patients performed stretching and relaxation exercises [47].

The frequency, volume and intensity of exercise prescriptions varied across studies. Most interventions lasted >3 days [40–53], with participants generally performing two daily sessions [37, 42–47, 55] of 20–30 minutes each [36, 39, 43, 55] at an intensity of 30%–60% of 1RM [38, 42–46].

Excluding ancillary analyses, eight studies [41–44, 48] evaluated overall physical performance using measures such as the Short Physical Performance Battery (SPPB), 30-second sit-to-stand (STS) test and timed up and go (TUG) test. Despite significant heterogeneity among the included studies (Q = 41.319, I² = 82.578%, P < 0.001), no evidence of publication bias was detected (P = .876). This finding was further corroborated by Egger’s regression analysis, which also indicated the absence of publication bias (P = .791). The results demonstrated that exercise interventions significantly improved physical performance (SMD = 0.42, 95% CI: 0.12–0.72, P = .007, Fig. 2). This effect persisted when analysed using the adjusted random effects model (SMD = 0.44, 95% CI: 0.02–0.87, P = .041). The mean model estimates are shown in Appendix 1 in the Supplementary Data section.

Following the exclusion of secondary analyses, seven studies evaluating functional independence were identified using tools such as the Katz and Barthel indices [37, 40–43, 48, 55]. Considerable heterogeneity was observed across studies (Q = 25.447, I² = 84.122%, P < .001). Nevertheless, the analysis showed no publication bias (P = .706). This was further substantiated by Egger’s regression test, which confirmed the absence of bias (P = .946). The findings revealed that exercise interventions significantly improved functional independence (SMD = 0.45, 95% CI: 0.14–0.77, P = .005, Fig. 3). This positive effect was sustained in the adjusted random effects model (SMD = 0.65, 95% CI: 0.43–0.86, P < .001). The estimated mean model is shown in Appendix 1 in the Supplementary Data section.

Figure 3.

Forest plot of functional independence in inpatient settings. CI, confidence intervals. n, number of subjects in each group. N, total subjects of the study. SMD, standardised mean difference.

Four studies evaluated handgrip strength using a dynamometer [40–43]. Substantial heterogeneity was detected across these studies (Q = 22.429, I² = 81.673%, P < .001). Nonetheless, the analysis revealed no evidence of publication bias (P = .107). This finding was further supported by Egger’s regression, which confirmed the absence of bias (P = .233). According to the Empirical Bayes results, the evidence for a significant improvement in handgrip strength was insufficient (SMD = 0.41, 95% CI: 0.00–0.82, P = .051, Appendix 1 Supplementary Data section). However, upon adjusting for publication bias, the effect became statistically significant (SMD = 0.47, 95% CI: 0.35–0.59, P < .001). The mean model estimates are presented in Appendix 1 in the Supplementary Data section.

Studies assessing strength using the 1RM test have identified significant improvements in the leg, bench and chest press [38, 52, 53]. Additionally, these studies reported significant gains in muscle power at 30%, 45%, 60% and 75% 1RM [38, 52, 53]. These findings were excluded from the meta-analysis because two studies were ancillary analyses of the same RCT [52, 53].

Cognitive function was primarily assessed using the Mini-Mental State Examination (MMSE), with approximately half of the studies reporting significant differences [43, 46, 50], while the remainder did not [42, 44, 49]. Other assessments that demonstrated significant differences included the Verbal and Arithmetic General Verbal Test (GVT), verbal fluency test and Trail Making Test Part A (TMT-A) [50, 52]. These studies were excluded from the meta-analysis owing to the limited number of independent studies, as only two were not classified as ancillary analyses.

Appendix 1 in the Supplementary Data section includes the only exercise intervention conducted in HaH settings [56]. Eleven older patients admitted to HaH completed a four-week cognitive neuromotor functional training programme. Baseline and post-intervention comparisons revealed significant balance, gait, strength and agility improvements.

Discussion

HaH may reduce the risk of functional and cognitive decline compared with inpatient hospital settings, although its effects on physical activity levels remain under-researched. Additionally, multicomponent exercise interventions in inpatient care have proven safe and effective in mitigating these declines. Still, further research is needed to evaluate the role of exercise within the HaH model.

Studies analysing the impact of HaH on functional decline have reported inconsistent findings, possibly influenced by patient characteristics and methodological variability, such as the timing of functional assessments [30, 31, 33] and the use of different measurement tools [30, 32].

Cognitive outcomes have been compared in only two studies [30, 31]. Although neither found significant differences in functional decline, both reported a significantly higher proportion of inpatients with worsening dementia, which may be partially explained by the fact that the hospital is a more deliriogenic environment than home [30, 31]. However, the rating scales used in these studies may lack the precision needed for accurate measurement, potentially leading to misinterpretation of the data [31]. Multiple studies have affirmed the efficacy of exercise interventions during conventional hospitalisation [39, 47, 54], particularly multicomponent programs that include resistance training to counteract muscle weakness [38, 43, 45, 50, 52, 53]. Such interventions have led to improvements in functional and cognitive status. However, some studies failed to show significant benefits, likely due to small sample sizes [36], inadequate adherence to exercise regimens [40], or insensitive measurement tools [37, 57].

Patient characteristics, such as baseline functional status, also contribute to heterogeneity in studies investigating exercise interventions. Patients with poorer functional status at admission often exhibit less favourable responses to such interventions [51], potentially influencing outcomes across different studies.

The limited research on exercise interventions within HaH settings includes a study that reported significant improvements in balance, gait, strength and agility. However, the absence of a control group makes it difficult to distinguish the effects of the exercise intervention from natural recovery from the underlying condition [56].

Traditional hospital care, characterised by prolonged immobility, can exacerbate age-related declines in strength and power, thereby increasing the risk of functional decline, frailty and sarcopenia [30, 38]. Their potential efficacy underscores the implementation of exercise interventions in the HaH model. Approximately 18% of medical admissions are estimated to be suitable for HaH, further highlighting the model’s potential to reduce healthcare costs and improve patient outcomes [58]. However, rigorous, well-controlled studies are required to validate the efficacy of exercise interventions within HaH.

Functional decline during hospitalisation is associated with increased mortality within a year post-discharge, underscoring the importance of interventions aimed at maintaining functional status during acute care episodes [51]. HaH models can play a pivotal role in shaping future healthcare practises that prioritise patient welfare and resource optimisation by fostering environments that mitigate the risks associated with traditional hospitalisation, such as extended immobility and related complications [58].

This review offers several strengths, including its comprehensive triple approach, which robustly analyses various acute medical care models and their impact on patient-related outcomes. However, this study also has some notable limitations that must be considered. First, the configuration and functionalities of HaH programs vary significantly across international contexts, affecting the uniformity and comparability of the results [34, 35]. Second, current studies differ widely in their functional endpoints and measurement tools, complicating the comparison and synthesis of results [30, 45]. Instruments like the Barthel Index are intended for performance-based assessments. However, many studies rely on patient self-reporting, which can lead to an overestimation of functional status [59].

Moreover, the outcomes assessed and measurement methods used across studies must be more consistent [45]. Adopting a unified framework for future studies or developing a new, standardised instrument to measure patient outcomes in HaH settings is crucial in addressing these challenges and advancing research in this field [59].

Personalisation of exercise prescriptions is another critical area that requires development, particularly for hospitalised older individuals. Research has shown that not all patients benefit equally from the same type of exercise intervention due to varying health statuses and capabilities [10, 51, 55]. Tailoring exercise programs according to patient’s needs and functional conditions could significantly enhance the effectiveness of interventions, particularly in HaH settings.

Moreover, exploring the interrelationships between cognitive and physical function is important. Enhancements in cognitive function have been observed to mediate improvements in physical function among acutely hospitalised older adults following exercise interventions [60]. Understanding and leveraging this relationship can lead to more effective strategies to address cognitive and physical decline.

Finally, future studies should include assessments of the cost-effectiveness of HaH programs, particularly those that incorporate exercise interventions. Previous evaluations of HaH’s cost-effectiveness may have overlooked the potential costs or savings from implementing these interventions, which could significantly impact healthcare expenditure [14]. Understanding the factors that predict the need for institutional care post-discharge from HaH could help optimise care pathways and reduce long-term dependency, improving quality of life and reducing healthcare burdens.

Conclusion

In conclusion, this review highlights the potential advantages of HaH for promoting physical activity during acute medical treatment. While evidence on reducing functional and cognitive decline in HaH settings is still emerging, there is a discernible trend towards decreased risk compared to inpatient care. Additionally, multicomponent exercise interventions during hospitalisation are safe and effective in preventing functional and cognitive decline.

Further research is essential, particularly regarding exercise interventions in HaH. Key areas for advancement include developing and validating measurement tools to assess outcomes in HaH accurately, personalising exercise prescriptions to individual health conditions and rigorously evaluating exercise interventions in HaH settings. Focusing on these areas will enhance our understanding of HaH, provide evidence for its benefits and facilitate its broader integration into healthcare systems. Ultimately, these efforts can improve patient outcomes while aligning with modern healthcare objectives such as reducing costs and improving care efficiency.

Declaration of Conflicts of Interest:

None.

Declaration of Sources of Funding:

None.

Research Data Transparency and Availability:

Data available from the authors upon reasonable request.