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Go Granny Go! Exercise Prescriptions for Older Adults Brian K. Unwin, M.D. Colonel, Medical Corps, United States Army Uniformed Services University USAFP 2010 How we want to be Reality? Stages and Age of Man Reality? Currier and Ives print Spectrum of exercise in older adults Overview • The Federal Activity Guideline • How do we get there? • What is exercise for the older adult? • Contraindications for exercise • What does Granny need? • What do we evaluate before we advise exercise? • Disease specific recommendations THE NEW FEDERAL ACTIVITY GUIDELINES 2008 Federal Activity Guidelines – Older Adults (ages 65 years and older) • Follow adult guidelines. When not possible, be as physically active as abilities and conditions allow. • Do exercises that maintain or improve balance if at risk for falling. • Those without chronic conditions and symptoms (e.g., chest pain or pressure, dizziness, or joint pain) do not need to consult a health care provider about physical activity. 2008 Federal Activity Guidelines – Adults (ages 18–64) • Minimum levels a week • 2 hours and 30 minutes (150 minutes) moderate-intensity aerobic activity; or • 1 hour and 15 minutes (75 minutes) vigorous-intensity aerobic activity; or • An equal combination • Muscle-strengthening activities that involve all major muscle groups should be performed on 2 or more days of the week. 2008 Federal Activity Guidelines Adults (ages 18–64) • For additional health benefits • 5 hours (300 minutes) moderate-intensity aerobic activity a week; or • 2 hours and 30 minutes (150 minutes) vigorous-intensity aerobic activity a week; or • An equivalent combination For More Information http://www.health.gov/paguidelines http://www.healthfinder.gov/getactive Overview • The Federal Activity Guideline • How do we get there? • What is exercise for the older adult? • Contraindications for exercise • What does Granny need? • What do we evaluate before exercise? What is exercise? • Lifestyle choice • Regular • Structured • Purposeful • Organized sports • Unstructured play Exercise impacts body composition • Genetic, lifestyle and disease factors • Metabolic, cardiovascular and musculoskeletal systems impacted • Lifestyle is under patient’s control Increased Muscle Mass • Endurance training emphasis • Walking isn’t enough • Progressive resistance training • DM prevention? • Dependency prevention? • Falls and fractures • Disuse • Sarcopenia • Frailty Exercise burns fat • Decreases in total body adipose tissue • Aerobic and resistive training • Energy restricted diets and/or high volume exercise (5-7 hours/week) • Visceral fat selectively mobilized What’s fat got to do with it? • Metabolic syndrome • Breast cancer • Vascular disease • Colon cancer • Osteoarthritis • Endometrial cancer • Gallbladder disease • Impotence • Diabetes • Osteoarthritis • Hypertension • Depression • Dyslipidemia • Disability • Sleep apnea Strength and Functional Status Normal Healthy Adults “Function” Near Frail THRESHOLD Poor Frail Adults “Strength” Low High Established Populations for Epidemiologic Studies of the Elderly (EPESE) . J Gerontology, 1994;49(3):M109-15 y, 1994;49(3):M109-15 How elders function and how they die… Terminal Illness Sudden Death High Cancer High Function Function 22% 7% Death Death Low Low Time Time Dementia Lung Frailty Organ Failure Strokes Heart Arthritis High Liver High Parkinson’s Hip Fracture Function Function 47% 16% Death Death Low Low Time Time Lunney, JR, Lynn J, Hogan, C. Profiles of Older Medicare Decedents. JAGS 50:1108-1112, 2002 Overview • The Federal Activity Guideline • How do we get there? • What is exercise for the older adult? • Contraindications for exercise • What does Granny need? • What do we evaluate before exercise? Contraindications to therapeutic rehabilitation • Unstable angina, left main coronary dz • End stage CHF or systemic disease • Unstable arrhythmias • Malignant hypertension • Expanding aortic aneurysm Contraindications to therapeutic rehabilitation • Cerebral aneurysm or intracranial bleed • Recent eye surgery or retinal hemorrhage • Acute/unstable musculoskeletal injury • Acute systemic illness (pneumonia, pyelo) • Severe dementia/behavioral disturbance Overview • The Federal Activity Guideline • How do we get there? • What is exercise for the older adult? • Contraindications for exercise • What does Granny need? • What do we evaluate before exercise? Disease Impairment Disability Handicap Difficulty Malnutrition shopping Physical Weakness Environment (multi-story house) Immobility Difficulty Loss of ability Knee Pain walking to live arthritis independently Apathy Social Social Isolation Environment Depression (loss of spouse) Prin. Geriat. Med, 5th edition, p. 289 What does Granny need? • Individualized assessment • Patient’s definition of quality of life • Current active medical problems • Medications • Strengths Assessment • Cognitive • Emotional • Physical Individualized decision making • Patient motivation • Importance of exercise • Confidence in their abilities • Trade-offs of risk vs. benefit • Patient and family preferences • Financial resources Overview • The Federal Activity Guideline • How do we get there? • What is exercise for the older adult? • Contraindications for exercise • What does Granny need? • What do we evaluate before exercise? What to evaluate? • Strengths assessment • Cognitive • Emotional • Physical • Physical exam • Functional exam Additional physical exam items • Postural vital signs • Visual Acuity • Strength, reflexes, coordination, sensation • Continence • Foot examination • Labs as indicated and Vitamin D Functional Exam • Identify risks • Establish a baseline • Aerobic capacity • Balance • Gait • Upper extremity strength and ROM • Lower extremity strength and ROM • Establishes goals Aerobic capacity: Timed Walk (or how far does Granny go?) Balance: Romberg’s test • Test for proprioception primarily to differentiate sensory ataxia (central and peripheral) from cerebellar ataxia • Sharpened Romberg’s may be helpful in the elderly Sharpened Romberg’s Timed ‘Up and Go’ test • Simple test of observing a person stand up from a chair, walk 10 feet, turn around, walk back, and sit down again. Sensitivity: 54-87% • Correlates with ADLs 74-87% Specificity: • Normal person takes < 10 seconds to for predicting falls complete the task • Note: use of hands, staggering, unsteadiness Podsiadlo 1991 Functional Reach Test • Measures forward and lateral balance; Sensitive to change over time • Simple to administer • Arm extension with 90 degrees of shoulder flexion while patient is upright and leaning forward or sideways • Results • < 6 inches related to falls • Minimal fall risk if >10 inches of reach Duncan 1990 Functional Reach test Gait evaluation Gait Stance (left and right) Strike (left and right) Swing (arms and legs) Step width (6” or less) Path (straight?) Alexander N. JAGS. 1996. 44: 434-451. Assessing Upper Extremity Function Unwin’s Shampoo Test Assessing Upper Extremity Function Hand grip dynamometer Assessing Lower Extremity Function Unwin’s Socks and Shoes Test Single-leg stance test • Best balance measure for any individual • If one can stay on one leg for 10 seconds, there are usually no significant balance problems Bohannon 1984, Janda 1996 Modified single leg stance Next step Exercise Prescription? Rehabilitation? Physical Therapy • Bed mobility and transfer • Gait and balance • Ambulatory endurance +/- gait aid and stair climbing • Hip and knee extensor training Mobility Aids Cane • Supports 15-20% of weight • Options: single point, quad or hemi-cane • Side opposite affected limb • Fitted to ulnar styloid • Contraindications • Arm weakness, moderate to severe gait or balance deficit • Potential problem: inadequate support Mobility Aid Walker • Supports ~30% of weight • Options: 4 post, 2 wheel/2 post, 3 wheel, 4 wheel, 4 wheel with seat and hand brakes (Rollator), 4 wheel with safety bars and sling seat (Merry Walker), forearm supports • Fitted to ulnar styloid • Contraindications: • Environmental hazards, severe arm and gait weakness • Problem: slows gait, maneuverability Mobility Aids Crutches Wheelchair • Supports full body weight • Supports full body weight • Options: underarm/forearm • Options: manual/motorized; accessories; lower to ground or • Fitting: 2 inches under one-sided drive (hemi-chair); shoulder; do not lean armpit racing, handcycle on crutch • Fitting: 1-1.5 inches around hips • Contraindications: arm and under knees; footplates weakness, shoulder clear floor by 1-2 inches; armrest at elbow height; arthritis, cognitive removable footrests and impairment armrests • Problems: neuropathy, • Contraindications: unable to sit, shoulder pain, difficult to or able to walk safely learn to use • Problems: deconditioning, contractures, pressure sores Occupational Therapy • ADL training • Fine motor training and adaptive equipment • IADL / homemaking / community survival skills • ROM / flexibility of • Cognitive and safety upper extremity awareness assessment and • Energy conservation remediation and joint protection • Muscle strength and endurance training THE ROLE OF ‘HOME’ IN EXERCISE AND FUNCTION Environment hazards for exercise • Indoor hazards – slippery floors, rugs/carpet, poor lighting, shoes, bathroom fixtures, height of chair and bed, unstable furniture, stairways. • Outdoor hazards- uneven pavement, steps, snow and ice, neighborhood safety Nevitt 1989, Gill 1999 Pets and exercise Certified Aging-in-Place Specialists (CAPS) http://www.aarp.org/family/housing/articles/caps.html J American Geriatrics Society, 2009, 57: 476-481 “Long Term Effect on Mortality of a Home Intervention…” “ABLE demonstrated that teaching elderly people new approaches to performing valued activities resulted in additional years of life.” CONDITION SPECIFIC REHABILITATION Leading causes of death • Cardiovascular disease • Cerebrovascular disease • Chronic lung disease • Alzheimer’s Disease • Accidents and falls • Leaving out pneumonia, influenza, malignancy CARDIAC REHABILITATION Cardiovascular rehabilitation • Less than 1/3 patients participate • www.ahrq.gov/news/press/prsrl2.htm • Components include: • Comprehensive • Long-term • Medical evaluation • Prescribed exercise • Risk-factor modification • Education • Counseling Cardiac rehab outcomes • Improved exercise tolerance for CAD and CHF • Decreased symptoms in CAD and CHF • Multi-factorial interventions improve lipids • Multi-factorial rehab reduces cigarette smoking (16-26% will quit) AHRQ Technical Reviews and Summaries, AHRQ Supported Clinical Practice Guidelines, Chapter 17. Cardiac rehabilitation Cardiac rehab outcomes • Improved psychosocial well-being • Mortality reduction of approximately 25% at three years (similar to B- blockers and ACE Rx) • No increase in morbidity or mortality Cardiol J. 2008; 15(5): 481-7 Outcomes Diagnosis Functional QOL Morbidity Mortality Capacity AMI +++ +++ ++ +++ CABG +++ +++ ++ ++ Stable +++ +++ + + angina PCI +++ ++ + ? CHF +++ ++ + + Cardiac +++ ++ ? ? Transplant Valve +++ ++ ? ? replacement Am Heart J. 2006; 152: 835-41 STROKE REHABILITATION Some ugly truths • Race disparities in use of stroke rehab programs and outcomes • Less likely to receive if DNR or Medicaid recipient Stroke rehabilitation • Initial assessment • Risk factors for CVA • Medical co-morbidities • Consciousness and cognitive status • Brief swallowing assessment • Skin assessment and pressure ulcers • Mobility and assistance needs • Risk of DVT • Emotional/social support of the family Reassessment of rehab progress • General Medical Status • Functional status • Mobility, ADL/IADL, Communication, nutrition, cognition, mood/affect/motivation, sexual function • Family support • Resources, caretaker, transportation • Patient and family adjustment • Reassessment of goals • Risk for recurrent CVA Assessment of discharge environment • Functional needs • Motivation and preferences • Intensity of tolerable treatments • Availability and eligibility for benefits • Transportation • Home assessment for safety PULMONARY REHABILITATION Lung disease rehabilitation • Cost effective and beneficial to system • Components: Multidisciplinary, individual assessment, exercise training, education, medical therapy, psychosocial support • Goals: • Reduce symptoms • Optimize function • Increase participation • Reduce healthcare costs Ries Al, et al. Pulmonary Rehab: Joint ACCP/AACVPR Evidence-based clinical practice guidelines. Chest 2007 May; 131(5 Suppl): 4S-42S. Recommendations and evidence • Mandatory exercise training (Level 1A) • Six to 12 weeks of pulmonary rehab produces benefits that decline over 12- 18 months (1A) • Maintenance strategies have modest effect on long-term outcomes (2C) • Lower extremity exercise at higher intensity has greater benefit (1B) Ries Al, et al. Pulmonary Rehab: Joint ACCP/AACVPR Evidence-based clinical practice guidelines. Chest 2007 May; 131(5 Suppl): 4S-42S. Recommendations and evidence • Low- and high-intensity exercise produce benefits (1A) • Strength training increases strength and muscle mass (1A) • No support for use of anabolic steroids (2C) • No support for inspiratory muscle training (1B) Ries Al, et al. Pulmonary Rehab: Joint ACCP/AACVPR Evidence-based clinical practice guidelines. Chest 2007 May; 131(5 Suppl): 4S-42S. Typical program • Stage III-IV COPD severity • 3-4 sessions/week, 3-4 hours/session • 6-12 week duration • Walking/resistance training • Horizon (?): heliox, O2, non- invasive ventilatory support, biofeedback, anabolic steroid Casaburi, ZuWallack. NEJM 2009; 360: 1329-35 Problem areas • COPD cachexia • ¼-1/3 of patients don’t improve • No uniform funding policy • $2200/person cost • Unavailable to low-income, minority and rural populations Casaburi, ZuWallack. NEJM 2009; 360: 1329-35 Outcomes • Improves dyspnea (Level 1A) • Improved Health Related Quality of Life (1A) • Reduces hospitalization and utilization (2B), Cost effective (2C) • Insufficient data for survival benefit • Psychosocial benefits (2B) Ries Al, et al. Pulmonary Rehab: Joint ACCP/AACVPR Evidence-based clinical practice guidelines. Chest 2007 May; 131(5 Suppl): 4S-42S. DEMENTIA REHABILITATION Exercise to preserve cognition • 8/11 studies of aerobic exercise interventions showed increased fitness • Largest effects were: • Motor function (1.17(?) effect size) • Auditory attention (0.52 effect size) • Delayed memory function (0.50 effect size) • Cognitive speed (0.26 effect size) • Visual attention (0.26 effect size) Angevaren, et. al. Cochrane Database of Systematic Reviews, 2008, Issue 2. CD005381 Physical activity for dementia patients • Limited RCTs of activity in AD • Generally improved: • Psychological/physical performance • Mobility • Balance • Strength • Gait speed • Sleep • Mood/agitation/cognitive function Rolland, et al. JAMDA 2008; 9: 390- 405 Not a pretty picture • Studies highlight sedentary life of the elderly • Average of 12 minutes a day of constructive activity in institutional settings • Is inactivity an early manifestation of dementia? FALL AND FRACTURE REHABILITATION Fall prevention: Cochrane Review of 11 RCTs • Wide variety of exercise programs • 5/11reduction in rate of falls or fall risk • 4 exercise only intervention • 1 multi-intervention + exercise is effective in lowering the risk of falls Conclusion: “Exercise in selected groups and should form part of fall prevention programmes. Lowering fall-related injuries will reduce health care costs…” Injury rehabilitation (hip fracture) There is insufficient evidence from RCTs to establish the effectiveness of the various mobilisation strategies used in rehabilitation after hip fracture surgery. • Seven trials early • Six trials after hospital discharge Handoll . Mobilisation strategies after hip fracture surgery in adults. Cochrane Database of Systematic Reviews 2007, Issue 1. Art. No.: CD001704. Summary • Exercise as prevention • Exercise as therapy • Team Rehab • Prescribed exercise
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