Exercise in Older People

Improving Health and Function in Old AgeBree 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:– Osteoarthritis– Falls/Frailty

• Discuss which elderly patients require an exercise treadmill prior to starting an exercise program

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?

• Over Age 65

– 75% are completely sedentary

• More active: male, wealthy, educated

• Inactive: increased morbidity & mortality

• Illness and activity: relationship unclear

Epidemiology

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

Exercise and Osteoarthritis

Osteoarthritis & Quadriceps Weakness

• 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

or

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

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, carEttinger JAMA 1997

Fitness Arthritis & Seniors Trial (FAST) Results

• Modest improvement on all functional tests

• 12% reduction in pain

• 10% reduction in disability

• 70% complianceEttinger JAMA 1997

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

Exercise Control P

ADL Disability 37% 53% 0.02

RR disability (exercise) 0.57 0.006RR disability (aerobic) 0.60RR disability (resistance) 0.53

Based on this study, aerobic = resistance

Penninx Arch Intern Med 2001

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

Falls and Frailty

Exercise and Frailty

• Problems with lower extremity function (walking speed and chair rising) predict future disability Guralnik et al NEJM 1995

• Sedentary people have a longer period of disability prior to death, compared to more active people Vita NEJM

• But can exercise reduce or prevent frailty?

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

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

Atlanta FICSIT

0

10

20

30

40

50

60

70

80

Fall #

Tai Chi prevents falls

EducationHi-techTai Chi

P=0.009

P=NS

Wolf JAGS 1996

Any Fall Serious Fall

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

Exercise and Frailty

• Results

– Increase in gait speed and walking endurance

– Greatest benefit in the weakest subgroup

Fiatarone NEJM 1994

Resistance Training in Oldest Old

-20 0 20 40 60 80 100

Strength

Activity

Stair Climb

Percent change

Exercise

Control

Fiatarone NEJM 1994

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

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

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

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

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 > 1Li Am J Prev Med

2002

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?

Who Needs A Treadmill?

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

Sudden Death During Vigorous Exercise

74

19 11

0

10

20

30

40

50

60

70

80

RR Sudden Death

<1/week 1-4/week >4/week

Frequency of Vigourous Exercise

Albert NEJM 2000

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 monitor

Gill JAMA July 19, 2000

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

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?

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.

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

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