Leaving hospital weaker – Knowledge

1. Why this article?

A pneumonia, a heart failure that gets out of hand, a urinary tract infection. Ten days in hospital, the inflammatory markers fall, the X-rays improve, the doctor is satisfied. And yet the person who used to shop and shower on her own leaves with a walking frame and needs help getting dressed.

This is neither rare nor bad luck. It has a name: hospital-associated disability. It means losing the ability to perform at least one basic everyday activity independently – washing, dressing, getting up, using the toilet, eating, walking across a room – where that loss is new between the onset of the illness and discharge [1].

The name says "hospital-associated", not "hospital-caused" – and rightly so. The loss of function arises from the interplay of pre-existing vulnerability, the acute illness, and conditions during the stay that are burdensome or in principle avoidable: immobility, inadequate nutrition, delirium, catheters, everyday activities being taken over unnecessarily [1] [3]. How large the hospital's own share of it is cannot be determined from the usual measurements – see section 2.2.

What matters for this article is something else: part of those conditions can be influenced. That is where something can be done.

This article explains how it comes about, who is most at risk, what is proven to help – and what is less well established than one would like. Every statement is referenced; the numbers in square brackets point to the list of references at the end.

2. How common is it?

2.1 The figures

The most widely cited meta-analysis pools the studies of recent decades and arrives at a frequency of 30 per cent (95% confidence interval 24–33%) among older people admitted for an acute illness [2]. A second finding of the same review is uncomfortable: that figure has barely changed over thirty years, despite programmes designed to reduce it [2].

Further orders of magnitude from the literature:

• More than half of people over 85 leave hospital with a new limitation in daily life [1].
• In an analysis of over 62,000 admissions to a US hospital, functional loss occurred in 20 per cent – including when the reason for admission was a comparatively minor condition treatable in primary care (16 per cent there) [14].
• Roughly half of all new disability in older age arises in the context of a hospital stay [1].

Timing matters: the loss often begins before admission, in the days while the illness builds up, and continues in hospital. Both count [1].

2.2 And now the honest appraisal

These percentages are less solid than they sound. A systematic review co-authored by Roger Hilfiker looked closely at what these studies actually measure [4]. The result:

• Across ten studies the frequency was 37 per cent (95% confidence interval 30–43%).
• Four different measurement tools and several different task lists were used. What counts as "functional loss" is therefore not defined consistently.
• When the person themselves was asked, the figures were 27 to 32 per cent. When relatives or nurses were asked, they were 59 to 70 per cent.

And the authors' central caveat: the frequency is probably overestimated, because illness-related and hospital-related loss cannot be cleanly separated in these numbers [4].

The reason lies in the measurement itself. What is usually compared is the state before the illness began – typically asked about for a point around two weeks before admission – with the state at discharge. That reference point makes sense: it prevents someone from counting as recovered who improved in hospital but remains below their earlier level. Between the two measurements, however, lie two phases: the days of illness before admission, and the stay itself. The loss from the first phase is not subtracted; it is part of the result. Covinsky and co-authors say so explicitly – the term covers both groups, and hospital processes can also simply leave an already existing loss unrecovered [1].

To separate the shares you would need three measurement points: before the illness, at admission, at discharge. Only then can you tell who lost function before admission and recovered in hospital, who did not recover, and who declined only during the stay. Studies that do this are still few [27]. Strictly speaking, then, it is less the frequency of functional loss that is overestimated than its interpretation: it is not a figure for harm caused by the hospital [4].

What follows from that? Not that the problem is small – the order of magnitude of "about a third" is stable across many countries and decades. Rather, that the figures should not be trusted to the percentage point, and that the decisive question is a different one: how much of it is avoidable?

There is a striking answer. A French study of 503 people aged 75 and over assessed every case individually in which the functional loss was caused by the care itself rather than by the illness. Such cases made up 11.9 per cent of all admissions – and 82 per cent of them were judged avoidable [18]. The most frequent reasons were: no physiotherapy (55 per cent of avoidable cases), unnecessary continence pads (49 per cent), urinary catheters (31 per cent) and prescribed bed rest (27 per cent) [18].

These 82 per cent apply to the cases classified as care-related, not to functional loss as a whole. Nobody knows exactly how large the avoidable share of the total loss is. That there is such a share, however, this study shows clearly [18].

3. Why does it happen?

As with falls or confusion, there is rarely one cause. It is the interplay of a vulnerable starting point, an acute illness and an environment geared towards treating organs rather than preserving everyday abilities [1] [3].

3.1 Lying down – the underrated main factor

The most striking figure comes from a study in healthy people. Eleven volunteers with a mean age of 67 stayed in bed for ten days – no illness, with adequate protein in their diet. Afterwards they had lost almost one kilogram of leg muscle mass and around 16 per cent of their knee extensor strength; aerobic capacity was 12 per cent lower [6].

That was without fever, without inflammation, without a drip. Ten days. Roughly as much muscle as a healthy person otherwise loses over several years.

And how much movement actually happens in hospital? A review of activity measurements arrives at sobering values: adults in hospital spend 87 to 100 per cent of their time sitting or lying, and are physically active for about 5 per cent of daytime hours [7].

That this is no cosmetic issue is suggested by an Israeli study using step counters: people who walked fewer than 900 steps a day in hospital lost everyday abilities considerably more often than those who walked more [8]. Nine hundred steps is roughly ten minutes of walking, spread over the whole day – strikingly little.

That study was an observation, however, not an experiment. Walking little may contribute to the decline; it may equally well indicate how ill or frail someone already is. The 900 steps are therefore neither a target nor a safety threshold, and they prove no causal link [8].

How muscle mass and strength are lost in older age, and how to get them back, is covered in detail in our article Muscle weakness in older age.

3.2 The illness itself accelerates the decline

Lying down does not explain everything. An acute infection, an operation or an injury triggers an inflammatory and stress response. Protein breakdown in muscle rises while the muscle at the same time responds less well to protein from food and to normal movement stimuli; glucose metabolism changes too. On top of that, many ill people eat and drink less [3].

Immobility, inflammation and too little energy and protein therefore reinforce one another. That explains two things. First, the decline often begins in the days before admission, while the illness is building up. Second, movement can achieve a great deal, but it cannot fully halt a pronounced illness-driven metabolism. Someone who is severely ill loses muscle strength even when everything in hospital is done right. That is not an argument against mobilisation, but against exaggerated expectations of it [3].

3.3 The mind is involved too

For a long time only muscles were considered. In a systematic review of 22 papers on hospital-associated decline, exactly one took cognitive function into account [3]. Yet it is inseparable from the rest.

Delirium – an acute confusional state with disturbed attention and awareness – is among the most important and clinically most significant risk factors. It is not a harmless side note: it doubles mortality during the admission, it increases the risk of moving into an institution afterwards, and it is associated with a markedly higher risk of a later dementia diagnosis [3]. In the analysis of risk factors, delirium doubles the risk of functional loss (odds ratio 2.34; 95% confidence interval 1.88–2.93) [23].

The treacherous part is the quiet form. The restless, agitated variant is noticed immediately. The quiet, apathetic variant is at least as common and at least as dangerous – but much less often recognised [1]. Someone lying in bed, speaking little and answering slowly is quickly written off as "just tired".

Below the threshold for delirium there are gradations: slowed thinking, anxiety, low mood. These states often persist beyond discharge and lead people to move less – which closes the circle back to physical decline [3].

3.4 Sleep

People sleep badly in hospital: noise, light, night-time measurements and medication rounds, pain, an unfamiliar bed. Poor sleep encourages daytime exhaustion, less movement and confusion – and the sleeping tablets given for it are themselves among the strongest triggers of delirium [1] [3].

How much sleep on its own contributes to functional loss is far less well studied than for delirium or frailty: the link is plausible but not established in the same way. What is well established is that sleep without medication is part of those ward programmes that demonstrably reduce delirium – see section 6.3 [22].

3.5 Eating and drinking

Muscles need protein and movement stimuli. In hospital both are often missing. Nil-by-mouth orders before investigations, diets nobody enjoys, meals going cold at the bedside while the person is asleep or away for a scan – it adds up [1] [3].

Fluid balance plays a part as well. In a Japanese cohort, about one third of older patients were dehydrated on admission. Three months after discharge this group had lost everyday abilities considerably more often than the rest (42 versus 27 per cent); self-care was particularly affected (odds ratio 2.25; 1.03–4.94) [17].

The authors themselves warn against reading this as simple cause and effect: dehydration is probably less a cause than a marker of an overall vulnerable situation – poorer cognition, less independence, more comorbidity [17]. Even so: a glass of water within reach, and someone who reminds you, costs nothing.

Prevention therefore involves more than "muscles need protein": nutritional screening on admission, enough energy and not only protein, an amount of protein tailored to the person, and assessment of chewing and swallowing problems. Malnutrition or the risk of it is among the established risk factors [23]. Conversely, protein alone replaces neither mobilisation nor training [3].

3.6 Enforced dependence

This is the point patients notice most readily – and mention least often.

In hospital, everything is quicker if someone does it for you. Washing, dressing, getting out of bed. Time pressure on the wards is real. But every activity taken off your hands when you could still do it yourself is one training session lost. The French study put numbers on this: among the avoidable cases of care-induced functional loss, unnecessary continence pads (49 per cent) and urinary catheters (31 per cent) came top [18].

In the specialist literature a urinary catheter is called a "one-point restraint" – it keeps a person in bed just as reliably as a strap, only less visibly [1]. The same is true of drip stands and oxygen tubing left in place longer than necessary. And incontinence that first appears in hospital often persists beyond discharge. Several things contribute: restricted mobility, catheters, delirium, medication, a lack of opportunities to reach the toilet, and getting used to pads [3].

3.7 It affects the whole body

A recent review by a European expert group makes clear that this is not only about muscle [3]. Lying down promotes constipation, constipation promotes urinary retention, urinary retention leads to a catheter. Lack of movement leads to fluid pooling in the legs and to pressure damage on the skin. After prolonged bed rest, blood pressure drops on first standing, which makes standing up harder still. And if the swallowing muscles waste too, eating itself becomes a problem – which accelerates muscle loss further [3].

Hence the term the group proposes: a condition "of body and mind", not a muscle problem.

4. Who is most at risk?

4.1 What increases the risk

A meta-analysis of 29 studies collated the patient-related risk factors. The risk is clearly raised with [23]:

• Pressure ulcers on admission (odds ratio 3.33; 1.82–6.09)
• Living in a nursing home (2.42; 1.29–4.52)
• Delirium (2.34; 1.88–2.93)
• Limitations in more demanding everyday tasks such as shopping, cooking or managing medication (2.08; 1.51–2.86)
• Impaired cognition (1.83; 1.56–2.14) and dementia (1.71; 1.23–2.38)
• Malnutrition or risk of it (1.76; 1.03–3.03)
• A history of falls (1.71; 1.00–2.92)

Two further factors stood out in the large US analysis: age – around threefold higher from 95 years compared with 65- to 74-year-olds – and length of stay. In the methodologically stricter analysis of the same study, stays of eight days or more carried roughly four times the risk of stays of one to two days [14].

A note of caution: length of stay is not only a cause but partly a consequence. People who lose abilities in hospital stay longer. The study authors say so themselves [14].

4.2 A simple score for the day of admission

A Japanese paper from 2026 built a score out of four pieces of information that are available on admission anyway [15]:

• Emergency admission: 3 points
• Frailty (Clinical Frailty Scale 5 or above): 2 points
• Impaired cognition (MMSE 23 or below): 2 points
• Age 80 or over: 1 point

Among 1292 people, 26 per cent developed functional loss. Below 3 points the risk was under 10 per cent; from 6 points it exceeded 40 per cent [15]. By far the strongest single factor was emergency admission (odds ratio 4.48; 3.20–6.28) – probably because a sudden onset allows no preparation at all, and bed rest, investigations and unfamiliar surroundings arrive all at once [15].

Notably, age alone was the weakest of the four factors. Frailty and cognition weighed more heavily. That fits the basic rule of geriatric medicine: it is not the year of birth that decides, but the reserve [15].

4.3 What the muscles can tell you

This is where it gets interesting for physiotherapy, and the findings are less consistent than one might expect.

Grip strength. In the large American Health ABC study, weaker grip strength before the hospital stay was associated with a higher risk of new functional loss afterwards (odds ratio 1.69 per standard deviation less strength; 1.11–2.59). In people with pre-existing cognitive impairment the association was considerably stronger (5.16; 1.30–20.5) [19]. Muscle mass – measured by bone density scan – showed no association [19].

And in hospital itself? A Japanese ultrasound study found that thigh muscle thickness was associated with the loss of mobility – whereas grip strength was not, once cognition, nutrition and baseline independence were taken into account [16]. The reason is plain: grip strength is a poor proxy for the legs. In a British longitudinal study, knee extensor strength fell by 11 per cent during the stay while grip strength remained unchanged [16].

The same paper found something else instructive: functional loss affected mobility more often than self-care (37.5 versus 30.0 per cent) – and for self-care no association with any muscle measure could be found [16]. When it comes to washing and dressing, what matters is apparently less the muscle than the environment: whether you are allowed to, whether you are given time, whether someone stands by instead of taking over.

5. What comes afterwards

This is the least pleasant section, but it belongs here, because it explains why prevention is worth so much.

In a study of older people who had lost everyday abilities in hospital, the picture one year later was this: 41 per cent had died, 29 per cent were still limited, and only 30 per cent had regained their pre-illness level [5]. Those are figures otherwise associated with a hip fracture [1].

Even among those who make it home, something often remains. In a longitudinal study of 515 community-living older people admitted for a non-critical illness, six months later 53 per cent could no longer walk a quarter of a mile and 61 per cent could no longer drive [3].

There are two pieces of good news in these statistics. First: part of the recovery is real and does happen – above all in the first three months. A Chinese longitudinal study of 375 affected people showed that the need for support falls fastest during this period and then levels off [20]. Second: what happens in that phase can be influenced – see section 9.

6. What helps in hospital

6.1 Movement – and the honest state of the evidence

Two things need to be kept apart here that are often conflated.

The first: are exercise programmes in hospital effective? The answer is more sobering than one would like to write in an article like this.

The definitive Cochrane review pools 24 studies with 7511 people (mean age 73 to 88) [9]:

• Independence in daily life: 1.8 points better on the Barthel Index (−0.43 to +4.12; scale 0–100). A difference of about 11 points is considered meaningful. Low certainty – so probably no noticeable difference.
• Functional mobility: 0.78 points better on the Short Physical Performance Battery (−0.02 to +1.57; scale 0–12; meaningful from about 1 point). Very low certainty.
• Quality of life: 6.0 points better (0.9–11.2; scale 0–100; meaningful from about 10 points). Low certainty.
• Falls: 34 per 1000 people in both groups (risk ratio 0.99; 0.59–1.65) – moderate certainty. There was thus no signal that exercise leads to more falls – but the confidence interval does not fully rule out either an increase or a decrease.
• Delirium: 73 instead of 81 per 1000 (0.90; 0.58–1.41), very low certainty – unclear.

Other reviews are friendlier. A Spanish review from 2025 found, for supervised multicomponent programmes, an improvement in physical performance (standardised mean difference 0.42; 0.12–0.72) and in independence (0.45; 0.14–0.77) [11]. The best-known single trial behind it: 370 people with a mean age of 87, doing 20 minutes of strength, gait and balance training twice daily during their stay – with better scores for performance, everyday independence, grip strength and even on the cognitive test [13].

Why the difference? Because the reviews include different studies and grade them differently. Cochrane pools everything, including weak programmes. The Spanish review looks specifically at supervised, multi-part programmes. The cautious summary: the programmes studied appeared safe overall, no signal of more falls was found, and where exercise works it does so most plausibly as a supervised programme with a strength component – but the effects on daily life are smaller than the enthusiasm in some papers suggests.

The second – and probably more important: what happens during the other 23 hours? An Australian review from 2026 examined exactly that: not exercise programmes, but building movement into the ordinary day – standing up for meals, walking to the toilet yourself, washing yourself, sitting in a chair instead of lying in bed [10]. Result from randomised trials: greater independence at discharge (standardised mean difference 0.29; 0.05–0.52), low certainty. From non-randomised studies in addition: better odds of maintaining function (1.95; 1.53–2.50), fewer pressure injuries (0.53; 0.32–0.89) and a stay about one day shorter [10].

Here too the authors are fair: on the Barthel Index the effect in the randomised trials amounts to 1.86 points – again below the threshold at which a difference becomes noticeable [10]. So perhaps the most important finding is a different one: people who were encouraged to move were more likely to believe that movement helps their recovery (84 versus 71 per cent) [10]. And that conviction goes home with them.

6.2 A look back from our own practice

In 2017, Marielle Tschopp and Roger Hilfiker carried out a systematic review with meta-analysis on exactly this question: can physiotherapy prevent or reduce hospital-associated disability? Of 1319 records screened, seven randomised trials with 692 patients remained – including only people aged 65 and over with conditions that do not in themselves cause lasting disability [26].

The pattern back then was already the same as today [26]:

• For measures during the stay: a small difference that was not statistically confirmed (standardised mean difference 0.28; −0.01 to 0.57).
• For measures beginning in hospital and continuing afterwards: also small (0.24; −0.01 to 0.48).
• For measures after discharge: a large effect (0.78; 0.47 to 1.09) – from only three trials, but all pointing the same way (heterogeneity I² = 0%).

To put these numbers in context: for a standardised mean difference, 0.2 counts as a small, 0.5 as a moderate and 0.8 as a large effect. The two authors rated the overall certainty of the evidence as very low under GRADE. Their first conclusion was: although hospital-associated disability is common, there are remarkably few studies of complete physiotherapy programmes during and after the stay [26]. Their recommendation to the profession – to implement and evaluate such programmes – was addressed explicitly to both sides of the hospital door.

What is remarkable is what has happened in the eight years since. See section 9.

6.3 Wards that work differently

More effective than any single measure is a whole ward organised differently. Three models have been studied:

Acute geriatric units. Interdisciplinary teams, floors and rooms that invite walking, no bed rest orders, daily review of medication and catheters, planning the return home from day one [1]. The most recent meta-analysis of 11 randomised trials with 7496 people shows: no confirmed difference at discharge (risk ratio 0.89; 0.75–1.04), but clearly less functional loss at six months (0.79; 0.66–0.93; moderate certainty) [21]. The chance of living at home at three months was slightly higher, without statistical certainty (1.06; 0.99–1.13) [21].

The Hospital Elder Life Program. Not an exercise programme but a bundle of simple things: reorientation, sleep without medication, glasses and hearing aids made available, drinks offered, daytime activity – mostly delivered by trained volunteers. In the meta-analysis the frequency of delirium fell by more than half (odds ratio 0.47; 0.37–0.59), and in the observational studies there were fewer falls (0.58; 0.35–0.95) [22]. The way to read this matters: what was studied is the bundle as a whole. That each single component – glasses, hearing aid, daylight, mobilisation, sleep hygiene, orientation – protects on its own is not what these studies show [22].

Ward programmes such as "Eat Walk Engage". In the cluster-randomised CHERISH trial with 539 people aged 65 and over, such a programme almost halved the rate of delirium (adjusted odds ratio 0.53; 0.31–0.90); for the other complications, discharge destination and mortality no difference was found [24].

The pattern is always the same: eat, move, engage the mind – carried by the whole team, not by one profession alone [3].

6.4 Hospital at home

Some acute treatments can be delivered at home. The review on this is cautious: for everyday abilities the results are inconsistent – two of five studies found an advantage for treatment at home, three did not. For cognitive status the picture was clearer: in both studies that examined it, cognition deteriorated more often in inpatients than in those treated at home [11].

The obvious explanation is named by the authors themselves: one's own home is an environment in which confusion arises less easily – familiar rooms, one's own rhythm, familiar people [11]. This is not yet established, and hospital at home is far from suitable for every condition. But it is a reason to ask, when a treatment is planned, whether it has to be an inpatient stay.

7. What you can do yourself in hospital

None of this replaces medical instructions. But much of it can be raised, and almost all of it is gladly supported if you say so.

• Ask whether you may get up – and if so, how often. "Do I have to stay in bed, or may I get up?" is the most important question of the first 24 hours. Bed rest is often not ordered but simply assumed [18].
• Eat in the chair, not in bed. That is three sit-to-stands a day, and it usually costs nobody extra time.
• Go to the toilet for as long as it is medically reasonable and safe – by yourself or accompanied. At night rather accompanied: with confusion, dizziness on standing, a need for oxygen or a high risk of falling, going alone is dangerous, and whether that applies is for the clinical team to judge. A continence pad, once you have one, is hard to get rid of [3].
• Wash and dress yourself as far as you are able – even if it takes longer. Tell the nurses: "I'll do this myself, I just need a bit of time."
• Wear your own clothes and firm shoes as soon as you can. People in a hospital gown rarely walk down the corridor.
• Bring your glasses, hearing aid and walking aid – and insist that they stay within reach. Seeing and hearing are among the most important protective factors against confusion, and a fixed part of the effective ward programmes [22].
• Ask every day whether the catheter, the drip and other lines are still needed. Every tube fewer is one more walk down the corridor [1]. Adjusting or stopping any of them is for the responsible clinicians alone – oxygen and medication explicitly included, and never to be reduced for the sake of a mobility goal.
• Keep a glass of water within reach and drink regularly, unless there is a reason not to [17].
• Set yourself a daily goal. Twice down the corridor, three times out of bed – written on a note on the bedside table. The 900 steps from the observational study are not a target, but they show how little movement already went with a difference [8].
• Ask for physiotherapy if you feel unsteady walking. The absence of physiotherapy was the single most frequent reason for avoidable functional loss in the French study [18].
• Sleep without sleeping tablets wherever possible. Earplugs, an eye mask, dimmed light. Sedatives and sleeping tablets are among the strongest triggers of confusion [1].

8. What relatives can do

Relatives are not visitors, they are part of the treatment. Several studies have looked at exactly this – programmes that deliberately involve the family in maintaining movement and independence [10].

• Walk along. A stroll down the corridor is often worth more than an hour on the edge of the bed – if the person wants to and their condition allows.
• Bring the "before" into the conversation. "Two weeks ago she was still doing her own shopping" is medically important information. Without it nobody can judge whether something has changed – and the level of function before the illness is usually missing from the records [1].
• Report changes in behaviour immediately. "He is more confused than usual" is the simplest and a surprisingly accurate question for detecting delirium [3]. Unusual silence counts too.
• Bring glasses, hearing aid, dentures, own clothes, slippers with a heel counter, a few photographs, a clock with a large face.
• Be there at mealtimes if eating is difficult. People who have company while eating eat more [3].
• Ask early about what comes next. Not on the day of discharge. What is needed at home – nursing support, physiotherapy, aids, a handrail, a change to the living situation?

9. After discharge: the first three months

This is where the evidence is strongest – above all for physical performance.

What Tschopp and Hilfiker could only suspect from seven studies in 2017 [26] can now be shown on considerably more material. A review from 2025 analysed 17 randomised trials with 1458 people who received an exercise programme after an acute hospital stay. The result [12]:

• A clear improvement in physical performance (standardised mean difference 0.78; 0.52–1.05) – measured with the Short Physical Performance Battery of balance, walking speed and rising from a chair.
• Scores also improved on the Timed Up and Go (−0.40; −0.65 to −0.15) and the six-minute walk distance (0.27; 0.08–0.46).
• No confirmed effect on grip strength, quality of life, mood, or readmission to hospital (risk ratio 0.64; 0.39–1.05).
• Virtually all studies reported no serious adverse events.

A detail that rounds this off: the effect size is the same as in 2017 – a standardised mean difference of 0.78, then with a confidence interval of 0.47 to 1.09, today of 0.52 to 1.05 [26] [12]. What rested on three post-discharge trials then, and had to count as very uncertain evidence, now rests on a broader base – with practically the same estimate.

What the programmes with the most favourable results had in common – as a description of the successful trials, not as a proven minimum dose [12]:

• Strength training, combined with walking or balance work – in the trials without a strength component no convincing effects were seen.
• At least three times a week, several studies with five or more sessions.
• Longer than four weeks. One study found nothing at 30 days and a clear effect at 60 days.
• Mostly at home, with instruction plus telephone calls or home visits for support – not as a leaflet alone.
• Starting right at discharge or in the days that follow.

Which of these components is decisive, and how much is needed as a minimum, is not settled by this. Nor does it follow that a programme without a strength component is of no use at all [12].

This fits the course of the need for support: it falls fastest in the first three months and then levels off [20]. Most is to be gained in those three months. Improvements remain possible afterwards, though – starting later is not starting in vain.

9.1 How this works in Switzerland

Three routes are available, and they do not exclude one another:

• Acute and transitional care (Akut- und Übergangspflege, AÜP). Nursing care prescribed by the hospital doctor at discharge for a maximum of 14 days, either at home or in a facility. It is prescribed when no longer rehabilitation is needed. The nursing costs are covered by health insurance and the canton of residence; you pay for accommodation and meals yourself [25].
• Physiotherapy on medical prescription. For a progressive strength and balance programme – as an outpatient in the practice or, if you cannot leave the house, at home with the doctor's note "Domizilbehandlung" (home treatment).
• Spitex for nursing and household support for as long as it is needed.

The practical advice: ask for these conversations before the day of discharge. If they are improvised on the final morning, you get exactly the gaps that prevent a good recovery [1].

10. Six common misconceptions

"In hospital you should rest."
For an acutely ill organ, perhaps. For the rest of the body it is the fastest route to dependence. Ten days of lying down cost even healthy 67-year-olds about a kilogram of leg muscle and a sixth of their knee extensor strength [6]. And no signal was found that movement in hospital leads to more falls [9].

"It comes with age."
Age is a risk factor, but the weakest of the four that make up the Japanese score – frailty, cognition and emergency admission weigh more heavily [15]. And where the loss was attributable to the care, 82 per cent of those cases were judged potentially avoidable [18].

"A few days in bed do no harm."
They do. And the loss is not symmetrical: what disappears in ten days takes months to come back – if it comes back. A year after functional loss in hospital, only 30 per cent had regained their previous level [5].

"Physiotherapy in hospital doesn't help anyway."
The effect of exercise programmes on daily life is indeed smaller than often claimed [9]. But that is an argument against the idea that two therapy sessions can offset 23 hours of lying down – not against physiotherapy. Its absence was the single most frequent reason for avoidable functional loss in the French study [18].

"Strength comes back on its own once I'm home."
Only partly. Progressive programmes after discharge are among the best-established parts of this whole topic – with a clear effect on physical performance [12]. Without them a gap often remains: six months after the stay, more than half could no longer walk a quarter of a mile [3].

"A pad is more practical than getting up at night."
In the short term, yes. But incontinence that first appears in hospital often persists beyond discharge – encouraged by restricted mobility, catheters, delirium, medication and a lack of opportunities to reach the toilet [3]. Unnecessary pads ranked second among avoidable cases, at 49 per cent [18].

11. When should you involve a professional?

Raise the subject if one or more of these apply:

• A hospital stay is coming up or has just ended
• You have walked less steadily since the stay
• You need help with things you managed alone before the illness
• You can no longer get up from a chair without using your hands
• You lost weight or ate noticeably less in hospital
• Relatives say you have been more forgetful or slower since then
• You avoid trips you used to take for granted

What to expect in physiotherapy: a conversation about how things were before the illness – that is the key reference point – measurement of walking speed, rising from a chair and balance, a look at strength and load tolerance, at walking aids and the home situation. From this comes a progressive strength and balance programme with clear steps up, plus a home programme for the days in between – in other words, exactly the format that proved effective after discharge in the trials [12].

In our practice the relevant services are Strength in later life, Power training in later life, Fall prevention and – if you cannot leave the house yet – treatment in your home.

What needs medical assessment: persisting confusion or forgetfulness after the stay, unintended weight loss, dizziness or blacking out on standing, a medication list that grew longer in hospital, and new incontinence. None of this has to stay, and none of it is a normal sign of ageing.

If a procedure is planned, you have the greatest advantage of all: time. The weeks beforehand can be used for strength and balance training. Someone who enters with more reserve has more to lose before it becomes critical – that is the logic behind the score in which frailty weighs more than age [15].

12. In summary

About a third of older people leave hospital less independent than they were before the illness. Part of that is due to the illness itself, with inflammation, a stress-driven metabolism and too little food. Another part depends on conditions that can be changed: lying down, activities being taken over, tubes, pads and sleeping tablets. In a French study, care-related functional loss was found in 11.9 per cent of all admissions; 82 per cent of those cases were considered potentially avoidable. How large the avoidable share is overall cannot be quantified – that there is one, can.

The most effective measures are unspectacular: get up for meals, walk to the toilet, wear your own clothes, keep glasses and hearing aid at hand, a few more metres each day, one tube fewer each day. None of them needs equipment, and few of them fail for lack of money – though sometimes for lack of time and staff.

The best window comes afterwards: most of the recovery happens in the first three months after discharge, and progressive strength and balance programmes are best established here – most clearly for physical performance. They should start at discharge, not when it becomes clear that things are not improving by themselves. Starting later is still better than not starting.

And one sentence that sets the direction: the hospital does not only treat the illness – it should also protect independence. Patients, relatives and the clinical team can do a great deal together to keep as much movement and self-directed activity as possible. Asking costs nothing, and it is done too rarely.

One limitation at the end, for the sake of honesty: the figures in this article come overwhelmingly from high-income countries, and the measurement methods differ so much between studies that the exact frequency remains uncertain [4]. What does not differ is the direction: where people in hospital keep moving, eat and stay mentally engaged, they do better afterwards.

References

All Digital Object Identifiers (DOIs) have been checked against the Crossref register. The links in the reference list lead via the DOI service to the publishers' pages. Some of these are located outside Switzerland and the EU. Clicking them transmits your IP address to the provider concerned – this does not happen on our own site. The reference on acute and transitional care leads to a Swiss page.

[1] Covinsky KE, Pierluissi E, Johnston CB. Hospitalization-associated disability: "She was probably able to ambulate, but I'm not sure". JAMA. 2011;306(16):1782–1793. https://doi.org/10.1001/jama.2011.1556

[2] Loyd C, Markland AD, Zhang Y, et al. Prevalence of hospital-associated disability in older adults: a meta-analysis. Journal of the American Medical Directors Association. 2020;21(4):455–461.e5. https://doi.org/10.1016/j.jamda.2019.09.015

[3] Welch C, Chen Y, Hartley P, et al. New horizons in hospital-associated deconditioning: a global condition of body and mind. Age and Ageing. 2024;53(11):afae241. https://doi.org/10.1093/ageing/afae241

[4] Giacomino K, Hilfiker R, Beckwée D, Taeymans J, Sattelmayer KM. Assessment tools and incidence of hospital-associated disability in older adults: a rapid systematic review. PeerJ. 2023;11:e16036. https://doi.org/10.7717/peerj.16036

[5] Boyd CM, Landefeld CS, Counsell SR, et al. Recovery of activities of daily living in older adults after hospitalization for acute medical illness. Journal of the American Geriatrics Society. 2008;56(12):2171–2179. https://doi.org/10.1111/j.1532-5415.2008.02023.x

[6] Kortebein P, Symons TB, Ferrando A, et al. Functional impact of 10 days of bed rest in healthy older adults. The Journals of Gerontology Series A. 2008;63(10):1076–1081. https://doi.org/10.1093/gerona/63.10.1076

[7] Fazio S, Stocking J, Kuhn B, et al. How much do hospitalized adults move? A systematic review and meta-analysis. Applied Nursing Research. 2020;51:151189. https://doi.org/10.1016/j.apnr.2019.151189

[8] Agmon M, Zisberg A, Gil E, Rand D, Gur-Yaish N, Azriel M. Association between 900 steps a day and functional decline in older hospitalized patients. JAMA Internal Medicine. 2017;177(2):272–274. https://doi.org/10.1001/jamainternmed.2016.7266

[9] Hartley P, Keating JL, Jeffs KJ, Raymond MJM, Smith TO. Exercise for acutely hospitalised older medical patients. Cochrane Database of Systematic Reviews. 2022;(11):CD005955. https://doi.org/10.1002/14651858.CD005955.pub3

[10] Baldwin C, Lynch E, Munn Z, et al. Incorporating "moving more and sitting less" into daily activities of hospitalised older medical patients: a stakeholder-directed systematic review with meta-analysis of complex interventions. Disability and Rehabilitation. 2026;48(9):2630–2652. https://doi.org/10.1080/09638288.2025.2584961

[11] Etayo-Urtasun P, Sáez de Asteasu ML, Izquierdo M. Comparison of hospitalisation settings and exercise interventions in acute care: a systematic review and meta-analysis. Age and Ageing. 2025;54(2):afaf035. https://doi.org/10.1093/ageing/afaf035

[12] Etayo-Urtasun P, Izquierdo M, Sáez de Asteasu ML. Effectiveness of post-discharge exercise interventions in older adults following acute hospitalisation: a systematic review and meta-analysis. The Lancet Healthy Longevity. 2025;6(7):100730. https://doi.org/10.1016/j.lanhl.2025.100730

[13] Martínez-Velilla N, Casas-Herrero A, Zambom-Ferraresi F, et al. Effect of exercise intervention on functional decline in very elderly patients during acute hospitalization: a randomized clinical trial. JAMA Internal Medicine. 2019;179(1):28–36. https://doi.org/10.1001/jamainternmed.2018.4869

[14] Skains RM, Zhang Y, Osborne JD, et al. Hospital-associated disability due to avoidable hospitalizations among older adults. Journal of the American Geriatrics Society. 2023;71(5):1395–1405. https://doi.org/10.1111/jgs.18238

[15] Umegaki H, Nakashima H, Yamada Y, et al. A simple admission-based risk score for hospital-associated disability in older adults. European Geriatric Medicine. 2026. https://doi.org/10.1007/s41999-026-01498-8

[16] Nagae M, Umegaki H, Yoshiko A, et al. Muscle evaluation and hospital-associated disability in acute hospitalized older adults. The Journal of Nutrition, Health and Aging. 2022;26(7):681–687. https://doi.org/10.1007/s12603-022-1814-8

[17] Nagae M, Umegaki H, Komiya H, et al. Dehydration and hospital-associated disability in acute hospitalized older adults. European Geriatric Medicine. 2023;14(1):113–121. https://doi.org/10.1007/s41999-022-00722-5

[18] Sourdet S, Lafont C, Rolland Y, Nourhashemi F, Andrieu S, Vellas B. Preventable iatrogenic disability in elderly patients during hospitalization. Journal of the American Medical Directors Association. 2015;16(8):674–681. https://doi.org/10.1016/j.jamda.2015.03.011

[19] Abay RJY, Gold LS, Cawthon PM, Andrews JS. Lean mass, grip strength, and hospital-associated disability among older adults in Health ABC. Alzheimer's & Dementia. 2022;18(10):1898–1906. https://doi.org/10.1002/alz.12527

[20] Yin Z, Ying Y, Li X, et al. Post-discharge care needs of the older people with hospital-associated disability: a longitudinal study. Journal of Clinical Nursing. 2023;32(7–8):1303–1315. https://doi.org/10.1111/jocn.16293

[21] O'Shaughnessy Í, Robinson K, O'Connor M, et al. Effectiveness of acute geriatric unit care on functional decline, clinical and process outcomes among hospitalised older adults with acute medical complaints: a systematic review and meta-analysis. Age and Ageing. 2022;51(4):afac081. https://doi.org/10.1093/ageing/afac081

[22] Hshieh TT, Yang T, Gartaganis SL, Yue J, Inouye SK. Hospital Elder Life Program: systematic review and meta-analysis of effectiveness. The American Journal of Geriatric Psychiatry. 2018;26(10):1015–1033. https://doi.org/10.1016/j.jagp.2018.06.007

[23] Geyskens L, Jeuris A, Deschodt M, Van Grootven B, Gielen E, Flamaing J. Patient-related risk factors for in-hospital functional decline in older adults: a systematic review and meta-analysis. Age and Ageing. 2022;51(2):afac007. https://doi.org/10.1093/ageing/afac007

[24] Mudge AM, McRae P, Banks M, et al. Effect of a ward-based program on hospital-associated complications and length of stay for older inpatients: the cluster randomized CHERISH trial. JAMA Internal Medicine. 2022;182(3):274–282. https://doi.org/10.1001/jamainternmed.2021.7556

[25] Bundesamt für Gesundheit (BAG). Krankenversicherung: Pflegeleistungen – Akut- und Übergangspflege (Art. 25a Abs. 2 und Art. 49a KVG). Bern, 2026. https://www.bag.admin.ch/de/krankenversicherung-pflegeleistungen

[26] Tschopp M, Hilfiker R. Prévenir ou réduire les handicaps associés aux hôpitaux grâce à la physiothérapie – Revue systématique. Kinésithérapie, la Revue. 2017;17(192):25–26. https://doi.org/10.1016/j.kine.2017.09.030

[27] Gallego-González E, Mayordomo-Cava J, Vidán MT, Valadés-Malagón MI, Serra-Rexach JA, Ortiz-Alonso J. Functional trajectories associated with acute illness and hospitalization in oldest old patients: impact on mortality. Frontiers in Physiology. 2022;13:937115. https://doi.org/10.3389/fphys.2022.937115