Transcript Prescribing an Exercise Program for the Older Adult

Prescribing an Exercise
Program for the Older Adult
David X. Cifu, M.D.
The Herman J. Flax, M.D. Professor and
Chairman Department of PM&R
Virginia Commonwealth University Health
System
Benefits of Exercise
 Physical activity represents an optional behavior and
physical fitness represents an achieved condition resulting
from increased physical activity.
 High levels of physical activity and physical fitness have
been shown to lessen morbidity.
 A graded, inverse relationship between total physical
activity and mortality has been identified.
 Physical activity initiated in late life continues to improve
mortality, having a strong effect on longevity, even when
accounting for factors such as smoking, hypertension,
family history and weight gain.
Paffenbarger: N Engl J Med 1993; 328:538-45
Lee: Exerc Sport Sci Rev 1996; 24:135-7118
Benefits of Exercise
 Studies have demonstrated benefits for patients with
conditions as varied as cardiovascular disease, respiratory
disease, dementia and cancer.
 More recent work has demonstrated that physical activity
may also offset disability.
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Analysis of the more than 10,000 older adults participating in the
Established Populations for Epidemiologic Studies of the Elderly
(EPESE) demonstrated that there was an almost 2-fold increased
likelihood of dying without disability among those most physically
active compared to those who were sedentary.
Morgan: Age Ageing 1998; 27 Suppl 3:35-40
Bath: Age Ageing 1998; 27 Suppl 3:29-34
Kiely:Am J Epidemiol 1994; 140:608-20
Lakka: N Engl J Med 1994; 330:1549-54
Shephard: Circulation 1999; 99:963-72
Specificity of Exercise
 Early studies utilizing forms of either endurance training or
resistance training evaluated physiologic outcomes, and
demonstrated improvements with regard to endurance,
aerobic power, balance, strength, muscle cross-sectional
area and fiber type distribution.
 As studies expanded to evaluate functional outcomes,
inconsistencies arose, with improvements in physiologic
outcomes not always leading to enhancements of function.
Specificity of Exercise
 Endurance exercise, most commonly evaluated in the form
of walking or bicycling, has strong effects on
cardiovascular impairments, leading to improvements in
morbidity and mortality.
 With regard to improvements in function with endurance
exercise however, studies have shown, at best, limited
improvements.
 Endurance exercise without any component of resistance
training, has a weak influence on function.
Pu CT, Nelson ME. Aging, Function and Exercise. In: Frontera W, ed.
Exercise in Rehabilitation Medicine. Champaign: Human Kinetics,
1999:391-424.
Exercise Threshold
 The relationship between impairments and function is nonlinear. There is a threshold after which enhancements in an
impairment, such as strength, will no longer add to
continued improvements in function.
 This helps explain why augmentation of strength could
produce dramatic improvements in function among frail
nursing home residents and at the same time produce
minimal effects on the function of healthy elders.
 Above the “functional threshold”, additional impairment
reduction may add to reserves of strength, augmenting
their resistance to functional decline.
Buchner: Ann Behav Med 1991; 13:91-98.
Jette: Gerontol A Biol Sci Med Sci 1998; 53:M395-404.
Fiatarone: New Engl J Med 1994; 330:1769-1775.
Specificity of Exercise
 Based upon these concepts, progressive resistance training
(PRT) has generally been best accepted as the optimal
means of enhancing and maintaining function in older
adults.
 These recommendations are supported not only through a
large number of intervention studies performed in both
community dwelling and institutionalized elders, but also
through a number of reports demonstrating the association
between impairments in strength and functional
performance.
Jette: J Gerontol A Biol Sci Med Sci 1998; 53:M395-404
Fiatarone-Singh:J Gerontol Med Sci 2002; 57A:M262-282
McCartney:J Gerontol Biol Sci Med Sci 1995;50:B97-104
McCartney Med Sci Sports Exerc 1999; 31:31-7.
Specificity of Exercise
 More recently, impairments in muscle power have been
gaining attention.
 Muscle power, reflecting the product of force and velocity,
is a related but different attribute from muscle strength,
which reflects the ability to exert force.
 Muscle power declines more precipitously in late life than
muscle strength.
 Across a large variety of important mobility tasks, the
associations between muscle power and function are
consistently larger than the associations between muscle
strength and function.
Evans: J Gerontol Med Sci 2000;55A:M309-M310
Bean: J Am Geriatr Soc 2002; 50:461-467
Bean JF: J Gerontol Med Sci 2003; 58A.
Specificity of Exercise
 Muscle power can be improved in older adults and, in
contrast to PRT, can produce greater enhancements in
power if there is a “high-velocity” component to the
exercise training.
 Resistance training designed to enhance muscle power has
been demonstrated to enhance function but has not been
demonstrated to be superior to PRT in this regard.
Fielding: J Am Geriatr Soc 2002; 50:655-662.
Earles: Arch Phys Med Rehabil 2001; 82:872-8.
Miszko: J Gerontol A Biol Sci Med Sci 2003; 58:171-5.
Specificity of Exercise
 In contrast to many of the previously mentioned studies
that utilized resistance training via exercise machines or
the use of free weights, other recent investigations have
examined the use of exercises that are very similar to the
target functional tasks.
 These studies build upon the well-established concept of
specificity of training. In sports, specificity refers to the
concept that optimal training will occur when an athlete’s
training exercise is very similar to the task for which they
are training.
Specificity of Exercise
 If the “sport” for which older adults are training is
functional independence, then it would make sense to
design exercises which are rich in functional specificity.
 Reports in both institutionalized and community-dwelling
older adults have demonstrated improvements in function
after performing exercises which are similar to bed
mobility, transfers and general mobility tasks.
Schnelle: J Am Geriatr Soc 2002; 50:1476-83
Schnelle: J Am Geriatr Soc 1995; 43:1356-62
Bean: J Am Geriatr Soc 2002; 50:663-670
Alexander: J Am Geriatr Soc 2001; 49:1418-27.
Bean: J Am Geriatr Soc 2003:In Press.
Screening Prior to Exercise
 It is well accepted that all older adults, regardless of their
underlying medical conditions, should receive a medical
screening prior to initiating an exercise program.
 Screening examinations should serve a number of
purposes, including:
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1) screening individuals for safety in performing exercise
2) identifying medical problems that would require modification of
the exercise prescription
3) identifying impairments and limitations that the exercise
program will target.
American College of Sports Medicine. Position Stand: Exercise and
physical activity for older adults. Med Sci Sports Exerc 1998; 30:9921008.
National Institute on Aging. Exercise: A Guide from the National Institute in
Aging. Bethesda: National Institute on Aging: National Institute of Health, 1999.
Screening Prior to Exercise
 Surprisingly, there are insufficient data regarding the risk
of adverse cardiac events in older adults initiating exercise.
 It is recognized that the risk for sudden death due to
exercise decreases with increased age.
 Estimates of cardiac events, such as myocardial infarction,
have suggested that the small increases in risk associated
with even vigorous exercise (i.e., > 6 MET, such as
climbing hills or doubles tennis) would be attenuated due
to the benefits of exercise training and that increases in
physical activity and exercise would over time reduce that
risk.
Shephard: Am. Ger. Soc. 1990; 38:62-69
Gill: JAMA 2000; 284:342-9
Screening Prior to Exercise
 In contrast, the adverse effects of a sedentary lifestyle are
well understood.
 A sedentary lifestyle adversely affects every major body
system, contributing to the functional decline associated
with all of the most prevalent chronic conditions of older
age.
 Therefore, as has been previously suggested, perhaps the
approach to the elderly patient contemplating exercise
should not start with the question “Is this patient safe to
exercise?” but rather “Is this patient safe to be sedentary?”.
Fiatarone-Singh MA. The Exercise Prescription. In: Fiatarone-Singh MA, ed.
Exercise, Nutrition and the Older Women. Boca Raton: CRC Press, 2000:37-104.
Screening Prior to Exercise
 Absolute contraindications to participation in an exercise
program
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Unstable Angina or severe left main coronary disease
End-stage Congestive Heart Failure
Severe valvular heart disease
Malignant or unstable arrythmias
Elevated resting blood pressure (i.e.-systolic >200mmHg, diastolic
>110mmHg)
Large or expanding aortic aneurysm
Known cerebral aneurysm or recent intracranial bleed
Uncontrolled or end-stage systemic disease
Acute retinal hemorrhage or recent ophthalmologic surgery
Acute or unstable musculoskeletal injury
Severe dementia or behavioral disturbance
Screening Prior to Exercise
 History and physical exam findings that would herald
further evaluation and treatment prior to initiation of
exercise include;
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delirium
previously undiagnosed heart murmur (esp. AS)
resting tachycardia
resting bradycardia (especially if not drug induced)
orthostatic hypotension
undiagnosed vascular murmur
undiagnosed bruit (carotid or abdominal)
pericardial rub, enlarged aorta, and symptomatic
undiagnosed hernia.
Screening Prior to Exercise
 Diagnostic tests should include a resting electrocardiogram
(EKG), ensuring that there are not new changes such as qwaves, S-T segment depressions or T-wave inversions.
 According to both the American College of Sports
Medicine and the American Heart Association, all older
adults for whom moderate to vigorous exercise is
considered require a screening exercise tolerance test.
Fletcher: Circulation 1995; 91:580-615
American College of Sports Medicine. Guidelines for Exercise
Testing and Prescription. Baltimore: Williams and Wilkins, 1995.
 There is controversy regarding these recommendations as
they pertain to older adults, especially to those 75 years or
older.
Gill: JAMA 2000; 284:342-9
Fiatarone: Top Geriatr Rehab 1990; 5:63-77
Screening Prior to Exercise
 Authors have stated that the guidelines are not applicable
to older persons and even if they were, could not be
implemented reliably.
 It is reasonable to only monitor older persons without overt
cardiac disease for signs and symptoms of cardiovascular
abnormalities during the initial stages of an exercise
program and then consider further evaluation only if
symptomatic:
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angina
decrease in systolic blood pressure of 20 mmHg
increase in systolic blood pressure to 250mmHg
diastolic blood pressure to 120mmHg
repeated increases in heart rate to 90% age-predicted maximum
Monitoring During Exercise
 The following conditions warrant monitoring during
exercise:
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Dementia - assess and monitor for supervision needs
Hernias, hemorrhoids or stress incontinence - monitor technique to
reduce excess Valsalva pressure
Diabetes mellitus, postural hypotension, stable cardiac or
pulmonary disease - Monitor stability of condition with initiation
of activity program
Cardiovascular disease - Monitor response to resistance training
(growing consensus that resistance training may actually reduce
the risk for adverse events in comparison to aerobic exercise)
Gordon: Am J Cardiol 1995; 76:851-3
McCartney:Med Sci Sports Exerc 1999; 31:31-7
Monitoring During Exercise
 The following conditions warrant monitoring during
exercise:
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Cardiovascular disease - Monitor response to resistance training
(growing consensus that resistance training may actually reduce
the risk for adverse events in comparison to aerobic exercise)
Musculoskeletal impairments due to contracture, joint instability or
inflammation will likely require directed treatment prior to
initiation or modification during an ongoing exercise program.
Gordon: Am J Cardiol 1995; 76:851-3
McCartney:Med Sci Sports Exerc 1999; 31:31-7
Arthritis
 As evidenced in recent consensus statements by both the
National Institute of Health and the American Geriatrics
Society, exercise is recognized as an effective treatment in
the primary, secondary and tertiary prevention of
osteoarthritis and its consequences.
 Reductions in disability have been reported with group,
individual and home-based exercise programs, with no
clear difference seen when modes of exercise are directly
compared.
Exercise prescription for older adults with osteoarthritis
pain: consensus practice recommendations. J Am Geriatr
Soc 2001; 49:808-23
Minor: Arthritis Rheum 1989; 32:1396-405
Ettinger: JAMA1997; 277:25-31
van Baar: J Rheumatol 1998; 25:2432-9
Arthritis
 Reports show that reductions in aerobic capacity due to
inactivity in these patients have been corrected effectively
through walking programs, use of a stationary bike or
aquatic exercises.
Minor: Arthritis Rheum 1989; 32:1396-405
Ettinger: JAMA 1997; 277:25-31
 Improvements in strength can be achieved through low and
high-intensity progressive resistance exercises, with
greater improvements reported in studies utilizing higher
intensity training.
Ettinger: JAMA 1997; 277:25-31
Mangione: J Gerontol A Biol Sci Med Sci 1999; 54:M184-90
Minor: Arthritis Rheum 1989; 32:1396-405
Arthritis
 At present, the consensus is that exercise for patients with
OA is safe, does not cause disease progression and rather
than increasing pain actually contributes to the reduction of
pain.
Guidelines on the management of chronic pain
in older adults. J Am Geriatr Soc 2001; 49:80823
Felson: Ann Intern Med 2000; 133:726-37.
 A recent report has suggested however, that knee
alignment and laxity may be an important factor to
consider before initiating quadriceps strength training.
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Greater strength in this muscle group contributed to increased
progression of radiographic changes among individuals with knee
joint mal-alignment and laxity.
Kokkinos: Cardiol Clin 2001; 19:507-16
Hypertension
 The benefits of exercise on hypertension are age
independent.
 A comprehensive meta-analysis in women and two
comprehensive reviews demonstrate that moderate
intensity aerobic exercise, regardless of the exercise mode,
can produce
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a 2% reduction in systolic blood pressure (~11mmHg)
produce a 1% reduction in diastolic blood pressure (~8 mmHg)
reduce left ventricular hypertrophy in patients with more advanced
hypertension.
Kokkinos: Cardiol Clin 2001; 19:507-16
Kelley: Hypertension 2000; 35:838-43
Hypertension
 A meta-analysis specifically addressing the role aerobic
plus resistive exercise suggests that improvements can be
achieved of 2% and 4% for resting systolic and diastolic
blood pressure, respectively.
Kokkinos: Cardiol Clin 2001; 19:507-16
 Recommendations are for hypertensive patients are to
undergo a combined exercise program including aerobic
and resistance training.
Coronary Heart Disease
 For individuals with coronary heart disease, a systematic
review of the effectiveness of exercise only and exercise in
the context of a comprehensive cardiac rehabilitation
program on mortality. Using a meta-analytic approach,
they reported that total cardiac mortality was reduced by
31% and 26%, respectively.
Jolliffe: Cochrane Database Syst Rev 2001;1
 No clear data supporting role of formalized cardiac
rehabilitation for elderly >75 years with CHD.
Pasquali: Am Heart J 2001; 142:748-55
Ades: J Am Geriatr Soc 1999; 47:98-105
Congestive Heart Failure
 Recent consensus statements from national and
international sources emphasizing the need for exercise
training in the treatment of congestive heart failure.
 Exercise improves
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CHF symptoms
maximal and submaximal exercise capacity
many pathophysiological mechanisms underlying CHF, including
abnormalities of heart rate, skeletal muscle myopathy, cytokine
expression and ergoreceptor function.
Witham: J Am Geriatr Soc 2003; 51:699-709.
Recommendations for exercise training in chronic heart
failure patients. Eur Heart J 2001; 22:125-35.
Kokkinos: Am Heart J 2000; 140:21-8.
Pina: Circulation 2003; 107:1210-25.
Congestive Heart Failure
 Older adults (mean age 77) with CHF with performed 10
weeks of progressive resistance training at 80% 1RM.
 They demonstrated improvements in
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muscle strength and endurance
increase in submaximal aerobic capacity
cellular changes in skeletal muscle consistent with improved
oxidative capacity.
 Improvements in peak VO2 were not seen with this form
of training.
 This study also demonstrated that high intensity resistance
training could be conducted safely within this population.
Pu: J Appl Physiol 2001; 90:2341-50
Congestive Heart Failure
 Older adults (mean age 65 years) with CHF participated in
12 months of combined aerobic and resistance training.
 Improvements were seen in peak VO2 and muscle
strength.
McKelvie: Am Heart J 2002; 144:23-30
 These studies underscore the fact that optimal aerobic and
peripheral skeletal muscle effects are seen with a
combination of aerobic and resistance training for older
adults with CHF.
Pu: J Appl Physiol 2001; 90:2341-50
McKelvie: Am Heart J 2002; 144:23-30
Diabetes Mellitus
 Exercise is now recognized as a critical component in the
prevention and treatment of diabetes mellitus.
 Similar to hypertension, most studies have focused on
physiologic outcomes
Ivy: Exerc Sport Sci Rev 1999; 27:1-35
Hamdy: Endocrinol Metab Clin North Am 2001; 30:883-907
 It is recognized that insulin sensitivity increases with
aerobic exercise and has been reported to increase with
resistance training as well.
Ishii: Diabetes Care 1998; 21:1353-5
Diabetes Mellitus
 A meta-analysis demonstrated that exercise training
reduces glycosylated hemoglobin by an amount that should
reduce the risk for diabetic complications. No significant
change in body mass was seen when compared to controls.
 Studies including individuals over age 60 years have
demonstrated similar findings.
Boule: JAMA 2001; 286:1218-27
Diabetes Mellitus
 Diabetic patients may reap many of the other
cardiovascular benefits from exercise, such as improved
lipid profile, blood pressure and energy expenditure, that
provide positive contributions to their overall health status
and reducing the risk for cardiovascular disease
Hu: Arch Intern Med 2001; 161:1717-23
Hu: Ann Intern Med 2001; 134:96-105
Horton: Kinetics, 1999:211-225
Chronic Obstructive Pulmonary Disease
 Older adults with COPD can make improvements in
aerobic capacity with exercise can be achieved with both
low and high intensity exercise.
Levine S, Johnson B, Nguyen T, McCully K. Exercise Retraining. In:
Cherniack NS, Altose MD, Homma I, eds. Rehabilitation of the
Patient with Respiratory Disease: McGraw Hill, 1999:417-430.
Celli B. Respiratory Disease. In: Frontera WR, ed. Exercise in
Rehabilitation Medicine. Champaign, IL: Human Kinetics, 1999:193210.
Chronic Obstructive Pulmonary Disease
 Greater ventilatory benefits are seen with higher intensity
training.
Epstein: J Cardiopulm Rehabil 1997; 17:171-7
 Endurance can be enhanced in elders with COPD, with
greater benefits seen with longer durations of participation,
producing mitochondrial oxidative changes in skeletal
muscle consistent with aerobic training in healthy elders.
Maltais: Am J Respir Crit Care Med 1996; 154:442-7
Maltais: Am J Respir Crit Care Med 1996; 153:288-93
Chronic Obstructive Pulmonary Disease
 Older adult COPD patients can improve their functional
capacity through exercise.
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 A number of studies have demonstrated improvements in
six-minute walk distance with lower extremity exercise
training.
de Torres: Chest 2002; 121:1092-8.
Chronic Obstructive Pulmonary Disease
 Interestingly, the use of distractive stimuli, such as music,
in combination with exercise appears to augment the
beneficial effects of dyspnea.
 This suggests that, as is the case with arthritis pain, along
with exercise, behavioral factors may mediate
improvements in functioning.
Chronic Obstructive Pulmonary Disease
 A recent randomized controlled trial of older adults with
COPD rehabilitation compared 3-month and 18 month
combined upper and lower extremity exercise programs.
 Those subjects who exercised for the longer duration
demonstrated 6% further six-minute walk distances, 11%
improvements in stair climb speed and 12% improvements
in disability.
Berry: J Cardiopulm Rehabil 2003; 23:60-8
Stroke
 In a randomized controlled trial in older adult, chronic
stroke survivors participating in a 10-week exercise
program (30 minutes of exercise, 3 times per week) using a
modified cycle ergometer, produced improvements in
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maximum oxygen consumption
workload, exercise time
systolic blood pressure at submaximal workloads
Potempa: Stroke 1995; 26:101-5
 In a non-randomized study of chronic stroke survivors,
treadmill aerobic exercise training produced improvements
in submaximal energy expenditure directly reducing the
cardiovascular demands of walking.
Macko: Stroke 1997; 28:326-30
Stroke
 Several small studies have evaluated the role of strength
training in stroke survivors.
 In African American stroke survivors, with approximately
1/3 of participants over age 60, a 12-week exercise
program produced improvements in peak VO2, strength
and flexibility. This training protocol included a
combination of cardiovascular, strength and flexibility
exercises.
Rimmer:Med Sci Sports Exerc 2000; 32:1990-6
Stroke
 Two other pilot studies have reported that when
progressive resistance training was a major component of a
post-stroke training program, there was
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enhancement of strength impairments in both the affected and
unaffected sides of the body
improvements in function
improvements in self-reported disability
Teixeira-Salmela: Arch. Phys. Med. Rehabil. 1999; 80:1211-1218
Weiss A: Am J Phys Med Rehabil 2000; 79:369-76
Stroke
 In a randomized, controlled trial, subjects 3 months
post-stroke (mean age 62.3 years) participated in a 4week circuit-training program of task-related exercises.
 Improvements were seen in functional performance,
endurance and force production within the affected leg.
Dean: Arch Phys Med Rehabil 2000; 81:409-17
Osteoporosis
 A wide variety of both randomized and non-randomized
controlled trials have illustrated that exercise can assist in
the maintenance of bone mass in late life. The overall
treatment effect of exercise training was a reversal or
prevention of bone loss of 0.9% per year.
Wolff: Osteoporos Int 1999; 9:1-12
 A common conclusion from both comprehensive literature
reviews and meta-analyses is that low impact, general
exercise programs, such as walking alone offer little
protective effect as compared to strenuous aerobic exercise
or resistance training.
Gutin: Osteoporos Int 1992; 2:55-69.
Wolff: Osteoporos Int 1999; 9:1-12
Osteoporosis
 Notable positive studies incorporating strenuous aerobic
exercise have studied combinations of fast walking, stair
climbing, jogging and calisthenics provided over 9-24
months.
 Generalized progressive resistance training conducted at
high intensities (approximately 60-80% the one repetition
maximum) has been reported to increase bone mass in both
men and women.
Iwamoto: J Orthop Sci 2001; 6:128-32
Hatori: Calcif Tissue Int 1993; 52:411-4
Kohrt: J Bone Miner Res 1995; 10:1303-11.
Dalsky: Ann Intern Med 1988; 108:824-8.
Menkes: J Appl Physiol 1993; 74:2478-84.
Nelson: JAMA 1994; 272:1909-1914.
Fractures from Falls
 Bone density is a focus in the management of osteoporosis
because of its high association with the potential for
fracture and associated morbidity and mortality.
 In addition to improvements in bone density, exercise can
be beneficial in modifying other important factors such as
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muscle mass
muscle strength
balance
risk for falls
Fractures from Falls
 Based upon the existing randomized controlled trials, the
estimated risk reduction in falls due to exercise is between
29-49%.
Wolf: J Am Geriatr Soc 1996; 44:489-97
Campbell: Age Ageing 1999; 28:513-8
Campbell: J Am Geriatr Soc 1999; 47:850-3
Buchner: J. Gerontol. 1997; 52:M218-M224
Tinetti: N Engl J Med 2003; 348:42-9
 The risk for injurious falls was reduced by 37% with an
exercise program that included strength, balance and
walking exercises.
Campbell: Age Ageing 1999; 28:513-8
Campbell: J Am Geriatr Soc 1999; 47:850-3
Fractures from Falls
 High-intensity progressive resistance training (HIPRT)
results in improvements in
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Bone Density
Muscle Mass
Strength
 This research highlights the appropriateness of this form of
exercise for older adults at risk for fracture.
Fiatarone-Singh: J Gerontol Med Sci 2002; 57A:M262-M282
McCartney: J Gerontol A Biol Sci Med Sci 1995; 50:B97-104
Nelson: JAMA 1994; 272:1909-1914
Fractures from Falls
 Individuals at risk for falls have demonstrated
improvements with other forms of dynamic exercise, such
as Tai Chi, weighted vest and standing ankle exercises
performed at high-velocity.
 The superiority of any single mode of exercise versus the
others in regard to balance or falls has yet to be
determined. It would seem however, that exercises which
enhance combinations of force production, speed of
movement, and balance would be beneficial.
Wolf SL: J Am Geriatr Soc 1996; 44:489-97
Wolf: Arch Phys Med Rehabil 1997; 78:886-92
Shaw: J Gerontol Med Sci 1998; 53:M53-M58
Richardson: Arch Phys Med Rehabil 2001; 82:205-9