August/September 2005

Quality of Life

By Alexis Perry, PT

Therapeutic exercise reduces mortality and increases function for geriatric patients

Exercise and physical activity among the elderly population have been associated with reduced mortality, improved quality of life, and improved functional status, leading to a greater ability to maintain independent living.^1-3 Physical therapists are often the first link between older adults and their ability to adapt to a lifestyle that implements increased physical activity and exercise. Although numerous studies and reports have documented the benefits of exercise for the geriatric population, physical therapists often face challenges in getting geriatric patients to comply with a home exercise program during treatment and maintain it after physical therapy has ended.

EXERCISE EFFECTS
The elderly population experiences an increased perception of effort with daily activities due to the normal physical changes associated with aging. However, the chronic physical adaptations and changes due to regular exercise can result in a perception of decreased effort to complete daily activities.^1,2,4 This may help an elderly patient maintain a higher level of independent functioning for a longer period of time. Exercise programs for the older population that include cardiovascular, strength, and balance training have all been found to have positive effects with regard to maintaining or improving functional status, as well as decreasing fall risks.^1,2,4 Physiological changes associated with increasing regular physical activity include increased strength and improved cardiovascular adaptations to exercise, resulting in a lower heart rate and blood pressure a given submaximal intensity.⁵

Regular aerobic exercise regimens result in benefits including: lower resting heart rate and blood pressure, increased maximal oxygen uptake, lower myocardial oxygen cost, increased exercise threshold, improved cholesterol levels, and reduced insulin needs with improved glucose tolerance.⁵ These physiological changes can help geriatric patients overcome the difficulties of completing daily functional activities associated with aging, resulting in a slower progression of functional limitations, and maintain independence with activities of daily living (ADLs).

The aging process affects the musculoskeletal system, with sedentary individuals losing 20% to 40% of muscle mass throughout their adult life.¹ Muscle weakness secondary to aging is both associated with and considered a major cause of falls.⁶ Increasing muscle mass in the elderly has been associated with the prevention of diabetes, maintenance of functional dependency, and decreased risk of falls.¹ The effects of weight training on frail elders have been found to enhance overall mobility as well as improve spontaneous activity.⁴

PREVENTION AND TREATMENT
A growing number of the population today is aging with decreased risk of disease and/or disability as a result of the recognition of the positive effects of exercise and lifestyle modification on the aging process. Evidence of exercise contributing to chronic disease prevention can be found in epidemiological literature reviews, which analyze the effects of exercise and different lifestyle modifications on a given population over a period of time.¹

Exercise should not just be seen as a way of avoiding disease in healthy older adults. A sedentary lifestyle is a major contributor to the development or severity of a chronic disease, and most therapists do not become involved with a patient until a disease or disability is present.

In many instances, therapeutic exercise can also be used as a means of secondary prevention. For example, following a myocardial infarction (MI), therapeutic exercise can be an important way to reduce the risk of another MI, improving cardiovascular status and quality of life.⁵ Therapeutic exercise has also been found to be an effective intervention in the treatment of diseases such as osteoarthritis, which is often a limiting factor in maintaining functional independence for older adults.¹

EXERCISE RECOMMENDATIONS
A common misconception among the elderly population is that they are not able to participate in exercise programs. The elderly may view exercise as something for the younger and more physically fit population. In developing a therapeutic exercise program for an elderly patient, it is important to consider that the goals and the application of an exercise program for older adults are different than those for younger people. The concepts of exercise frequency, duration, and mode may be similar; but, in older adults, prescribing exercise intensity may be a challenge secondary to a variety of factors associated with the aging process.¹

The first step in prescribing an exercise program for an elderly adult is to assess the patient's current physical status. Limitations and impairments regarding the person's musculoskeletal, cardiopulmonary, and general health status should be noted and taken into account when choosing a mode of exercise. Even the frailest of elderly persons can show physical benefits from a simple therapeutic exercise routine, resulting in an improved ability to complete ADLs.

When choosing a mode of exercise for an elderly patient, consider something that is both enjoyable and easy for the patient to do. Walking, riding a stationary bike, or doing water aerobics are all examples of activities that many elderly patients can do safely and with limited stress on their joints. Begin with a program that is low in intensity, and gradually increase the intensity and duration. It is recommended that 30 minutes of exercise be performed daily, but the 30 minutes does not need to be completed all at once for benefits to occur.⁴,⁵ For example, a patient can do three 10-minute exercise sessions throughout the day.

Maintaining and improving muscle strength in older adults requires strength training that overloads the muscle. Exercises using therapeutic bands and/or the patient's own body weight as resistance can be sufficient to achieve minimal to moderate strength gains. General guidelines provided by the American College of Sports Medicine for strength training in older adults include:

• At least one set of eight to 10 different exercises using all major muscle groups;
• Ten to 15 repetitions with a perceived exertion rating of somewhat hard;
• Progress by initially increasing the number of repetitions, then the resistance;
• Perform exercises at least twice a week for 20 to 30 minutes.⁵

EXERCISE PROMOTION AND COMPLIANCE
A key component of an elderly patient's ability to achieve and maintain strength and aerobic gains is adherence and compliance with a home exercise program. Unfortunately, it has been shown that the elderly population has poor adherence and high dropout rates when it comes to maintaining an exercise program. A number of barriers prevent the elderly from participating in a regular exercise program, including a lack of knowledge about the benefits of exercise, attitudes about how appropriate exercise may be, and possible environmental or architectural conditions that may not encourage exercise.⁴

For the elderly patient, improved exercise compliance and adherence to a home exercise program may be achieved through extra input from physical therapists, including increased education, motivation, and support. Gradually increasing the intensity of an elderly patient's exercise routine can help improve compliance. An exercise program that involves doing too much too soon or is too intense may be detrimental to achieving exercise adherence.⁵

Some studies have shown that the use of exercise logs can help improve exercise compliance.³ Another study completed by Nelson et al found up to 82% exercise compliance with a minimally supervised home exercise program, resulting in improved functional activity and balance.⁷ Seniors participating in the Nelson et al study were provided with a detailed home-based program and had their functional performance measured through a variety of tests. When developing a home exercise program for older adult patients, offering handouts with clear directions and easy-to-follow pictures can help to improve compliance by helping patients remember what to do. Following up with patients also can prove to be beneficial and encouraging, especially when positive changes can be noted.

Group exercise classes have also been found to increase adherence to an exercise program, with older adults who regularly participate experiencing improved mortality rates.³ Group exercise classes provide social reinforcement and encouragement for elders, contributing to increased adherence and compliance.⁷ Elders who participate in weekly exercise groups as well as complete a home exercise program are also at a decreased risk for falls.⁸

REGULAR PARTICIPATION
With the given benefits of exercise, it is important that physical therapists promote and encourage their elderly patients to participate in regular exercise programs. Many patients are often seen in therapy for only a short period of time, so it is important to provide these patients with an exercise routine that they are able to follow well after therapy has ended. There tends to be a growing trend in the community of gyms tailored toward the older and disabled population. Many of these gyms offer equipment that is easy to use, with trained instructors to provide assistance and guidance to the elderly gym members. These facilities can provide elders with an opportunity to continue with and advance the exercise programs that they began in therapy. Hopefully, through providing education, guidance, and encouragement to elderly patients, we will be able to improve their compliance with therapeutic exercise for optimal daily functioning.

Alexis Perry, PT, is a therapist at Spaulding Rehabilitation Hospital, Framingham, Mass.

REFERENCES

1. Singh MAF. Exercise comes of age: rationale and recommendations for a geriatric exercise prescription. J Gerontol. 2002;57A:M262-282.
2. Spirduso WW, Cronin DL. Exercise dose-response effects on quality of life and independent living in older adults. Med Sci Sports Exerc. 2001;33:S598-S608.
3. Morey MC, Pieper CF, Crowley GM, Sullivan RJ, Puglisi CM. Exercise adherence and 10-year mortality in chronically ill older adults. J Am Geriatr Soc. 2002;50:1929-1933.
4. Heath JM, Stuart MR. Prescribing exercise for frail elders. J Am Board Fam Pract. 2002;15:218-228.
5. Franklin BA. ACSM's Guidelines for Exercise Testing and Prescription. 6th ed. Baltimore: Lippincott Williams & Wilkins; 2000:3-8, 223-225.
6. Honeycutt PH, Ramsey P. Factors contributing to fall in elderly men living in the community. Geriatr Nurs. 2002;23:250-257.
7. Nelson ME, Layn JE, Bernstein MJ, et al. The effects of multidimensional home-based exercise on functional performance in elderly people. J Gerontol A Biol Sci Med Sci. 2004;59:154-160.
8. Barnett A, Smith B, Lord SR, Williams M, Baumand A. Community-based group exercise improves balance and reduces falls in at-risk older people: a randomised controlled trial. Age Aging. 2003;32:407-414.

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