Exercise at any Age, with any Chronic Condition (Part 1)

Steven C. Castle, MD

Republished from: http://www.aginglifecarejournal.org/exercise-at-any-age-with-any-chronic-condition/

Introduction

Exercise and physical activity for older adults was an important theme discussed at the 2015 White House Conference on Aging.  Specific initiatives discussed included the NIH Go4Life campaign and the YMCA initiative to provide intergenerational physical activity.  The implementation of exercise and fall prevention programs on state and national levels sheds light on the importance of physical activity as being viewed as the core to healthy aging and preventing and lessening the impact of chronic disease.  Exercise is now known as an essential component of falls prevention, demonstrated by the fact that $5 million of President Obama’s budget is targeted for the National Falls Prevention Resource Center. Moreover, the CDC has also recognized its importance by providing free online webinars on falls prevention, which are currently being used by health care providers like Kaiser Permanente.  The reduced health care costs as a result of physical activity as well as the reduction of the most common form of accidental injury (falls) may also reduce the need for long-term services prematurely.

Everyone has heard that exercise is good for you, right?  Of us older adults, how many are heeding that advice?  How many of our primary care providers have spent the time to find out and help us do more exercise to the degree that they prescribe or monitor lipid lowering meds and follow cholesterol levels?  One reason why we as a society are falling short, as described below, is because there is a bias AGAINST exercise in older adults that no one is talking about.

Why Exercise?

Exercise is essential to improving balance and reducing risk of falls.  While the National Council on Aging (NCOA) has made a list of evidence-based programs, the evidence is not equal, and there may be other programs in the community which are actually more robust in improving balance.  A recent review on efficacy of exercise programs in preventing falls identified that 32 multicomponent exercises demonstrated reduction in falls by an average of 30%, while three single component (either walking or strength training) programs were not effective (Gillespie LD 2012).  The multicomponent programs target activities that address balance, strength, endurance, and walking.  Among successful programs, total weekly exercise time ranged from 80 minutes to more than seven hours. The duration of programs ranged from eight weeks to two years, while one review suggested a minimal dose of 50 hours of balance exercise is needed to be effective. Participation was improved by having a convenient location, incorporating social activities, and reimbursement for travel costs (Ganz DA personal communication).

In addition, engaging in physical activity is essential for maintaining mobility as we age. Dr. Debra Rose, Director of the Center for Successful Aging at Cal State Fullerton, defines mobility as “the ability to move oneself independently and safely from one place to another.”  The ability to walk 400 meters has been defined as an excellent proxy for community ambulation, which is central to aging in place and quality of life. This became the primary outcome measure of the LIFE (Lifestyle Interventions and Independence for Elders) Study (Pahor J, 2014).  This study randomized 818 (mean age 78.7 years) to physical activity (2x/week in a center and 3-4x/week at home) with 817 (mean age 79.1 years) to a health coaching group.  Of the physical activity group, 85.3% remained independent in community mobility versus only 80.2% of the health coaching group, for a 28% reduction in the risk of becoming dependent (p=.006).

How well are we doing?

Data from the National Health Interview Survey and the Centers for Disease Control (CDC) from interviews of the civilian and non-civilian population show that 42.4% of adults age 65-74 are reporting achieving aerobic activity goals as are 28.1% of adults age 75 and over (goal >50%).  Not bad.

However, only 14.4% of adults age 65-74 and only 7.9% of adults age 75 and over are achieving the goal of both the aerobic and muscle-strengthening activities.  Why aren’t older adults doing more muscle strengthening exercise? Probably because we are not aware of the benefits and have a bias that it will do harm. This is also due to the lack of resources, training, and coaching / supervision needed.

How much exercise should older adults participate in?

The US Office of Disease Prevention and Health Promotion established physical activity guidelines for “Healthy People 2020” to gain substantial public health benefits:

• Avoid inactivity, some physical activity will provide some health benefits (goal <33%)
• For substantial health benefits, older adults should do aerobic activity.
• At least 150 minutes (2 hours and 30 minutes) a week of moderate intensity (goal >50%)
• Or 75 minutes (1 hour and 15 minutes) of vigorous intensity (goal > 33%)
• Or an equivalent combination, performed in 10 minute increments
• Extensive health benefits occur when increased to 300 minutes (5 hours) of moderate intensity or 150 minutes of vigorous activity.
• Muscle strengthening exercises should be done 2 or more days per week of 8-10 exercises that train all major muscle groups (goal >25%)

Additional Recommendations for older adults from the American College of Sports Medicine:

• Maintain or increase flexibility (stretching) for at least 10 minutes a day, twice a week
• To reduce the risk of injury from falls, perform exercises that maintain or improve balance

In the paper “Exercise is the Real Polypill” (Fiuza-Luces C 2013), the evidence of the impact of exercise in comparison with medications on reducing chronic conditions such as  glucose intolerance, lipids, blood pressure, and risk of thrombosis-related cardiovascular events (heart attacks and stroke) is discussed.  The paper reviews a meta-analysis which demonstrates that weight resistance training in particular was equivalent to the polypill (1-3 blood pressure lowering meds, a lipid lowering med, and aspirin), while other types of exercise had a more modest effect on lowering blood pressure in particular. It also identified that there was lower dropout rates in exercise groups (10%) versus the polypill group (20% dropout versus 10% for placebo pill).

In addition, the paper discusses the release of beneficial myokines and anti-inflammatory substances secreted as a result of muscle strengthening exercise, as well as possible substances associated with longevity and reduced risk of colon cancer.  Muscle strengthening exercise provides something different than the more traditional aerobic or cardio-fitness exercises we think of older adults actively engaged in.

A 1-Hour Walk, 3 Times a Week, Has Benefits for Dementia

By GRETCHEN REYNOLDS MAY 24, 2017

Exercise may bolster the brain function and thinking skills of people with dementia, according to a new report. The study’s findings suggest that walking a few times per week might alter the trajectory of the disease and improve the physical well-being of people who develop a common form of age-related memory loss that otherwise has few treatments.

The study looked at vascular cognitive impairment, the second most frequent form of dementia worldwide, after the better-known Alzheimer’s disease. The condition arises when someone’s blood vessels become damaged and blood no longer flows well to the brain. It is often associated with high blood pressure and heart disease.

One of the particular hallmarks of vascular dementia in its early stages, researchers have found, is that it tends to make the brain function less efficiently. In past brain-scan studies, people with a diagnosis of vascular cognitive impairment generally showed more neural activity in parts of their brains that are involved with memory, decision-making and attention than did people without the disease, indicating that their brains had to work harder during normal thinking than healthier brains did.

But while a great deal of research attention has been devoted to Alzheimer’s disease, less has been known about the progression of and potential curbs on vascular dementia. Some research has indicated that reducing blood pressure lessens the symptoms of the disease.

Exercise can likewise improve blood pressure and cardiovascular health. And some research suggests that frequent, brisk walks may improve memory and physical abilities in those in the early stages of Alzheimer’s disease. But, rather surprisingly, few past studies had examined whether exercise might also improve brain function in people with vascular dementia.

So for the new study, which was published in April in The British Journal of Sports Medicine, researchers at the University of British Columbia in Canada and other institutions decided to look into the effects of walking on this type of dementia.

They began by recruiting 38 older people in British Columbia who had been given diagnoses of a mild, early form of vascular cognitive impairment. None currently exercised. All agreed to visit the university’s lab frequently for six months.

On the participants’ first lab visit, the scientists measured their general health and also memory and thinking skills.

They then scanned each volunteer’s brain while he or she concentrated on a computerized test of attention and decision-making skills that involved rapidly clicking keys to indicate the direction that an arrow should point. This scan was designed to reveal neural activity and how hard different parts of the brain were working during the task.

Finally, the scientists randomly assigned their volunteers to start either walking or, as a control group, to visit the lab for weekly education sessions about nutrition and healthy living.

The walking program was simple, consisting of supervised one-hour sessions at the lab three times a week. The walkers were asked to move briskly enough during workouts to raise their heart rates to about 65 percent of their maximum capacity.

“We wanted to have some intensity” in the exercise, says Teresa Liu-Ambrose, the director of the Aging, Mobility and Cognitive Neuroscience Lab at the University of British Columbia and the lead author. Most of the walkers completed all of the sessions and “seemed to be enjoying the exercise” by the end of the six months, she says.

At that point, the volunteers in both groups repeated the physical and cognitive tests from six months earlier, as well as the brain scan. The results showed that the two groups had drifted apart, in terms of the functions of their bodies and brains. Most obviously, the walkers generally had lower blood pressures now than the volunteers in the control group.

But more striking, their brains also were working differently. The walkers’ brains showed less activation in portions of the brain required for attention and rapid decision-making than did the brains of those in the control group.

The differences were subtle, Dr. Liu-Ambrose says, but they correlated neatly with improvements on the cognitive tests. The less someone’s brain had to work to maintain attention and make quick decisions, the better that person typically performed on the tests of general thinking ability.

In essence, the walkers had more efficient brains and better thinking skills now than the control group did, she says.

Of course, this study was short term, lasting only six months, after which the volunteers were free to stop exercising — and most did. Dr. Liu-Ambrose and her colleagues hope in the future to study whether and how rapidly the brains and bodies of exercisers lose any gains if they become sedentary again. They also want to look into different “doses” of exercise and whether shorter or easier workouts would have an effect on brain function in people with vascular dementia.

Obviously, anyone with memory or other cognitive problems should consult with a doctor before starting to exercise and should probably not exercise alone, Dr. Liu-Ambrose says.

But even with so many questions remaining, the results of this study are encouraging, she says. They show that in the early states of vascular dementia, “something as simple and accessible as walking may make a meaningful difference” in how well the brain works.

Reprinted from: https://www.nytimes.com/2017/05/24/well/move/a-1-hour-walk-3-times-a-week-has-benefits-for-dementia.html?_r=1