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Exercise in Older People

Exercise in Older People. Improving Health and Function in Old Age Bree Johnston MD MPH & Louise Aronson Division of Geriatrics San Francisco VAMC & UC San Francisco. Learning Objectives. List physical activity interventions that have been shown to be effective in clinical trials for:

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Exercise in Older People

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  1. Exercise in Older People Improving Health and Function in Old Age Bree Johnston MD MPH & Louise Aronson Division of Geriatrics San Francisco VAMC & UC San Francisco

  2. Learning Objectives • List physical activity interventions that have been shown to be effective in clinical trials for: • Osteoarthritis • Falls/Frailty • Discuss which elderly patients require an exercise treadmill prior to starting an exercise program

  3. What to Prescribe? • Mrs. L. is a 75 year old woman with HTN, mild osteoarthritis, and hyperlipidemia. She has fallen twice and is asking you what she can do to “stay out of a nursing home”. She is taking HCTZ 25mg daily, ASA, and acetaminophen. She does no structured exercise. • What exercise do you prescribe, if any? • Does she need a treadmill first?

  4. Epidemiology • Over Age 65 • 75% are completely sedentary • More active: male, wealthy, educated • Inactive: increased morbidity & mortality • Illness and activity: relationship unclear

  5. Benefits of Exercise • CAD, Mortality, DM, HTN, CHF, obesity, insomnia, Parkinson’s disease, osteoporosis, depression, COPD, QOL, lipids, functional decline, cognition, inflammatory mediators • Osteoarthritis • Falls • Frailty

  6. Exercise and Osteoarthritis

  7. Osteoarthritis & Quadriceps Weakness or • About 30% of muscle mass lost between age 30 and 80 • Some data suggests that quadriceps weakness appears to be a risk factor for osteoarthritis of the knee • But quadriceps strength may be a risk factor in patients with varus or valgus deformities Slemenda et al. Ann Int Med 1997 Sharma Ann Int Med 2003

  8. Osteoarthritis: Seattle FICSIT • RCT 105 patients, 68-85 years, +/- OA • 4 groups: endurance, strength, both, control • Inclusion: no tandem, knee strength <50% • Results at 6 months: • Fluctuations in joint sx common • Joint sx not related to exercise • Bottom Line: Exercise does not exacerbate OA Coleman JAGS 1996

  9. Fitness Arthritis & Seniors Trial (FAST) 18 month single-blind RCT • 439 pts >60y, knee OA with pain & disability • Endurance vs. resistance vs. health education • Functional outcomes: stairs, 10lb, walk, car Ettinger JAMA 1997

  10. Fitness Arthritis & Seniors Trial (FAST) Results • Modest improvement on all functional tests • 12% reduction in pain • 10% reduction in disability • 70% compliance Ettinger JAMA 1997

  11. What Exercise is Best for OA? • 2 center randomized single blind trial • 439 with knee OA randomized to aerobic exercise, resistance exercise, or control • 250 people free of ADL problem at entry used for analysis • Outcome: ADL problem during 18 months of follow up Penninx Arch Intern Med 2001

  12. Exercise Control P ADL Disability 37% 53% 0.02 RR disability (exercise) 0.57 0.006 RR disability (aerobic) 0.60 RR disability (resistance) 0.53 Based on this study, aerobic = resistance Penninx Arch Intern Med 2001

  13. Osteoarthritis: Summary • Quadriceps strength may be related to OA in complex ways • Patients with OA can exercise • Exercises decreases pain and disability • Exercise maintains function • ? Optimum dose, type, schedule • I favor endurance when possible

  14. Falls and Frailty

  15. Exercise and Frailty • Problems with lower extremity function (walking speed and chair rising) predict future disabilityGuralnik et al NEJM 1995 • Sedentary people have a longer period of disability prior to death, compared to more active peopleVita NEJM • But can exercise reduce or prevent frailty?

  16. The FICSIT Trials 8 independent prospective RCTs Goal: reduction in falls and frailty Pre-planned Meta-analysis Intervention RR Falls 95% CI any exercise .90 (.81-.99) balance .83 (.70-.98) Province JAMA 1995

  17. Atlanta FICSIT • RCT: 200 healthy, >70, community dwelling • 15 weeks Tai Chi vs. hi-tech vs. education • 4 month follow up • Results • decreased fear of falling • 47% decrease in falls in Tai Chi vs. other groups (p=0.009) Wolf JAGS 1996

  18. Atlanta FICSIT Wolf JAGS 1996 P=0.009 P=NS Any Fall Serious Fall

  19. Exercise and Frailty • RCT of 100 nursing home patients, able to walk 6 meters • Mean age 87 years • Intervention: weight training, 45 minutes 3X/wk for 10 weeks Fiatarone NEJM 1994

  20. Exercise and Frailty • Results • Increase in gait speed and walking endurance • Greatest benefit in the weakest subgroup Fiatarone NEJM 1994

  21. Resistance Training in Oldest Old Fiatarone NEJM 1994

  22. The New Zealand Study of Women • 223 women >80 years • Intervention: PT tailored to individual needs, with resistance and balance training • Results: • Clinical balance, chair rise improved • RR for falls .47 (CI .04-.90) • RR for injurious falls .61 (.39-.97) Campbell BMJ 1997

  23. Follow Up on Tai Chi • Randomized controlled trial • 94 healthy but physically inactive older adults • Mean age 73 (65-96) 88% white; 90% women • low active defined as noninvolvement in a regular exercise program in the month prior to study Li Am J Prev Med 2002

  24. Intervention Intervention Group N= 49 • 60-minute (15-min warm-up, 30-min of Tai Chi, and 15-min cool down period) practice sessions twice a week for 6 months. Control Group N = 45 • Instructed to maintain their routine activities and not to begin any new exercise programs. • Promised a 4-week Tai Chi program at the end of the study. Li Am J Prev Med 2002

  25. Outcomes • Physical functioning domain of SF-20: • vigorous activities • moderate activities • walking uphill, climbing stairs • bending, lifting, stooping • walking one block; • ADLs • Study measures were completed on Week 1, Week 12 and Week 24 Li Am J Prev Med 2002

  26. RESULTS: Physical Functioning Improved in All 6 Measures • Vigorous activities NNT=2* • Moderate activities NNT=4* • Walking uphill, climbing stairs NNT=3* • Bending, lifting, stooping NNT=2 • Walking one block NNT=3* • Performance of ADLs NNT=2 *CI > 1 Li Am J Prev Med 2002

  27. Exercise, Frailty, Falls: Summary • Exercise can improve falls and frailty, even in oldest old • Challenges • Do these RCTs translate to our practices? • Targeting, duration, maintenance?

  28. Who Needs A Treadmill?

  29. Risks of Exercise: MI Vigorous activity triggered 4-7% MIs RR of MI with exertion 2.1-5.9 Increased risk with heavy exertion (jogging, shoveling) Greatest risk in otherwise sedentary group Mittleman NEJM 1993 Albert NEJM 2000

  30. Sudden Death During Vigorous Exercise Albert NEJM 2000

  31. Guidelines for Minimizing Cardiac Risk • Identify contraindications: • MI within 6 months or active angina • Signs & symptoms of CHF • Resting SBP >200 or DBP > 110 • Test cardiac reserve by: • walk up flight of stairs or cycle for 1 minute • if unable, further evaluation or monitorGillJAMA July 19, 2000

  32. Minimizing Cardiac Risk • Lower risk: start with low intensity program such as: gait training, balance, Tai-chi, self-paced walking, lower extremity resistance training • Understand circulatory stressors • stairs > heavy load > incline moderate load > incline > horizontal walking • warm up and cool down JAMA 2000

  33. What to Prescribe? • Mrs. L. is a 75 year old woman with HTN, mild osteoarthritis, and hyperlipidemia. She has fallen twice, and is asking you what she can do to “stay out of a nursing home”. She is taking HCTZ 25mg daily, ASA, and acetaminophen. She does no structured exercise. • What exercise do you prescribe, if any? • Does she need a treadmill first?

  34. What to Prescribe? • On exam, her Bp 136/80 P70 R 12 • General examination is normal • Her “up and go test” shows that she has difficulty standing from a chair without using her arms to get up. The timed component is 13 seconds (a little slow, but below the cutoff). Her knees have changes of OA but are well aligned. She seems a bit hesitant.

  35. What to Prescribe? • Greatest likely benefit: Cardiovascular • Other benefits: OA, osteoporosis, falls, frailty • Prescribe: • Gradually increasing walking program HR goal is (220-75) x .70 = 102 Comfortable walk, can easily talk or sing • Warm up and Cool Down • Quadriceps strengthening • No Treadmill necessary if started slowly

  36. Summary • Exercise improves outcomes in many conditions in older people, including OA, falls, and frailty • Risks are acceptable in most cases • It’s never too late to start! • Writing an exercise Rx is an important intervention to consider in the elderly

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