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Even Frail Elderly Patients Can Benefit From Exercise
by Barry Simkin, D.O.
Geriatric Times July/August 2002 Vol. III Issue 4
Physical activity is an effective strategy for promoting wellness in patients of all ages. Although physical activity has long been thought to have value in the maintenance of health, only in the last 50 years have direct correlations between fitness and specific health benefits been scientifically established. Significant attention has been focused on the effects of exercise on elderly people. A growing body of literature supports increased physical activity in the older population as a means of counteracting the negative physiological effects of normal aging. Physical activity in older patients has also been shown to be a powerful prevention and treatment strategy for many medical conditions. As our understanding of these benefits broadens, many researchers and clinicians have attempted to apply these concepts to the frail elderly population.
Which elderly patients are considered frail? Although the term frail is frequently used, researchers have not developed standard criteria for classifying this subgroup. Many restrict the term to those at risk for or already requiring assistance to perform basic activities of daily living. Others have defined frailty as a combination of inactivity with low energy intake, weight loss or low body mass index (Chin A Paw et al., 1999). The underlying causes of disability vary greatly and are not necessarily direct by-products of illness. Due to the lack of precision in defining this category, one must continue to consider this population to be heterogeneous.
A number of factors (e.g., disease burden, socioeconomic status, cognitive function, social support) that have been associated with increased disability on the instrumental activities of daily living (IADL) scale are largely nonmodifiable. However, simple measures of physical performance also have been identified as having a strong inverse relationship with IADL disability. These include grip strength, gait velocity, chair rise and balance (Judge et al., 1996). Although most of these tasks do not rely on muscle strength alone, that is clearly an important and unifying theme among them.
Lean muscle mass decreases 30% to 40% relative to total body mass as we age. This process begins at around 30 years of age and progresses exponentially with time. Muscle strength also decreases over the same period. Initial strength loss is usually subtle, but can often be recognized by the patient at around 50 years of age.
The relationship between muscle loss, physical performance and disability has logically led researchers to attempt strength training to modify disability in older adults.
Fiatarone et al. (1994) explored the effect of exercise on physical frailty in the elderly, ambulatory residents of a long-term care facility. Subjects were randomly assigned to receive resistance training, a multinutrient supplement, both treatments, or a placebo activity and supplement. Subjects not assigned to resistance training engaged in recreational therapy and either the supplement or placebo. The training consisted of knee and hip extensors versus recreational therapy for 10 weeks.
Subjects who completed the progressive resistance training had on average a 189% increase in knee extension strength and an 87% increase in hip extension strength. Minimal effect on muscle strength was found in the recreational therapy group. The greatest strength increases were seen in those who were weakest at the start. Nutritional supplementation did not have a statistically significant effect on either group. Increased muscle strength translated into increased gait velocity (+12%), stair climbing power (+28%) and spontaneous physical activity (+34%).
Although the Fiatarone et al. subjects were institutionalized, they all were ambulatory. Few studies have investigated the effects of moderate- or high-intensity exercise on elderly patients with less mobility. Meuleman et al. (2000) reported increased muscle strength with resistance training in debilitated elderly patients. More than 80% of these subjects used a wheelchair as their usual mode of ambulation. The results showed that, as in Fiatarone et al.'s study, subjects in the training group tended to have a greater improvement in functional activity than those in the control group.
Fall Prevention
Falls are a major concern in the elderly population. The Frailty and Injuries: Cooperative Studies of Intervention Techniques (FICSIT) research initiative was a multicenter trial sponsored by the National Institute on Aging and the National Institute for Nursing Research. Eight independent clinical trials were implemented to determine the effects of unique intervention strategies on falls. In the majority of the studies, exercise was the major intervention.
A meta-analysis of the FICSIT trials concluded that treatments including exercise reduce the risk of falls in the elderly population (Province et al., 1995). Although it can be difficult to interpret meta-analysis data, balance exercises, including tai chi, appeared to have the most significant impact on lowering fall risk. However, none of the resistance exercise groups were associated with a statistically significant reduction in falls.
The Fiatarone et al. study was part of the FICSIT trial and one of two sites that focused on frail elderly patients living in long-term care settings. The second site used a more general program of exercise (Mulrow et al., 1993). Neither site was able to demonstrate fall reductions in long-term care facility residents. Despite the lack of correlation between resistance training and fall prevention in the FICSIT study, the strength of secondary outcomes evidence, such as physical performance measures, is still compelling. Also, many factors inherent in the design of the FICSIT meta-analysis limited its ability to test the power of any specific exercise modality individually.
The FICSIT trial also included a study by Tinetti et al. (1994) that utilized a multifactorial intervention strategy for at-risk community-dwelling elderly. This approach identified risk factors including postural hypotension, benzodiazepine use, polypharmacy, environmental hazards and transfer difficulties. It also assessed measures of physical performance, such as gait or balance impairment and strength or range of motion limitations. Exercise interventions included balance training and low- to moderate-intensity resistance programs with elastic bands. Although this trial produced statistically significant reductions in falls, the interventions had negligible effect on falls causing serious injury. Also, the exercise component produced little effect on improving physical performance compared with the control group. Exercise has not been shown to affect fracture rates despite its ability to prevent falls.
Bone loss is a hallmark of aging. Along with bone mineral density loss, osteoporosis risk factors are prevalent in the frail elderly population. The National Institutes of Health Consensus Development Panel on Osteoporosis Prevention, Diagnosis, and Therapy (2001) reported that both resistance and weight-bearing exercise combined with calcium and vitamin D supplementation in elderly patients probably have a modest effect on slowing bone mineral density loss. Early data (David Lowenthal, M.D., Ph.D., personal correspondence, 2001) demonstrate protection of bone mineral density in patients on chronic steroids who participated in a resistance exercise program.
Implementation
Frail elderly patients who have severe cognitive impairment or are medically unstable are not candidates for exercise programs. Often, frail elderly patients are unable to tolerate aerobic exercise routines on a regular basis due to lack of endurance. While age-related changes in the cardiovascular system have significant effects on cardiac performance, it has been estimated that 50% of endurance loss can be related to decreased muscle mass.
Both impaired mobility and high levels of disease burden in the frail elderly population also cause aerobic activity to be poorly tolerated. Older adults' ability to tolerate orthopedic stress is impaired. If an elderly patient is an acceptable candidate for aerobic exercise, care should be taken to insure only low-impact activities are attempted. Even extended periods of low-impact exercise prior to starting a more vigorous, high-impact program did not have a protective effect on injury in elderly patients (Pollock et al., 1991).
Supervised resistance exercise has been shown to be safe and well-tolerated in frail elderly patients. Nearly all studies using resistance training with elderly subjects have reported low levels of minor musculoskeletal complaints. For instance, in the Fiatarone et al. study, only one participant discontinued the study and two had their training protocols modified for musculoskeletal complaints.
Degenerative changes in articular hyaline cartilage due to aging lead to osteoarthritis. The high prevalence of osteoarthritis among frail elderly patients has often been cited as a major consideration in their limited activity, but in fact, the American College of Rheumatology recommends exercise for the treatment of osteoarthritis. The Fitness Arthritis and Seniors Trial reported a decrease in pain scores with no radiographic evidence of worsening joint degeneration (Ettinger et al., 1997). No differences in pain scores or degeneration were seen between groups participating in either aerobic walking or resistance training programs.
Resistance and balance exercise training programs for the frail elderly population require little modification from standard protocols. As patient frailty increases, so does the need for supervision by a trainer experienced in working with older subjects who have chronic medical problems. Resistance training sessions should occur two to three times per week to build muscular strength and endurance. A basic set of eight to 10 exercises with 10 repetitions each should be able to adequately train all major muscle groups.
Since ambulation is a major issue in the frail elderly population, many programs focus on the lower extremity musculature. Others have used more extensive physical therapy evaluation procedures to identify specific areas of need. Strength programs with resistive bands, free weights or machines have all been used in the elderly population with success (Meuleman et al., 2000). Most studies demonstrate response to training with moderately high loads (>40% of one repetition maximum). Studies in which minimal weights were used or loads were not progressively increased to match increasing strength were not as effective (McMurdo and Johnstone, 1995).
No specific balance protocols have been found to be superior to others. Tai chi has received significant attention in the press and was shown to be effective as part of the FICSIT study (Wolf et al., 1993). Simple balance exercises requiring minimal instruction can be performed at home effectively.
In summary, both resistance and balance training are safe and effective techniques to enhance measures of physical performance in the frail elderly population. Exercise appears to decrease the risk of falls, maintain bone mineral density and reduce functional dependence. Many of the studies produced their greatest benefit in those who were initially most impaired. Practitioners who have experience working with this population should supervise training to maximize benefits and minimize hazards.
Dr. Simkin is assistant professor in the department of internal medicine, division of geriatrics at University of North Texas Health Science Center.References
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