Exercise at any Age, with any Chronic Condition (Part 3)

Steven C. Castle, MD

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

What this Geriatrician learned from the Gerofit program

The following describes an exercise program, Gerofit, and its proven benefits for its participants. The Gerofit program was started by Dr. Miriam Morey at the Durham VA and for the past 30 years has successfully provided an exercise venue for older adults with chronic conditions (Morey MC, 2007). The program requires a referral from the primary care provider, with a chart review and telephone interview. Then baseline and quarterly Senior Fitness Test assessments (Rikli RE 2013) tell you your percentile ranking by gender and five year age group.  This allows a prescribed individualized exercise program that includes exercises for aerobic/cardio, weight resistance, and balance.  Program participants demonstrated a 25% reduction in mortality over five years, and in a related study, those that showed a 0.1m/sec increase in usual gait speed had less hospital days and reduced one-year costs (Purser JL 2005).

This author was skeptical of this program and had concerns about its safety. What I learned from exercising with older Veterans, doing assessments, and adjusting exercise protocols was this:  besides being a lot of fun, the gym is a true respite from illness.  Everybody has chronic conditions, and instead of focusing on them, everyone is working to improve their fitness.  Second, I realized I was biased against exercise because I was fearful someone would get hurt.  Instead, what I have learned is to assess their fitness, then prescribe an appropriate starting place for cardio, weight-resistance training, and balance based on that assessment. Third, older adults need guidance/reminders to do exercises correctly and to adapt exercise to chronic musculoskeletal conditions, and most importantly, to progress the intensity of the exercises.  I also learned it is very hard to predict in whom exercise will really take hold and become life changing.  Prior history of some physical fitness training provides a clue, but is not a guarantee; while many with no background in exercise can just as readily take off.  Exercise is life changing in this cohort.

What do we do about exercise in the significant portion of older adults with varying forms of cognitive impairment?

How do we implement an exercise program that includes cardio, muscle strengthening, and some balance exercise in this population?  What I have learned from Gerofit is that some of the older adults in a program will develop cognitive decline, some will be unrecognized at time of enrollment but become more obvious when they do not learn exercise routines or technique; and in both cases, they will exercise effectively but need supervision and coaching. Those with moderate dementia can fit well into a group exercise program if there is enough staff support or their caregivers are trained and supervised as well.  Folding cognitive impairment participants into a fitness program really provides optimal socialization and engagement when the focus is on fitness and set exercise routines.  

Participants with dementia with past history of physical activity will have motor memory that exceeds cognitive memory.  Regardless, improvement in fitness assessment is the norm if participants engage in the exercise, and there is significant benefit to mood and reduced anxiety.

How can an Aging Life Care Manager™ help?

Aging Life Care Managers have an important role in promoting exercise for their older clients. Care managers can facilitate the interaction of older adults, families, and health care providers, making the initiation of an exercise program more possible.  Care managers can recommend exercise programs for their clients for fall prevention, but can also help to identify clients that have already fallen that could benefit from exercise as an intervention.

The recommendation by the CDC is that if someone has had two or more falls or a fall with injury in the past year, has decreased activities due to changes in their balance, or has demonstrated at-risk screening measures mentioned above, then the following should be done:

• Address chronic medical conditions that may be contributing to changes in balance, including inadequately controlled hypertension.
• Review possible risky medications that may impair balance for indication, efficacy, and safer alternatives.  A careful review of how medications are being administered for adequate adherence, and if a blood thinning medication is appropriate given the falls risk, adherence with meds and risk/benefit of the blood thinner.
• Have a thorough mobility and balance assessment, including drop in blood pressure with standing, vision (acuity and peripheral fields) cognition, and gait assessment.
• Be encouraged to participate in a balance exercise program.
• Address vision, appropriate shoes (no barefoot or socks), lighting and environmental risks.

An Aging Life Care Professional™ is in a unique position to encourage clients and their families to follow through with these recommendations, and begin or continue exercise programs that meet the guidelines.

We, as care managers and health care providers, need to address our own bias about exercise for older adults, in order to become effective advocates for this essential component of health and wellness.

Exercise at any Age, with any Chronic Condition (Part 2)

Steven C. Castle, MD

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

Why should Grandma and Grandpa perform muscle strengthening (weight resistance) training?

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.

What are the components of exercise that help improve balance, reduce falls, and achieve mindful awareness? (Rose D, 2010)

The following are descriptions of the positive outcomes exercise can provide for older adults and how these outcomes can improve balance, reduce falls, and increase safety awareness.

1. Posture and control of Center of Gravity

Older adults who experience a decline in posture often develop inaccurate perceptions of true vertical. Curvature of the spine with decline in flexibility was significantly associated with falls (Kasukawa Y 2010). Mindful awareness of vertical targets (doors, windows, corners) is helpful in restoring postural alignment. Progressive improvement in balance from exercises can start with seated, progress to standing activities, and utilize compliant (foam) or irregular surfaces. In addition, posture control strategies using the ankle, knee, or hip should be included in the exercise training.

2. Strength and Endurance

Muscle strength declines as much as 20-40% between age 30 and 80. Weakness in the body core (alignment of low back, pelvis, hips) contributes to poor balance, and weakness of the muscles in the legs can cause significant challenge in going from a seated to standing position. Strength becomes of increasing importance in individuals with poor balance control. More strength is needed to correct posture to prevent a fall because inappropriate weight shift results in moving the center of gravity off the base of support.

3. Flexibility

Joint range of motion and muscle flexibility decline with age and are associated with impairment in function. Loss of flexibility to perform shoulder or spinal rotation is directly related to functional limitations and increased susceptibility to falls. Reduced flexibility in legs results in less efficient gait (limits endurance) and a decline in balance control (leaning) that also contributes to falls.

4. Gait speed and efficiency

Because of many of the changes described above, stride length and decreased height of each step results in a decline in gait speed. Slow gait results in less stability and shorter steps: shuffling increases the risk of tripping or catching a toe. Exercise programs that require negotiating obstacles and vary surface conditions allow participants to develop a walking pattern that is more efficient, flexible, and adaptive, with more speed to improve stability.

What else can we do to improve mobility and balance?

Falls prevention is difficult to achieve, while mobility and balance awareness should not be.  For the needed behavior changes for exercise and adaption to changes, mobility and balance awareness provides a platform for patients, family, and care managers.  One way to better address mobility and balance awareness is by doing balance assessments, including the 8 foot up and go as part of the Senior Fitness Test, or the more balance-focused Short Form of the Fullerton Advanced Balance Scale (Hernandez D 2008).  These objective measures provide the opportunity to discuss changes in balance which most of us are not cognizant or aware.  Most 80-year-olds will recognize their balance is not like when they were 30, but all 60 and most 70-year-olds are not aware of decline at all; and all older adults are not aware of the size of the risk or that they have the ability to improve their balance through a formal balance exercise program or the need to adjust their lifestyle to match.

Once aware of their change in mobility and balance, the next step is to try and have older adults work with their providers to figure out the cause of mobility and balance changes. A practical approach to identifying the underlying causes is by symptom categories:

• D:  Dizziness/Vestibular:  Benign positional vertigo, vestibular neuronitis, Meniere’s Disease, brainstem infarcts
• LH:  Light headed/Postural Hypotension: drop in blood pressure with standing
• BB:  Bad Balance
• Frame – kyphoscoliosis, leg length discrepancy
• Central – infarcts in basal ganglia, central microvascular infarcts, Parkinson’s, cerebellar
• Peripheral – Peripheral neuropathies, spinal stenosis
• Impaired vision – especially discrepancy between eyes
• Meds – sleep aids, neuropathic pain meds, psychotropics
• Barefoot or socks increases the risk of falls 10-13 times vs. wearing shoes w/heel; poor weight transfer to balls of feet (studies have shown that wearing socks or walking barefoot inside increases the risk of falling 10-14 fold.)
• W:  Weakness – MS, focal weakness (stroke, motor neuropathy)
• PA:  Poor awareness – all of us as we age, dementia (Lewy Body & Vascular in particular)

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