Geriatric Exercise Handout

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Information about Geriatric Exercise Handout

Published on June 18, 2007

Author: Malbern


Prescribing an ExerciseProgram 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 PMandamp;R Virginia Commonwealth University Health System Benefits of Exercise:  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 Blair: JAMA 1995; 273:1093-8 Benefits of Exercise:  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. 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 Leveille: Am J Epidemiol 1999; 149:654-64 Specificity of Exercise:  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:  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:  Exercise Threshold The relationship between impairments and function is non-linear. 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:  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. Rantanen: J Gerontol Biol Sci Med Sci 1999;54:M172-66. Specificity of Exercise:  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:  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:  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:  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:  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: 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; 30:992- 1008. 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:  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., andgt; 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:  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:  Screening Prior to Exercise Absolute contraindications to participation in an exercise program 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 andgt;200mmHg, diastolic andgt;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:  Screening Prior to Exercise History and physical exam findings that would herald further evaluation and treatment prior to initiation of exercise include; 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:  Screening Prior to Exercise Diagnostic tests should include a resting electrocardiogram (EKG), ensuring that there are not new changes such as q-waves, 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:  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: 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:  Monitoring During Exercise The following conditions warrant monitoring during exercise: 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:  Monitoring During Exercise The following conditions warrant monitoring during exercise: 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:  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:  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:  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; 49:808- 23 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. 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 :  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 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 :  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 :  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 andgt;75 years with CHD. Pasquali: Am Heart J 2001; 142:748-55 Ades: J Am Geriatr Soc 1999; 47:98-105 Congestive Heart Failure :  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 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 :  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 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 :  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:  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:  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:  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:  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, 1999:193- 210. Chronic Obstructive Pulmonary Disease:  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:  Chronic Obstructive Pulmonary Disease Older adult COPD patients can improve their functional capacity through exercise. 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:  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:  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:  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 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:  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:  Stroke Two other pilot studies have reported that when progressive resistance training was a major component of a post-stroke training program, there was 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:  Stroke In a randomized, controlled trial, subjects 3 months post-stroke (mean age 62.3 years) participated in a 4-week 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:  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:  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:  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 muscle mass muscle strength balance risk for falls Fractures from 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:  Fractures from Falls High-intensity progressive resistance training (HIPRT) results in improvements in 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:  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

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