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Facilitators and barriers to enhancing physical activity in older patients during acute hospital stay: a systematic review
International Journal of Behavioral Nutrition and Physical Activity volume 19, Article number: 99 (2022)
To improve older patients’ physical activity (PA) behavior, it is important to identify facilitators and barriers to enhancing PA in older patients (≥ 65 years) during hospitalization from the perspectives of patients, caregivers, and healthcare professionals (HCPs).
In this systematic review, a search of PubMed, CINAHL, PsycINFO, EMBASE, and Web of Science (January 2000–May 2021) was performed, and quantitative, qualitative, and mixed-methods studies were included. The methodological quality of included studies was assessed using the Mixed Methods Appraisal Tool. Identified facilitators and barriers were categorized using the social ecological model at the intrapersonal, interpersonal, and institutional levels.
The 48 included articles identified 230 facilitators and 342 barriers. The main facilitators at the intrapersonal level included: knowledge, awareness, and attitudes; interpersonal level: social support, including encouragement and interdisciplinary collaboration; and institutional level: stimulating physical environment, patient activities and schedules, and PA protocols. The main barriers at the intrapersonal level included: physical health status, having lines or drains, patients’ fear, and HCPs’ safety concerns; interpersonal level: patient-HCP relation and HCPs’ unclear roles; and institutional level: lack of space and resources, including time and equipment. Best evidence synthesis provided moderate level of evidence for three barriers: patients’ unwillingness or refusal to move, patients having symptoms, and patients having lines or drains. No moderate level of evidence was found for facilitators.
The PA behavior of older adults during hospitalization is multidimensional. Our overview highlights facilitators and barriers on multilevel scale (intrapersonal, interpersonal, and institutional levels) that guides patients, caregivers, HCPs, and researchers in future clinical practice, and intervention development and implementation.
Aging is associated with a higher prevalence of age-related diseases and health-related events . Figures from high income countries show that up to 50% of all patients admitted to the hospital are over 65 years [2,3,4], which is expected to increase in the coming years with an increasingly older population . Regardless of disease on admission or treatment, hospitalized older patients are at increased risk of loss of functional capacity, which can be long lasting, even after discharge [5,6,7,8]. Loss of functional capacity is defined as the loss of ability to perform activities of daily living (ADL), which may lead to considerable consequences, including increased risk of readmission, institutionalization, and even death [9,10,11,12]. Low in-hospital physical activity (PA) behavior is an important risk factor for loss of functional capacity that can be prevented [5, 6, 8, 10, 13].
Although PA is important to prevent loss of functional capacity in older patients, few patients engage in PA during hospital admission. Figures show that older patients, including patients who might be able to ambulate independently, spend at least 80% of the day lying in bed during hospitalization [14,15,16,17]. Restricted PA and bedrest are harmful, resulting in large reductions in muscle mass and function, loss of aerobic capacity, increase in fatigue, and decrease in quality of life [18,19,20,21,22]. Especially for older patients, the impact of bed rest and low PA appears to have more deleterious effects on the aforementioned muscle function, aerobic capacity, and ADL functioning than for younger adults [18, 22, 23].
It is indicated that augmenting PA during hospitalization seems to be effective for improving physical functioning, emotional status, social well-being , and may lead to a possible reduction in patient falls . However, despite the proven added value of PA, the idea of ‘being cared for’ and ‘lying in the hospital’ seems deeply rooted and should change into ‘working on recovery’ in order to increase patients’ PA behavior [7, 26]. To achieve this change, it would be necessary to gain insight into factors that positively or negatively contribute to the level of PA in older patients during hospitalization.
To the best of our knowledge, a systematic overview of the literature regarding facilitators and barriers toward PA in older hospitalized patients is lacking. Recently, studies identifying facilitators or barriers to enhancing PA have been reviewed for hospitalized patients of all ages [27,28,29], as well as for older patients in the home setting [30, 31]. From these home-setting studies, it is known that there might be specific factors for older persons, such as fear of falling, that are barriers to PA . Furthermore, it is known that there are specific hospital-setting factors, such as the influence of healthcare professionals (HCPs), patients’ health status or lack of resources [27,28,29]. Given the specific hospital setting in the current review, in which patients enter a different and unfamiliar context, it is conceivable that facilitators and barriers might be different for patients over 65 years than for younger patients.
The first step in changing PA behavior in older hospitalized patients is to explore which modifiable factors are related to PA. The aim of this study was to systematically review the literature focusing on the identification of facilitators and barriers to enhance PA in older patients (≥ 65 y) during hospital admission from the perspectives of patients, caregivers, and HCPs (e.g., nurses, physiotherapists, medical doctors, dietitians) working in an acute care setting with older patients.
This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Additional files 1 and 2) . The protocol was registered in PROSPERO (CRD42020172923).
Criteria for inclusion and exclusion
To be included in this review, studies had to explore facilitators and/or barriers to PA in older patients during hospitalization. Studies were included if: 1) they were published between January 1, 2000, and May 29, 2021; 2) they were written in English, German, or Dutch; 3) they used a quantitative, qualitative, or mixed-methods study design; and 4) the study population consisted of patients aged ≥65 years (baseline mean age of 65 years or older), caregivers, or HCPs. Furthermore, PA was defined as any kind of bodily movement produced by skeletal muscles that results in energy expenditure . Therefore, for this review, PA concerned all patient activities (e.g., ADL, with or without assistance sitting, standing, walking, or exercising) that contributed to preventing functional decline. Barriers were defined as perceived obstacles to engage in behavior to enhance PA, and facilitators were defined as the forces acting in, on, or around a person to encourage PA behavior.
Studies were excluded if they were: 1) editorials, opinion papers, conference abstracts, or literature reviews; 2) targeting patients with moderate to severe dementia according to standard diagnostic criteria (e.g., DSM-4-TR, DSM-5, NINCDS-ADRDA, and NINCDS-AIREN) or palliative patients; 3) studies with no original participant data regarding barriers and facilitators; and 4) studies that were performed in an inpatient rehabilitation or psychiatric unit, or in healthcare settings other than hospitals, such as outpatient clinics.
A literature search was conducted using PubMed, CINAHL, PsycINFO, EMBASE, and Web of Science databases (Additional file 3). The search string combined the following key words: hospitalization, PA, facilitators or barriers, and older patients. For each keyword, synonyms and subject heading terms were included. The search strategy was drafted with the help of an experienced librarian.
All records obtained were deduplicated using RefWorks bibliographic management software (ProQuest). The titles and abstracts of the retrieved studies were independently screened by two reviewers (FD and GS) using Rayyan . After initial screening, the full texts of these studies were retrieved and independently screened for eligibility. In case of discrepancies, these were resolved by discussion and, with remaining doubts, by seeking the opinion of another reviewer (HH).
Two reviewers (FD and GS) independently assessed the methodological quality of each included study using the validated Mixed Methods Appraisal Tool (MMAT, version 2018) . The MMAT is a critical appraisal tool that is designed for appraisal of systematic mixed studies reviews, i.e. reviews that include qualitative, quantitative and/or mixed methods studies . The MMAT was chosen to appraise a diverse study design types. The use of one instrument, instead of using a diverse set of instruments for different study design types, provided the opportunity to compare methodological quality results with each other.
The MMAT has five sets of criteria for the following five categories: a) qualitative, b) randomized controlled trials (RCTs), c) non-randomized, d) quantitative descriptive, and e) mixed-methods studies. For each included study, the appropriate set of criteria was rated on a categorical scale (yes, no, cannot tell). For mixed-method studies, 15 criteria were rated instead of five. Discrepancies were discussed until consensus was reached, and when necessary, they were resolved with a third reviewer (HH).
To provide an indication of the quality of each study (low or high), an overall quality score was calculated. The overall quality score reflected the number of criteria satisfied, varying from no criteria met to all five criteria met. For mixed-method studies, the lowest score was used as overall quality score. Subsequently, the overall quality scores of each study were used to group studies into two categories: high (MMAT score 4 or 5) and low (MMAT score 0–3) quality. The categories were determined based on a previous similar review  and by team consensus. An overall quality score was preferred instead of a detailed presentation of the ratings as suggested by the MMAT authors , since these categories were not used as inclusion or exclusion criteria.
Data extraction and synthesis
One researcher (FD) extracted data from the selected full-text studies. The characteristics extracted included author details, year of publication, aim, study design, methods, participant characteristics, and main results. For the facilitators and barriers, the original study had to indicate whether a factor was a facilitator or barrier to enhancing PA. Uncertainties or questionable issues were resolved by discussion between two authors (FD, HH). A randomly selected 20% of the data extraction records were cross-checked by another author (GS).
Data synthesis was performed by two researchers (FD and GS). A framework synthesis was used as a starting point to synthesize the factors influencing PA, and the integration of qualitative and quantitative research emerged [37, 38]. The adapted framework of the social ecological model  was therefore used, consisting of intrapersonal, interpersonal, and institutional levels (Additional file 4), which was used previously in systematic reviews [30, 31]. The extracted facilitators and/or barriers with related concepts were organized into descriptive major themes and subthemes using an inductive approach. Next, (sub)themes were categorized based on the levels of the social ecological model. Furthermore, to determine whether reported PA interventions were possibly working as facilitators or barriers to PA, the characteristics of the performed PA intervention and their clinical effects were described. Per included study, the whole PA intervention was interpreted as one factor that might enhance patients’ PA, since it was impossible to distinguish what kind of element within the PA intervention was the facilitating and/or hampering factor.
Best evidence synthesis
The level of evidence of facilitators and/or barriers from quantitative studies and quantitative parts of mixed-methods studies was assessed using the best evidence synthesis approach [40, 41]. The approach was applied to facilitators and barriers that were reported at least once in RCTs or at least twice in non-randomized studies. The approach considered the study’s quality (defined by MMAT scores), study design, the number of articles, and finding consistency, to classify the evidence as strong, moderate, limited, conflicting, or insufficient  (Table 1).
Study selection and characteristics
A flowchart of the search strategy is presented in Fig. 1. The initial search of the databases yielded 19,060 records. After removing duplicates, a total of 12,690 articles were screened on title and abstract, of which 12,590 did not meet the inclusion criteria. Of the 100 articles for which the full text was read, another 52 did not meet the inclusion criteria. The 48 articles included in the review comprised 18 qualitative, 19 quantitative, and 11 mixed-methods studies (Additional file 5). The studies were conducted in 14 countries, of which the most common were the USA (n = 16) and Australia (n = 6). Over half (60%) of the included studies have been published since 2018. Twenty studies focused on patient perspectives [42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61], ten described HCPs’ perspectives [62,63,64,65,66,67,68,69,70,71], 16 focused on both patients and HCPs [72,73,74,75,76,77,78,79,80,81,82,83,84,85,86], one described patient and caregiver perspectives , and one described patient, caregiver, and HCP perspectives . Furthermore, 12 studies [49, 51, 53, 56, 72, 74, 76,77,78,79,80, 83] investigated the effects of a PA intervention by comparing two study population groups.
Quality assessment of included studies
The methodological quality scores of the included quantitative studies ranged from no score to a maximum score of 5 (Additional file 6). Of the 19 quantitative studies, 13 studies were categorized as low quality [42, 46,47,48,49, 53, 55, 57, 58, 64, 69, 73, 74]. Six quantitative studies were categorized as high quality [44, 45, 50, 51, 56, 85]. The methodological quality of qualitative studies ranged from a score of 3 to 5, of which three studies were categorized as low quality [59, 68, 87], and 15 studies were categorized as high quality [43, 52, 54, 61,62,63, 65,66,67, 71, 81, 82, 86, 88, 89]. For the mixed-methods studies, the total methodological quality scores varied from no score to a score of 2, with all 11 studies categorized as low quality [60, 70, 72, 75,76,77,78,79,80, 83, 84].
Facilitators and barriers
Of the 48 articles, 230 facilitators and 342 barriers related to PA in older hospitalized patients were retrieved. These factors were reduced to a total of 17 major themes and 39 subthemes across the three perspectives (Table 2). Examples of facilitators and barriers are provided to reflect themes. Our best evidence synthesis results ranged from insufficient to moderate levels of evidence, of which results classified with limited and moderate levels of evidence were reported in the sections below. Further details of the unique facilitators and barriers mapped to the (sub)themes are presented in Additional file 7, and the best evidence synthesis classification is presented in Additional file 8.
In total, 53 facilitators and 90 barriers at the intrapersonal level were identified, resulting in theme 1) patients’ knowledge, awareness, and attitude; theme 2) patients’ personal and health factors; and theme 3) medical-related factors.
Common facilitators of PA of theme 1 ‘patients’ knowledge, awareness and attitude’ were: patients’ positive attitudes, or expectations toward mobilization [52, 61, 76, 80, 81]. Furthermore, patients’ awareness of the need for mobility [59, 60, 88, 89], patients who want to promote functional recovery [54, 59, 77, 84], and perceived benefits due to mobilization were facilitators [52, 54, 60, 76, 87]. Facilitators of theme 2 ‘physical health’ were: sufficient baseline functional status scores, or sufficient baseline PA level of patients [42, 50, 55, 57, 84, 85]. Facilitators of theme 3 ‘medical-related factors’ were: improving medical status or no acute complications [45, 50], and lower illness severity scores [55, 57].
Common barriers to PA on theme 1 ‘patients’ knowledge, awareness, and attitude’ were negative attitudes of patients [52, 76, 80]. Specifically, patients’ expectation that hospital admission was not associated with mobilization hampered PA . Furthermore, patients refused to move [49, 51], or they preferred to stay in bed, because they believed it would contribute to aiding recovery [60, 80, 81, 88]. Barriers of theme 2 ‘physical health’ were: patients’ fears, in particular fear of falling [43, 51, 60, 82, 84, 86, 88], fear of burden to nurse when falling , and fear of injury [51, 54, 59, 84]. Furthermore, frequently reported barrier was patients with poor or impaired physical health status [52, 81, 86, 89]. Specifically, patients having symptoms such as pain, dyspnea, dizziness, feeling ill, or fatigue [42, 43, 48, 51, 54, 60, 61, 76, 82, 84, 85, 87]. On theme 3 ‘medical-related factors’ was the presence of lines or attachments that hindered patients walking a barrier, such as catheters [45, 50, 51, 54, 59, 60, 81, 82].
The best evidence synthesis suggested moderate evidence for three barriers: patients’ unwillingness or refusal to move, patients having symptoms, and having lines or drains (Additional file 8). Limited evidence was found for two facilitators: higher baseline functional status score and improved medical status, and two barriers: patients’ fears and continuous oxygen therapy.
At the interpersonal level, 21 facilitators and 23 barriers were identified, resulting in theme 4) social support. Facilitators of theme 4 ‘social support’ were: the identification and support of family or friends [43, 61, 76, 87], and the presence and encouragement of professionals to enhance mobilization [43, 54, 60, 61, 75, 89].
Common barriers of theme 4 ‘social support’ were: patients being alone and lacking encouragement [51, 75], and the presence of visitors whereby patients were sitting in bed [75, 89]. In addition, HCPs’ discouragement or lack of support [51, 54, 59, 89] and lack of interest in the importance of mobility  were barriers. Furthermore, patients felt that they were not seen or known by HCPs [43, 89], and they received inconsistent or limited advice on mobility [59, 86] or how to handle tubes while walking .
The best evidence synthesis suggested limited evidence for two barriers: lack of companion encouragement and lack of professional help.
In total, 23 facilitators and 31 barriers were identified and were reduced to theme 5) physical environment, theme 6) resources, and theme 7) organizational factors.
Common facilitators of theme 5 ‘physical environment’ were: more space in patient rooms, ambulation routes, and seating and handrails in hallways [43, 53, 81, 83, 89]. A facilitator of theme 6 ‘resources’ was staff education to understand patients . Facilitators for theme 7 ‘organizational factors’ were daily schedules [43, 81], patient goal setting [52, 87], and hospital routines and providing ADL, particularly in the morning, with statistically significant improvement of PA .
Barriers of theme 5 ‘physical environment’ were: uninviting furnishing in the department, clutter in rooms or hallways, limited seating [59, 61], and lack of space to mobilize . Barriers of theme 6 ‘resources’ were: staff shortage or staff lacking time [61, 82, 88], and lack of equipment and assistive devices [51, 54, 60]. Barriers to theme 7 ‘organizational factors’ were the first day of admission [42, 48, 50] and the afternoon .
The best evidence synthesis suggested limited evidence for three barriers: lack of space, lack of equipment, and first day of admission.
Three facilitators and six barriers at the intrapersonal level were identified in two studies, resulting in theme 8) caregivers’ knowledge, awareness, and attitude. Facilitators of theme 8 were: awareness of the need for mobility and seeing benefits of mobilization [87, 88]. Barriers to theme 8 were anxiety or feeling overwhelmed , perceived bedrest to aid recovery , and safety concerns regarding patient falling .
Zero facilitators and two barriers of patient mobilization were identified at the interpersonal level, resulting in theme 9) patients’ health status and medical-related factors. Barriers reported in one study were poor patient physical symptoms, such as pain or fatigue, and comorbidities .
No facilitators and barriers were identified at the institutional level.
Health care professional
In total, 20 facilitators and 34 barriers were identified, resulting in theme 10) HCPs’ knowledge, awareness, and attitude, and theme 11) HCPs’ expertise and characteristics.
Common facilitators of theme 10 ‘HCPs’ knowledge, awareness, and attitude’ were HCPs experiencing positive benefits of PA for themselves and patients [76, 77], and awareness of mobility importance [71, 84, 88, 90]. Facilitators of theme 11 ‘HCPs’ expertise and characteristics’ were experience in geriatric specialization, long-term care setting, or rehabilitation [65, 67].
Common barriers of theme 10 ‘HCPs’ knowledge, awareness, and attitude’ were not seeing PA as part of usual hospital care or questioning the need for PA for older patients, as specifically reported by nurses [65, 70, 81]. Furthermore, barriers were staff resistance toward health promotion [66, 89], or staff lacking awareness of the intervention . Moreover, and commonly reported, HCPs lacked knowledge, including mobilization techniques [62, 68], patient mobility status and safety assessment [68, 78, 80], patients’ psychosocial needs, and how to inform or motivate them [62, 81]. In addition, on theme 10, barriers were fear of patient falling [62, 82] and safety concerns regarding staff or patient injury [64, 68, 69, 85].
In total, 58 facilitators and 81 barriers were identified, resulting in theme 12) patient cooperation, theme 13) clinician and team influences, and theme 14) patient health status and medical-related factors.
Common facilitators of theme 12 ‘patient cooperation’ were: family support and involvement of patient’s family in care provision to enhance PA [62, 63, 65, 67, 88], HCP encouragement [62, 65, 67, 70, 71], HCPs knowing patients and their functional ability [62, 63], and physiotherapists in ‘sporty clothes’ . Facilitators of theme 13 ‘clinician and team influences’ were: multidisciplinary collaboration [62, 63, 66, 71, 78, 80, 89] and being responsible for patient mobility [72, 79, 90], including shifting responsibility toward nurses.
Common barriers of theme 12 ‘patient cooperation’ were: patients lacking knowledge and awareness [68, 90], the adoption of a sick-role behavior of patients, including wearing pajamas during the day [63, 67, 68, 70, 90], and rejection of patients to mobilize [64, 68, 85], especially when asked by nurses . In addition, on theme 12, barriers were: the belief of family that patients needed to rest in bed , quiet or nursing home patients [62, 65], and during contact with patients, HCPs told unintentionally how comfortable the bed was or HCPs were servicing self-supporting patients [67, 70, 81].
Common barriers of theme 13 ‘clinician and team influences’ were: discussion or lack of communication between staff [68, 78, 80], unclear HCPs’ roles, and lack of professional autonomy toward patients’ mobilization [62, 66, 86]. In addition, on theme 13, HCPs defined mobilization differently, including which tasks and actions were important to influence patients’ mobility [67, 80]. Furthermore, nurses and physicians did not perceive mobilization as part of their core tasks [14, 67]. Barriers on theme 14 ‘patients health status and medical-related factors’ were: patients’ poor health condition [62,63,64,65, 67, 71, 73, 82, 85, 86], the presence of lines or attachments [68, 81, 82], and bed rest orders [63, 65, 76].
In total, 52 facilitators and 75 barriers at the institutional level were identified, resulting in theme 15) physical environment, theme 16) resources, and theme 17) organizational factors.
The facilitator of theme 15 ‘physical environment’ was an encouraging hospital environment [62, 67, 80, 81, 83, 88], including space for walking. Facilitators of theme 16 ‘resources’ were: presence of mobility equipment [62, 65, 68, 70], patient education [62, 68], staff training [66, 68, 80], and monitoring patients’ mobility status [65, 68, 79]. Facilitators of theme 17 ‘organizational factors’ were: setting patient goals [72, 79], providing daily patient activities [68, 81, 89], and integrating PA into daily usual care [66, 72]. In addition, on theme 17, facilitators were facility-wide adoption of PA promoting philosophy, clear expectations of unit level and accountability, and alignment with institutional priorities to improve patient mobilization [62, 65, 66, 70].
Common barriers of theme 15 ‘physical environment’ were lack of space, intimidating environment, or objects in corridors [62, 67, 68, 76, 78, 82]. Barriers of theme 16 ‘resources’ were: shortage of staff, especially in the evening and during weekend [62, 64, 67, 68, 73, 82, 88], workload [63, 64, 68, 70, 73], and time and competing priorities of staff leading to lower prioritization of PA [49, 62,63,64, 67, 68, 70, 71, 76, 78, 80,81,82, 85, 86, 88, 89]. In addition, on theme 16, barriers were: lack of proper mobility equipment [68, 78, 80, 82], and lack of system to document and monitor mobility [68, 80]. Barriers of theme 17 ‘organizational factors’ were busy days [65, 76], lack of follow-through on mobilization , and staff starting ambulation in phase ‘getting ready for discharge’ with little time . Furthermore, barriers of theme 17 were unfamiliarity and lack of mobility protocols [80, 81], and policies deterring PA, including zero-fall initiatives [62, 63, 80, 86, 88].
The best evidence synthesis suggested limited evidence for one barrier: time constraints.
Studies with PA intervention as a possible facilitator
Twelve quantitative studies described a PA intervention and reported clinical intervention effects (Table 3). In total, four types of PA interventions were identified that might act as facilitators to increase patients’ PA. Facilitating factors were: 1) adding extra patient ambulation sessions provided by physiotherapists , volunteers , or mobility technicians ; 2) changing the physical environment, including more space in patient rooms to mobilize [53, 83]; 3) adding a tool in daily patient practice to enhance patient PA, including a booklet with PA information  or a patient’s activity board ; and 4) PA interventions with more than one changing element, for example, a combination of the aforementioned facilitating factors of PA interventions, or a combination of these with training of HCPs in communication or collaboration [72, 74, 77, 79, 80].
Eleven studies reported improvements in clinical outcome variables, including an increase in patient step counts per day [49, 51, 56, 76, 80, 83]; more out-of-bed PA or less sedentary behavior [51, 53, 56, 77, 83] and improvements were seen in patients’ mobility level or physical functioning during a hospital stay [49, 51, 79].
In this systematic review of 48 studies, the identified facilitators and barriers of older patients’ PA behavior during hospitalization, from the perspective of older patients, caregivers, and HCPs, were multidimensional. The best evidence synthesis suggested that PA behavior is influenced by knowledge, awareness, and attitudes, including patients’ unwillingness or refusal to move, and by patients’ physical health status or medical treatment, including having symptoms or having lines. Furthermore, patients’ fears, such as falling and safety concerns, hampered mobilization. Social support positively stimulated patients’ PA,’ including encouragement from HCPs, and patients’ PA declined due to a lack of companion encouragement. In addition, caregivers could be more involved in patient mobilization. Moreover, HCPs expressed the need for consultation, clear roles, and team collaboration, as well as sufficient staff to motivate and help patients to increase PA. Furthermore, PA behavior was influenced by sufficient resources, including time and equipment, and an attractive physical environment, whereas lack of space hampered patients’ PA. Patient activities and awareness of PA protocols positively influenced mobilization, whereas zero-fall policies within hospitals restricted PA. Overall, identified facilitators and barriers spanned multiple levels of the social ecological framework, indicating patients’ PA behavior is complex and multifaceted.
In line with previous studies [27, 29, 91], the importance of awareness and knowledge about mobilization to improve patients’ PA behavior was recognized in the current review. However, when it comes to prioritizing poor health status or fear of falling, it seems that safety and zero-fall policies can sometimes take precedence over the known benefits of mobility. However, fatigue can actually be reduced by mobilization , and mobilization has the potential to reduce falls . Therefore, since it might be possible for patients to mobilize, despite their health status, the focus on safety should not outweigh the benefits of PA , and PA policies should be adopted within the hospital culture, which might require a rethinking of the organization .
The current review showed that HCPs and caregivers can provide valuable support to increase patients’ mobility. Interestingly, the current review identified only two studies on the caregiver’s perspective, while in included studies [62, 67, 88] it was appointed several times by patients or HCPs to involve family by inpatient mobilization, e.g. by motivating and providing practical assistance. Despite the increased attention on PA in the last decade [92,93,94], there seems to be little focus on involving caregivers within the mobilization of older patients. In the intensive care setting, the concept of family involvement in inpatient mobilization is already gaining interest. Studies showed that family involvement has the potential to optimize patient outcomes, such as illness and recovery experience, as well as redirecting family psychological distress into an active participatory role, and supporting HCPs with the constraints of time and staffing [95,96,97]. Moreover, caregiver involvement may lead to better functional performance after discharge . However, due to limited research on family participation in inpatient mobilization, the evidence on the effects of interventions that include family participation is low, and it is therefore difficult to draw strong conclusions.
In daily practice, clarifying roles and expectations of each other regarding mobilization appears to be complex among patients, caregivers, and HCPs. Older patients can take a passive role in their mobility and wait for encouragement from HCPs, while HCPs can see unwilling or unmotivated patients, leading to incorrect assumptions of each other. Unclear expectations of each other occur not only in older patients, but in all age groups [27, 91]. It is therefore important to tailor PA promotion, since patients may be waiting for instructions or assistance. Furthermore, despite interdisciplinary collaboration among staff, unclear responsibilities for mobility promotion tend to blur role clarity. It might be that mobility promotion is seen as a task of the physiotherapist and may not have been fully implemented by nurses  or other disciplines. Enabling PA should be a shared responsibility in which all professions have expertise that can promote patient mobility .
Modifiable factors at the institutional level, including sufficient resources, stimulating physical environment, and patient activities, were also reported in previous research and multidimensional interventions were suggested [27,28,29, 91, 100] which is in line with our results. Our review showed that multidimensional intervention studies, including an increase of resources, adding ambulation pathways, or monitoring physical functioning, might result in positive effects on patients’ step count per day [72, 80], or faster recovery of physical functioning . Interestingly, in the identified PA interventions in current review, it seems that changing one element at institutional level might also act as a facilitator of PA and positively influences patient outcomes. For example, adding only extra ambulation sessions [49, 76, 78], or providing patient education . Therefore, despite the fact that PA behavior is a complex phenomenon , starting with changing one element incorporated in daily care and tailored per ward, might also be a step forward to improve patients’ PA behavior.
This study had several strengths. First, both quantitative and qualitative data were included, as well as inclusion of the perspectives of patients, caregivers, and HCPs. To the best of our knowledge, this broad inclusion of study type and population has not been performed before and provides an enriched set of data. Second, many facilitators and barriers were reported by both study designs and across different geographical settings worldwide, improving the generalizability of our findings. Third, errors in the selection of studies, data extraction, quality appraisal, and data analysis were minimized by the involvement of at least two researchers. A limitation is that most all of our included studies took place in high income countries. Therefore, it is possible that important facilitators and barriers of low and middle income countries are underexposed, and future studies in these countries are needed. Secondly, in our review, palliative care patients were excluded. However, since many of them can benefit from mobilization, we suggest to include this population for future research. Furthermore, no meta-synthesis was performed. However, the best evidence synthesis was performed for the quantitative studies to weight the results and to provide insight into the level of evidence of our results. We are aware that these results show mostly insufficient or low evidence. It should be noted that conducting research in such a complex hospital environment and with a heterogeneous population makes it difficult to conduct strong methodological research studies with sufficient power. However, in our review, the evidence and reliability of the results of quantitative studies were enhanced by similar findings in qualitative studies. Furthermore, it could be argued that the best evidence synthesis results might have been influenced by the use of the MMAT, which in turn indicated a relatively large number of low methodological quality RCTs and non-randomized studies. Moreover, by using the MMAT, we were aware of the recommendation of the MMAT authors  to not calculating an overall total quality score since this may be a reason to exclude studies without specifying contents or criteria. In the current review, the use of a total score was not a limitation, since we included all studies despite low quality scores. Furthermore, a limitation of the MMAT might be the ‘can’t tell’ category, in which it is not clearly described whether a study has performed a certain criterion, or that it has not. The reader should be aware that this ambiguity might lead to underestimation or to overestimation of the overall quality results. Since it can be both ways, the overall quality scores might be more difficult to interpret. For future implications, high methodological quality studies should be conducted to increase the evidence for facilitators and barriers toward PA in older hospitalized patients.
In conclusion, the identified facilitators and barriers of PA behavior in older patients during hospitalization were multidimensional and spanned interpersonal, intrapersonal, and institutional levels. By including the perspectives of patients, caregivers, and HCPs, it was possible to provide a deeper insight into the complex interactions between those involved. However, it was found that facilitators and barriers were not extensively described from the perspective of caregivers, and future research on this perspective is warranted. Considering facilitators and barriers in a structured behavioral change framework might clarify potential strategies to enhance older patients’ PA behavior. We recommend that when enhancing PA in older hospitalized patients, attention should be paid to facilitators and barriers at the intrapersonal, interpersonal, and institutional levels, specifically targeting the health benefits of PA, patients’ health condition and willingness to move, healthcare team influences, resources, and hospital policies.
Availability of data and materials
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
Activities of daily living
Mixed Methods Appraisal Tool
Randomized controlled trials
World Health Organization. World report on ageing and health. Luxembourg: World Health Organization; 2015.
NHS Digital. Hospital admitted patient care activity: 2015–16. 2016;
CBS StatLine. Ziekenhuisopnamen en -patiënten; diagnose-indeling VTV, 2013–2018. 2021;
Statista Research Department. U.S. population with a hospitalization 2000–2018 by age. 2021;
Sourdet S, Lafont C, Rolland Y, Nourhashemi F, Andrieu S, Vellas B. Preventable iatrogenic disability in elderly patients during hospitalization. J Am Med Dir Assoc. 2015;16:674–81.
Zisberg A, Shadmi E, Sinoff G, Gur-Yaish N, Srulovici E, Admi H. Low mobility during hospitalization and functional decline in older adults. J Am Geriatr Soc. 2011;59:266–73.
Lafont C, Gérard S, Voisin T, Pahor M, Vellas B. Force T members of IAGG/ AMPAT. Reducing “iatrogenic disability” in the hospitalized frail elderly. J Nutr Health Aging. 2011;15:645–60.
Covinsky KE, Pierluissi E, Johnston CB. Hospitalization-associated disability “she was probably able to ambulate, but i’m not sure.”. JAMA. 2011;306:1782–93.
Covinsky KE, Palmer RM, Fortinsky RH, Counsell SR, Stewart AL, Kresevic D, et al. Loss of independence in activities of daily living in older adults hospitalized with medical illnesses: increased vulnerability with age. J Am Geriatr Soc. 2003;51:451–8.
Creditor MC. Hazards of hospitalization of the elderly. Ann Intern Med. 1993;118:219.
Loyd C, Markland AD, Zhang Y, Fowler M, Harper S, Wright NC, et al. Prevalence of hospital-associated disability in older adults: a meta-analysis. J Am Med Dir Assoc. 2020;21:455–461.e5.
Boyd CM, Seth Landefeld C, Counsell SR, Palmer RM, Fortinsky RH, Kresevic D, et al. Recovery in activities of daily living among older adults following hospitalization for acute medical illness. J Am Geriatr Soc. 2008;56:2171–9.
Admi H, Shadmi E, Baruch H, Zisberg A. From research to reality: minimizing the effects of hospitalization on older adults. Rambam Maimonides Med J. 2015;6:e0017.
Pedersen MM, Bodilsen AC, Petersen J, Beyer N, Andersen O, Lawson-Smith L, et al. Twenty-four-hour mobility during acute hospitalization in older medical patients. Med Sci Cite J: J Gerontol A Biol Sci Med Sci. 2013;68:331–7.
Mudge AM, Mcrae P, Mchugh K, Griffin L, Hitchen A, Walker J, et al. Poor mobility in hospitalized adults of all ages. J Hosp Med. 2016;11:289–91.
Brown CJ, Redden DT, Flood KL, Allman RM. The underrecognized epidemic of low mobility during hospitalization of older adults. J Am Geriatr Soc. 2009;57:1660–5.
Fazio S, Stocking J, Kuhn B, Doroy A, Blackmon E, Young HM, et al. How much do hospitalized adults move? A systematic review and meta-analysis. Appl Nurs Res. 2020;51:151189.
Kortebein P, Symons TB, Ferrando A, Paddon-Jones D, Ronsen O, Protas E, et al. Functional impact of 10 days of bed rest in healthy older adults. J Gerontol – Ser Biol Sci Med Sci. 2008;63:1076–81.
Van Ancum JM, Scheerman K, Jonkman NH, Smeenk HE, Kruizinga RC, Meskers CGM, et al. Change in muscle strength and muscle mass in older hospitalized patients: a systematic review and meta-analysis. Exp Gerontol. 2017;92:34–41.
Ferrando AA, Paddon-jones D, Wolfe RR. Bed rest and myopathies; Curr Opin Clin Metab Care. 2006;9(4):410-5.
Kortebein P. Rehabilitation for hospital-associated deconditioning. Am J Phys Med Rehabil. 2009;88:66–77.
Kehler DS, Theou O, Rockwood K. Bed rest and accelerated aging in relation to the musculoskeletal and cardiovascular systems and frailty biomarkers: a review. Exp Gerontol. 2019;124:110643.
Buurman BM, Hoogerduijn JG, Van Gemert EA, De Haan RJ, Marieke J, Rooij SED. Clinical characteristics and outcomes of hospitalized older patients with distinct risk profiles for functional decline : a prospective cohort study. PLoS One. 2012;7(1):e29621.
Kalisch BJ, Lee S, Dabney BW. Outcomes of inpatient mobilization: a literature review. J Clin Nurs. 2014;23(11-12):1486–501.
Seeger JPH, Koenders N, Staal JB, Hoogeboom TJ, et al. Effects of general physical activity promoting interventions on functional outcomes in patients hospitalized over 48 hours: a systematic review and meta-analysis of randomized controlled trials. Int J Environ Res Public Health. 2021;18(3):1233.
Falvey JR, Mangione KK, Stevens-lapsley JE. Rethinking hospital-associated deconditioning: proposed paradigm shift. Phys Ther. 2015;95:1307–15.
Koenders N, Marcellis L, Nijhuis-van der Sanden MW, Satink T, Hoogeboom TJ. Multifaceted interventions are required to improve physical activity behaviour in hospital care: a meta-ethnographic synthesis of qualitative research. J Phys. 2021;67:115–23.
Parry SM, Knight LD, Connolly B, Baldwin C, Puthucheary Z, Morris P, et al. Factors influencing physical activity and rehabilitation in survivors of critical illness: a systematic review of quantitative and qualitative studies. Intensive Care Med. 2017;43(4):531–42.
Geelen SJG, van Dijk-Huisman HC, de Bie RA, Veenhof C, Engelbert R, van der Schaaf M, et al. Barriers and enablers to physical activity in patients during hospital stay: a scoping review. Syst Rev. 2021;10(1):293.
Baert V, Gorus E, Mets T, Geerts C, Bautmans I. Motivators and barriers for physical activity in the oldest old: a systematic review. Ageing Res Rev. 2011;10(4):464–74.
Alphen HJMV, Hortobágyi T, Heuvelen MJGV. Barriers, motivators, and facilitators of physical activity in dementia patients : a systematic review. Arch Gerontol Geriatr. 2016;66:109–18.
Moher D, Shamseer L, Clarke M, Ghersi D, Liberati A, Petticrew M, et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Rev Espanola Nutr Hum Dietetica. 2015;20:148–60.
Caspersen CJ, Powell KE, Christenson GM. Physical activity, exercise, and physical fitness: definitions and distinctions for health-related research. Public Health Rep. 1985;100:126–31.
Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan-a web and mobile app for systematic reviews. Syst Rev. 2016;5:210.
Hong QN, Pluye P, Fàbregues S, Bartlett G, Boardman F, Cargo M, et al. Mixed methods appraisal tool (MMAT), version 2018. Registration of Copyright (#1148552), Canadian Intellectual Property Office, Industry Canada. 2018.
Peppen van R, Harmeling - van der Wel B, Kollen B, Hobbelen J, Buurke J. Effecten van fysiotherapeutische interventies bij patiënten met een beroerte : een systematisch literatuuronderzoek. Nederlands Tijdschrift Voor Fysiother. 2004;5:126–48.
Flemming K, Noyes J. Qualitative evidence synthesis: where are we at? Int J Qual Methods. 2021;20:1–13.
Carroll C, Booth A, Leaviss J, Rick J. “Best fit” framework synthesis: refining the method. BMC Med Res Methodol. 2013;13-37.
Mcleroy KR, Bibeau D, Steckler A, Glanz K. An ecological perspective on health promotion programs. Health Educ Behav. 1988;15:351–77.
Slavin RE. Best evidence synthesis: an intelligent alternative to meta-analysis. J Clin Epidemiol. 1995;48:9–18.
van Tulder M, Furlan A, Bombardier C, Bouter L. Updated method guidelines for systematic reviews in the cochrane collaboration Back review group. Spine (Phila Pa 1976). 2003;28:1290–9.
Agostini PJ, Naidu B, Rajesh P, Steyn R, Bishay E, Kalkat M, et al. Potentially modifiable factors contribute to limitation in physical activity following thoracotomy and lung resection: a prospective observational study. J Cardiothorac Surg. 2014;9:1–6.
Boltz M, Capezuti E, Shabbat N, Hall K. Going home better not worse: older adults’ views on physical function during hospitalization. Int J Nurs Pract. 2010;16:381–8.
Chase JAD, Lozano A, Hanlon A, Bowles KH. Identifying factors associated with mobility decline among hospitalized older adults. Clin Nurs Res. 2018;27:81–104.
Chua MJ, Hart AJ, Mittal R, Harris IA, Xuan W, Naylor JM. Early mobilisation after total hip or knee arthroplasty: a multicentre prospective observational study. PLoS One. 2017;12:1–15.
Evensen S, Sletvold O, Lydersen S, Taraldsen K. Physical activity among hospitalized older adults - an observational study. BMC Geriatr. 2017;17:1–8.
Fisher SR, Graham JE, Brown CJ, Galloway RV, Ottenbacher KJ, Allman RM, et al. Factors that differentiate level of ambulation in hospitalised older adults. Age Ageing. 2012;41(1);107–11.
Haines KJ, Skinner EH, Berney S. Association of postoperative pulmonary complications with delayed mobilisation following major abdominal surgery: an observational cohort study. Physiotherapy (United Kingdom). 2013;99:119–25.
Hamilton AC, Lee N, Stilphen M, Hu B, Schramm S, Frost F, et al. Increasing mobility via in-hospital ambulation protocol delivered by mobility technicians: a pilot randomized controlled trial. J Hosp Med. 2019;14:272–7.
McCullagh R, Darren D, Horgan NF, Timmons S. Factors associated with walking in older medical inpatients. Arch Rehabil Res Clin Transl. 2020;2:100038.
Moreno NA, de Aquino BG, Garcia IF, Tavares LS, Costa LF, Giacomassi IWS, et al. Physiotherapist advice to older inpatients about the importance of staying physically active during hospitalisation reduces sedentary time, increases daily steps and preserves mobility: a randomised trial. J Phys. 2019;65:208–14.
O’Hare L, Savage E, McCullagh R, Bantry White E, Fitzgerald E, Timmons S. Frail older adults’ perceptions of an in-hospital structured exercise intervention. Physiotherapy (United Kingdom). 2017;103:478–84.
Shannon MM, Elf M, Churilov L, Olver J, Pert A, Bernhardt J. Can the physical environment itself influence neurological patient activity? Disabil Rehabil. 2019;41:1177–89.
So C, Pierluissi E. Attitudes and expectations regarding exercise in the hospital of hospitalized older adults: a qualitative study. J Am Geriatr Soc. 2012;60:713–8.
Zisberg A, Syn-Hershko A. Factors related to the mobility of hospitalized older adults: a prospective cohort study. Geriatr Nurs. 2016;37:96–100.
Porserud A, Aly M, Nygren-Bonnier M, Hagströmer M. Objectively measured mobilisation is enhanced by a new behaviour support tool in patients undergoing abdominal cancer surgery. Eur J Surg Oncol. 2019;45:1847–53.
Hartley P, DeWitt AL, Forsyth F, Romero-Ortuno R, Deaton C. Predictors of physical activity in older adults early in an emergency hospital admission: a prospective cohort study. BMC Geriatr. 2020;20:177.
Ishikawa K, Fukushima A, Yokota T, Takada S, Furihata T, Kakutani N, et al. Clinical impact and associated factors of delayed ambulation in patients with acute heart failure. Circ Rep. 2019;1:179–86.
King B, Bodden J, Steege L, Brown CJ. Older adults experiences with ambulation during a hospital stay: a qualitative study. Geriatr Nurs. 2021;42:225–32.
Scheerman K, Schoenmakers AHC, Meskers CGM, Maier AB. Physical, motivational and environmental factors influencing physical activity promotion during hospitalization: older patients’ perspective. Geriatr Nurs. 2021;42:599–604.
Stefánsdóttir NÞ, Pedersen MM, Tjørnhøj-Thomsen T, Kirk JW. Older medical patients’ experiences with mobility during hospitalization and the WALK-Copenhagen (WALK-Cph) intervention: a qualitative study in Denmark. Geriatr Nurs. 2021;42:46–56.
Boltz M, Capezuti E, Shabbat N. Nursing staff perceptions of physical function in hospitalized older adults. Appl Nurs Res. 2011;24:215–22.
Chan E, Philosophy D, Leting M, Hong I, Nursing S, Nurse S, et al. Older patients ’ participation in physical activity during hospitalization : a qualitative study of ward nurses ’ perceptions in an Asian context. Geriatr Nurs. 2019;40(1):91-8.
Dermody G, Kovach CR. Nurses’ experience with and perception of barriers to promoting mobility in hospitalized older adults: a descriptive study. J Gerontol Nurs. 2017;43:22–9.
Doherty-King B, Bowers B. How nurses decide to ambulate hospitalized older adults: development of a conceptual model. Gerontologist. 2011;51:786–97.
Kavanagh AY, O’Brien LJ, Maloney SR, Osadnik CR. Barriers and facilitators to adopting functional maintenance initiatives for acutely hospitalised older adults. Disabil Rehabil. 2020;42:3808–15.
Kirk JW, Bodilsen AC, Sivertsen DM, Husted RS, Nilsen P, Tjørnhøj-Thomsen T. Disentangling the complexity of mobility of older medical patients in routine practice: an ethnographic study in Denmark. PLoS One. 2019;14:e0214271.
Moore JE, Mascarenhas A, Marquez C, Almaawiy U, Chan WH, D’Souza J, et al. Mapping barriers and intervention activities to behaviour change theory for mobilization of vulnerable elders in Ontario (MOVE ON), a multi-site implementation intervention in acute care hospitals. Implement Sci. 2014;9:160.
Babine RL, Hyrkäs KE, Mckenzie CG, Wierman HR. Mobilizing older adults: a multi-site, exploratory and observational study on patients enrolled in the hospital elder life program (HELP). Geriatr Nurs. 2019;40:239–45.
Scheerman K, Mesters JW, Borger JN, Meskers CGM, Maier AB. Tasks and responsibilities in physical activity promotion of older patients during hospitalization: a nurse perspective. Nurs Open. 2020;7:1966–77.
Pedersen MM, Brødsgaard R, Nilsen P, Kirk JW. Is promotion of mobility in older patients hospitalized for medical illness a physician’s job?—an interview study with physicians in Denmark. Geriatrics (Switzerland). 2020;5:1–23.
King BJ, Steege LM, Winsor K, VanDenbergh S, Brown CJ. Getting patients walking: a pilot study of mobilizing older adult patients via a Nurse-driven intervention. J Am Geriatr Soc. 2016;64:2088–94.
Dermody G, Kovach CR. Barriers to promoting mobility in hospitalized older adults. Res Gerontol Nurs. 2018;11:17–27.
Resnick B, Galik E, Wells CL, Boltz M, Holtzman L. Optimizing physical activity among older adults post trauma: overcoming system and patient challenges. Int J Orthop Trauma Nurs. 2015;176:100–6.
Belala N, Maier C, Heldmann P, Schwenk M, Becker C. A pilot observational study to analyze (in)activity and reasons for sedentary behavior of cognitively impaired geriatric acute inpatients. Zeitschrift fur Gerontol Geriatr. 2019;52:273–81.
Lim S, Ibrahim K, Dodds R, Purkis A, Baxter M, Rogers A, et al. Physical activity in hospitalised older people: the feasibility and acceptability of a volunteer-led mobility intervention in the SoMoVe™ study. Age Ageing. 2020;49:283–91.
Mudge AM, McRae P, Cruickshank M. Eat walk engage: an interdisciplinary collaborative model to improve care of hospitalized elders. Am J Med Qual. 2015;30:5–13.
Tousignant-Laflamme Y, Beaudoin AM, Renaud AM, Lauzon S, Charest-Bossé MC, Leblanc L, et al. Adding physical therapy services in the emergency department to prevent immobilization syndrome - a feasibility study in a university hospital. BMC Emerg Med. 2015;15:1–7.
van der Sluis G, Goldbohm RA, Bimmel R, Galindo Garre F, Elings J, Hoogeboom TJ, et al. What augmented physical activity and empowerment can bring to patients receiving total knee replacement: content, implementation, and comparative effectiveness of a new function-tailored care pathway in a routine care setting. Biomed Res Int. 2015;2015:745864.
Zisberg A, Agmon M, Gur-Yaish N, Rand D, Hayat Y, Gil E. No one size fits all - the development of a theory-driven intervention to increase in-hospital mobility: the “wALK-FOR” study. BMC Geriatr. 2018;18:1–9.
De Klein K, Valkenet K, Veenhof C. Perspectives of patients and health-care professionals on physical activity of hospitalized patients. Physiother Theory Pract. 2019;0:1–8.
Brown CJ, Williams BR, Woodby LL, Davis LL, Allman RM. Barriers to mobility during hospitalization from the perspectives of older patients and their nurses and physicians. J Hosp Med. 2007;2:305–13.
Feenstra F. Reactivating hospital. Active Patients Through Special Design. 2021;14:87–105.
Haslam-Larmer L, Donnelly C, Auais M, Woo K, DePaul V. Early mobility after fragility hip fracture: a mixed methods embedded case study. BMC Geriatr. 2021;21:181.
Said CM, Delahunt M, Ciavarella V, Al Maliki D, Boys A-M, Vogrin S, et al. Factors impacting early mobilization following hip fracture: an observational study. J Geriatr Phys Ther. 2021;44:88–93.
Pavon JM, Fish LJ, Colón-Emeric CS, Hall KS, Morey MC, Pastva AM, et al. Towards “mobility is medicine”: socioecological factors and hospital mobility in older adults. J Am Geriatr Soc. 2021;69(7):1846-55.
Sun V, Raz DJ, Kim JY, Melstrom L, Hite S, Varatkar G, et al. Barriers and facilitators of adherence to a perioperative physical activity intervention for older adults with cancer and their family caregivers. J Geriatr Oncol. 2020;11:256–62.
Lim SH, Ang SY, Ong HK, Lee TZY, Lee TXL, Luo EZ, et al. Promotion of mobility among hospitalised older adults: an exploratory study on perceptions of patients, carers and nurses. Geriatr Nurs. 2020;41:608–14.
Andreasen J, Soendergaard LN, Holst M. Factors affecting patient and nursing staff adherence to an integrated physical activity and nutritional intervention targeting functional decline on an acute medical ward: a qualitative study. Patient Prefer Adher. 2018;12:1425–35.
De Klein K, Valkenet K, Veenhof C. Perspectives of patients and health-care professionals on physical activity of hospitalized patients. Physiother Theory Pract. 2021;37:307–14.
Stutzbach J, Jones J, Taber A, Recicar J, Burke RE, Stevens-Lapsley J. Systems approach is needed for in-hospital mobility: a qualitative metasynthesis of patient and clinician perspectives. Arch Phys Med Rehabil. 2021;102:984–98.
Brown CJ. After three decades of study, hospital-associated disability remains a common problem. J Am Geriatr Soc. 2020;68:465–6.
Taylor NF, Harding KE, Dennett AM, Febrey S, Warmoth K, Hall AJ, et al. Behaviour change interventions to increase physical activity in hospitalised patients: a systematic review, meta-analysis and meta-regression. Age Ageing. 2022;51:afab154
Smart DA, Dermody G, Coronado ME, Wilson M. Mobility programs for the hospitalized older adult: a scoping review. Gerontology and Geriatric Medicine. 2018;4:2333721418808146.
Haines KJ. Engaging families in rehabilitation of people who are critically ill: an underutilized resource. Physical Therapy. 2018;98:737–44.
Delft LMMV, Valkenet K, Slooter AJC, Veenhof C. Family participation in physiotherapy-related tasks of critically ill patients : a mixed methods systematic review. J Crit Care. 2021;62:49–57.
Felten-Barentsz KM, van de Wetering-van Dongen VA, Vloet L, Koenders N, Nijhuis-van der Sanden MWG, Hoogeboom TJ. Family participation during physical activity in the intensive care unit: a longitudinal qualitative study. J Crit Care. 2021;65:42–8.
Van Dijk M, Vreven J, Deschodt M, Verheyden G, Tournoy J, Flamaing J. Can in-hospital or post discharge caregiver involvement increase functional performance of older patients? A systematic review. BMC Geriatr. 2020;20:1–12.
Baldwin CE, Phillips AC, Edney SM, Lewis LK. Recommendations for older adults’ physical activity and sedentary behaviour during hospitalisation for an acute medical illness: an international Delphi study. Int J Behav Nutr Phys Act. 2020;17:1–17.
Kavanagh AY, O’Brien LJ, Maloney SR, Osadnik CR. The effectiveness of multicomponent functional maintenance initiatives for acutely hospitalized older adults: a systematic review and meta-analysis. J Geriatr Phys Ther. 2021;45(1):50-61.
We would like to thank Ms. L. Hartman, a librarian at Hanze University of Applied Sciences, for her contributions to the search strategy.
This work was supported by SIA SPRONG FAITH [grant number SPR.VG01.001]. The funding organization had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.
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PRISMA 2020 Checklist for Systematic Reviews. Completed PRISMA 2020 for Systematic Reviews checklist for this systematic review.
PRISMA 2020 Checklist for Abstract. Completed PRISMA 2020 for Abstracts checklist for this systematic review.
Search strategy. Presentation of the used search terms with databases.
Social ecological model with definitions. Presentation of levels of influence within the social ecological model.
Characteristics of included studies. Table presenting the characteristics of included studies.
Methodological quality. Table presenting detailed information of assessment of methodological quality of included studies.
Overview of facilitators and barriers per (sub)theme. Table presenting an overview of all identified facilitators and barriers per (sub)theme and per perspective.
Best-evidence synthesis classification. Table presenting an overview of the best-evidence synthesis classification for facilitators and/or barriers within quantitative studies.
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Dijkstra, F., van der Sluis, G., Jager-Wittenaar, H. et al. Facilitators and barriers to enhancing physical activity in older patients during acute hospital stay: a systematic review. Int J Behav Nutr Phys Act 19, 99 (2022). https://doi.org/10.1186/s12966-022-01330-z
- Physical activity
- Older adults
- Systematic review