Feasibility of home-based cardiac rehabilitation in frail older patients: a clinical perspective

Figures & data

Figure 1. Overview of the CCB program including home-based cardiac rehabilitation.

Blue depicts the nurse coordinated care, red describes the exercise components of home-based cardiac rehabilitation by physiotherapists. In addition, physiotherapists coached on active lifestyle and monitored complications; DSMS = Dutch Safety Management System, BORG = Borg scale of perceived exertion

Table 1. Characteristics physiotherapists

Therapist (n = 8)	A	B	C	D	E	F	G	H	Total (Median)
Age (years)	23	64	25	56	54	58	57	28	45 (IQR 27–57)
Gender (m/f)	f	m	f	f	f	f	f	m	Male: 25%
Work experience (years)	2	38	2	32	10	35	29	6	20 (IQR 5–33)
Specific work experience (More than one year)
Cardiac Rehabilitation (CR)	-	-	-	-	+	+	+	+	n = 4 (50%)
Geriatrics	+	+	-	+	+	+	+	+	n = 7 (87.5%)
Home-based treatment	+	+	+	+	+	+	+	+	n = 8 (100%)
Working in multidisciplinary team	+	+	-	+	+	+	+	+	n = 7 (87.5%)
Education on CR	-	-	-	-	+	MSc	+	-	n = 3 (37.5%)
Education Geriatrics	-	+	-	-	MSc	MSc	-	-	n = 3 (37.5%)
Other relevant education	COPD	Home care	-	Home care	-	COPD PAD MI	COPD	-

CR = cardiac rehabilitation; COPD = Chronic Obstructive Pulmonary Disease; PAD = Peripheral Artery Disease; MI = motivational interviewing; MSc = Master of Science level; IQR = Interquartile range; n = number; – = no; + = yes

Table 2. Baseline characteristics of the patients (n = 8) in the observed treatment sessions

Characteristic	Mean (SD) or n (%)
Age (years)	82.8 (SD 7.8)
Gender (male)	5 (62.5%)
Nationality
Dutch	6 (75%)
Suriname	1 (12.5%)
German	1 (12.5%)
Highest Education
Primary school	1 (12.5%)
Secondary school	2 (25%)
Lower professional education	3 (37.5%)
Higher professional education or university	2 (25%)
Screening instrument for frail older adults of the Dutch Safety Management System (DSMS)
Score 1	1 (12.5%)
Score 2	5 (62.5%)
Score 3–4	2 (25%)
Mini-Mental State Examination (MMSE)	25.1 (SD 2.9)
Reason hospital admission
Heart failure	5 (62.5%)
Atrial Fibrillation	1 (12.5%)
Endocarditis	1 (12.5%)
Unstable angina	1 (12.5%)
Number of medicines	10.3 (SD 1.5)
Charlson comorbidity index
0 comorbidities	2 (25%)
1–2 comorbidity	3 (37.5%)
3–4 comorbidities	3 (37.5%)

SD, standard deviation; n, number; DSMS: 1 point is scored for each present geriatric condition (max 4): limitations in Activities of Daily Living (ADL), falls, malnutrition and risk of delirium; MMSE: score < 24 indicates cognitive impairment

Table 3. Reasons for physiotherapists’ adherence or non-adherence to the CCB Cardiac Rehabilitation protocol

Characteristics Gursus	Adherence	Non-adherence
System characteristics	Positive culture for change Preexisting network for organized teamwork (e.g. community care organization) Availability of measurement instruments (e.g. for blood pressure, oxygen saturation)	Task: high workload, time restrictions Tools: Manageability of paper care file No functioning communication transfer system from hospital to physiotherapist (e.g. secure e-mail system)
Provider characteristics	Positive attitude and outcome expectancies intervention Motivation to participate in research Normative beliefs that measurements should be performed properly Familiarity with tools (BORG, METs) Knowledge of content CCB exercise protocol	Usual habits of practice with frail elderly Preexistent high level of expertise with frail elderly Low outcome expectancies of parts of the program (e.g., application of METs or aerobic exercise)
Guideline characteristics (provided exercise program)	Low complexity of exercise program Observability of patient improvements	Limited compatibility with patients Limited time for try-out (only nine sessions of 30 minutes)
Implementation characteristics	Intervention supported by direct leadership Financial support for the intervention	Limited financial support for long term implementation More time needed for treatment and traveling than was financed
Patient characteristics	High level of motivation to be independent Higher activity level before hospital admission	Comorbidities: diabetes, wounds, gout, COPD, anemia, knee osteoarthritis, kidney failure, stroke, psychiatric condition Low level of motivation Sedentary lifestyle before hospital admission

BORG = Borg scale of perceived exertion ranging from 6–20, MET = Metabolic Equivalents Table, COPD = Chronic Obstructive Pulmonary Disease

Table

General information and instructions It is well known that shortly after hospital discharge it is important to improve activities of daily living (ADL). Patients’ independence and physical health can deteriorate. Therefore, it is important to monitor their medical status, e.g. cardiac decompensation, recurrent angina, arrhythmias. Knowledge of these conditions (Dutch cardiac rehabilitation guideline: https://www.kngf2.nl/binaries/content/assets/kennisplatform/onbeveiligd/guidelines/cardiac_rehabilitation_practice_guidelines_2011.pdf) (Achttien et al., 2011) is considered a prerequisite. If in doubt about the cardiovascular status of the patient, please consult the cardiac team in the hospital. For other questions or serious adverse effects, contact the general practitioner. The structure of the exercise program is primarily based on the expertise of the healthcare professional. There is no fixed training schedule because the situation can differ too much per patient. Therefore, per week the structure is outlined. The following principles do apply: an important goal is to strive for the exercise standard of 30 minutes of moderate physical activity per day; better aerobic endurance reduces the risk of one year mortality; given the age, it is very important to match the exercise program with the goals and wishes at the limitation and participation level of the patient. Before each training session, always: check the medical status of the patient and whether he/she has recovered from the previous training session; check the resting heart rate and, if indicated, the blood pressure. Start slow and build up slowly. Start with muscular endurance first, followed by muscular strength and only later in the course build up aerobic endurance. When the exercise capacity is very low, you can train in the phosphate system (training stimulus < 15 seconds (sec), recovery 30 sec. or more if necessary). Train functionally as much as possible, e.g. climbing stairs, carrying shopping bags.
Week and Objective	Frequency	Intensity	Type and Time
Week 1–2 Including intake: Medical status Check vital functions Set activity goals. 2MST 30 sec chair stand test Setting up functional exercises (ADL) Accustom to physical exertion Removing uncertainties Advising what is permissible Promote healthy lifestyle Support self-management	2 x per week 30 minutes	11–12 RPE on the Borg scale Achieve 250 MET in the first week Achieve 300 MET in the second week	- Muscle endurance 10 min - Muscle strength 5 min - Aerobic endurance 5 min Integrate muscle strength and muscular endurance exercises into functional activities as much as possible If possible, strive for 2 minutes of stepping on a 20 cm high step in the 2^nd week Step at patients own pace Stepping up a bench is a powerful cardiovascular training stimulus
Week 3–4 Check how the patient responds to exertion after the habituation phase If the patient’s capacity allows it, try to increase the exercise intensity Interim evaluation: repeat 2MST and 30SCST to evaluate and show progress Identify risk situations and barriers to healthy exercise behaviors – Build new skills & routines	2 x per week And 1 x per week	11–13 RPE on the Borg scale Achieve 350 MET in the third week Achieve 400 MET in the fourth week	Muscle endurance 10 min Muscle strength 7,5 min Aerobic endurance 7,5 min Integrate muscle strength and muscular endurance exercises into functional activities as much as possible If possible, build up to 3 minutes of stepping up 20 cm high step (stair step) Train ADL activities, e.g.: walking; climbing stairs; lifting; vacuuming; mopping; dancing
Week 5–6 Build up to the improvement of the aerobic endurance Final evaluation ninth session and adjust program: repeat 2MST; repeat 30SCST	1 x per week	12–13 RPE on the Borg scale Strive for an intensity of 13 RPE on the Borg scale during exercise, depending on the patient’s load capacity. Achieve 450 MET in the fifth week Achieve 500 MET in the sixth week Maintain 450–500 MET per week	Muscle endurance 5 min Aerobic endurance 20 min Integrate muscle strength and muscular endurance exercises into functional activities as much as possible If possible, in the sixth week see if 4 minutes or longer of stepping on a 20 cm high step at own pace is feasible Train ADL activities, e.g.: walking; climbing stairs; lifting; vacuuming; mopping; dancing

ADL = Activities of Daily Living; Sec = Seconds; Min = Minutes; 2MST = Two Minute Step Test; 30SCST = 30-Second Chair Stand Test; RPE = Rate of Perceived Exertion; MET = Metabolic Equivalent of Task

Table

Risk domain	Instrument	Questions	Cut-off	Score^a
Fall risk	Single question	Did you fall in the last six months?	yes	1
Malnutrition	SNAQ [2]	Assessing whether the patient: 1) lost weight unintentionally in the last month (>3 kg) or last six months (>6 kg) and/or 2) experiences a decreased appetite and 3) used supplemental drinks or tube feeding	Question 1 = yes or Question 2 + 3 = yes	1
Delirium	Single questions	Assessing whether: 1) the patient has cognitive impairment; 2) the patient needed help with self-care in the last 24 hours; 3) the patient has previously undergone a delirium	≥ 1 point	1
ADL-limitations	KATZ-6 [3]	Assessing whether the patient needs help with: 1) bathing, 2) dressing, 3) toileting, 4) transferring from bed to a chair, 5) eating, and 6) whether the patient uses incontinence material	≥ 2 points	1
Total score				0–4

^aPatients are at high risk of functional decline if aged 70–79 years and score ≥ 2 or aged ≥ 80 years and score ≥ 1; ADL-limitations = Limitations in Activities of Daily Living; KATZ-6 = Modified KATZ-6 index; kg = kilogram; SNAQ = Short Nutritional Assessment Questionnaire

Figure C1. Conceptual interdisciplinary framework of clinicians’ compliance with evidence-based guidelines, by Gurses 2010.

Table

Factors	Barriers	Possible actions
Caregiver
Knowledge about the protocol/guideline Does the caregiver know how to follow the protocol/guideline?
Attitude toward the protocol/guideline Does the caregiver believe that following the protocol/guideline is of value?
Usual habits in daily practice What does the caregiver normally do in comparable situations?
Work environment
Task Who is responsible for following the protocol/guideline?
Means and technical tools Which materials are available and are being used? (e.g. training material: e.g. dumbbells)
Decision support How often are tools available and how often are they in use?
Physical environment In what way does the environment influence adherence or non-adherence to the protocol/guideline?
Organizational structure In what way does the organizational structure influence adherence or non-adherence of the protocol/guideline?
Administrative support In what way does administrative support structure influence adherence or non-adherence of the protocol/guideline?
Monitoring/feedback of performance? How does the caregiver know that they adhere to the protocol/guideline?
Culture in the organization In what way does the culture in the organization influence adherence or non-adherence of the protocol/guideline?
The CR protocol/guideline
Applicability to patients in the CCB study
Difficulty/Ease of following the protocol/guideline In what way does the protocol/guideline influence the workload of the caregiver?

Table

Factors	Exemplary questions
Caregiver
Knowledge of the protocol/guideline Does the caregiver know how to follow the protocol/guideline?	Can you explain in what way you apply the protocol/guideline in daily practice? Can you provide an example? How new is the information in the protocol for you? How do you experience the extensiveness of the protocol? How do you experience the complexity of the protocol? What is your opinion about the applicability of the BORG-scale, MET-scale? What is your opinion about monitoring vital parameters such as: weight, medication, blood pressure?
Attitude toward the protocol/guideline Does the caregiver believe that following the protocol/guideline is of value?	Can you explain how important it is for you to adhere to the protocol? Can you give an example of what will or will not happen if you do not follow the protocol? Which parts of the protocol do you disagree with? To what extent do you feel capable of following the protocol? How hard is it for you to follow the protocol? What is your opinion about the prescribed intensity in the protocol? To what extent did you experience a need to implement this protocol in daily practice? What is your experience with interprofessional collaboration within this study? Did you have contact with another caregiver? In what way? What was your contact about? What went well/wrong in interprofessional collaboration? What is your opinion about performing measurements in this study? (BORG/MET/Exercise tests: two-minute step test)
Usual habits in daily practice What does the caregiver normally do in comparable situations?	Can you explain the usual procedure prior to this protocol? How satisfied are you with the usual procedure? To what extent is it possible to change “old” habits in accordance with the study protocol?
Self-experienced compliance with the study protocol How often does the care provider do everything according to the study protocol?	Can you tell me to what extent you are currently following the study protocol? E.g. 80%/90%. What do you encounter when you do or do not follow the protocol? To what extent does the therapist need advice in the protocol regarding abnormalities, e.g. due to comorbidity?
Work environment
Task Who is responsible for following the study protocol?	Can you tell who in your institution is/are responsible for following the study protocol? What is the general workload? How often do you have a lot to do? How much time do you have to carry out the study protocol? How tired were you last week? How tense did you feel last week? How satisfied are you with the quality of your care? How satisfied are you with your work? Social norms To what extent did you feel pressure to follow the study protocol? To what extent were you rewarded for following the study protocol?
Means and technique What stocks and materials are available or in use?	What materials are currently available to carry out the care according to the protocol? Think of checklist, training schedule, logbook, workbook, point software, digital map. How up to date is this material? Also think about blood pressure meter/saturation meter etc. What materials are actually used?
Decide support How often are tools available and used?	What tools are available to follow the study protocol? (e.g. overview map, workbook)
Physical environment In what way does the environment influence whether or not the study protocol is followed?	Can you tell how the environment influences whether you can follow the study protocol? For example, how busy or noisy is the environment?
Organizational structure In what way does the organizational structure (e.g. staffing) influence whether or not the study protocol is followed?	Can you tell me how the organizational structure affects whether or not you can follow the study protocol? How do you normally experience the effectiveness of your organization? To what extent do you experience support from your organization for following the study protocol?
Administrative support In what way does the current administrative support influence whether the study protocol is followed?	Can you tell me how the administrative support affects whether or not you can follow the study protocol? Is information available on time?
Monitoring/feedback on performance How does the care provider know that they are/are not following the study protocol?	Can you tell me how you get feedback on following the study protocol? If applicable: Do you need that feedback? Can you tell how this is monitored? How do you experience the financial support for the implementation according to the study protocol?
Culture How does (working) culture influence whether you follow the study protocol?	Can you tell me in what way the (working) culture influences whether or not you are able to follow the study protocol? How is the culture (e.g. open, about deviations from prescribed actions may be communicated)?
The study protocol
Applicability to patients in the CCB Is the study protocol applicable to the specific patients in the cardiological care bridge? Think of: age, type and severity of comorbidity, patient motivation, degree of independence.	Can you tell me to what extent the study protocol is applicable to the patients you have seen within the cardiological care bridge? To what extent do you feel that you have been able to give cardiac rehabilitation instead of geriatric rehabilitation? To what extent does comorbidity influence the following of the protocol? To what extent do you have knowledge about the comorbidity the patient had? In what way does the motivation of the patient(s) influence following of the protocol? Do you lack knowledge in motivating the patient? To what extent did the patient’s fear influence the following of the protocol?
Ease of following the study protocol How does the study protocol influence the workload of the care provider?	Can you tell how following the study protocol affects your workload? What makes the time pressure higher when performing cardiac rehabilitation in this specific patient group? What is the benefit or additional benefit of the study protocol? To what extent do you experience room to try out the study protocol through trial and error? What do you think of the level of evidence that supports the study protocol?

Achttien RJ, Staal JB, Merry AH, van der Voort SS, Klaver RJ, Schoonewille S, Verhagen SJ, Leeneman HT, van Beek J, Bloemen S, et al. 2011 KNGF clinical practice guideline for physical therapy in patients undergoing cardiac rehabilitation; [Accessed 25 May 2021]. https://www.kngf2.nl/binaries/content/assets/kennisplatform/onbeveiligd/guidelines/cardiac_rehabilitation_practice_guidelines_2011.pdf.

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