Rejuvenating Patients—One Step at a Time
THE PHYSICIAN AND SPORTSMEDICINE - VOL 27 - NO. 11 - OCTOBER 15, 1999
We are watching a vast natural experiment: Take millions of Americans off farms, off manual labor. Give them desk jobs, cars, and televisions. Add sanitation and antibiotics to increase life span. Then sit back and watch what—and how—the people do. You know the results from epidemiologic studies and from your own practice: The average American lives a long time, but he or she is sedentary, fat, unfit—and, often, chronically ill. The worst impact is on the older adults who have accumulated a lifetime of this comfortable but ultimately disabling lifestyle.
Fortunately, much research has demonstrated the results of this hypothetical "experiment," as well as the solution—exercise (1). Even when begun late in life, exercise helps older adults maintain or increase their independence and capacity for enjoyable activities; habitual exercise reduces the burden of chronic disease. In fact, the people who have the most to gain from enhanced physical fitness—and thus from promotion of exercise by their physicians—are the elderly, who are the subject of this special issue of The Physician and Sportsmedicine.
Probably none of this comes as a surprise. But it's just as likely that you've been lacking some of the tools you need to give effective fitness advice to older patients. Here we give you the information you need to acquire or sharpen those tools. The authors, who are noted for their expertise in dealing with this important topic from both clinical and research perspectives, offer detailed assistance to any physician motivated to understand and implement exercise prescription for the elderly.
Consider first the rationale for the effort. To begin with, physical activity may not be a fountain of youth, but it is the closest thing we have. While certain aspects of physical function—such as maximal heart rate, skeletal muscle oxidative capacity, ligament strength and flexibility, and bone mineral density—deteriorate inexorably with age, most physiologic decline stems from inactivity and is therefore reversible. For example, while maximal aerobic capacity declines by approximately 1% per year after the age of 25 in the typical sedentary American, only half the change is attributable to a decline in maximal heart rate (2). The other half is due to a decline in fitness, which is reversible. In other words, an active and fit 70-year-old can have the same maximal aerobic capacity as a sedentary and unfit 25-year-old.
Similarly, older patients' muscles respond positively to resistance training. It can improve strength, muscle mass, recruitment of muscle units, neuromuscular coordination, flexibility, risk for falls, and injuries from falls (3). For example, Ettinger et al (4) tested a combined program of aerobic and resistance training in patients older than 60 who had significant knee osteoarthritis and functional disability. The result was significant improvement in disability and in physical performance such as climbing stairs, getting in and out of a car, and lifting and carrying 10 pounds. Pain was also decreased.
Further, a wide range of common chronic conditions in the elderly may be prevented, delayed in onset, or improved physiologically by physical activity; their functional burden may be decreased as well. In many cases, significant quality-of-life enhancements are possible among those who are already ill or very old (5). Conditions improved with exercise include osteoporosis, osteoarthritis, obesity, diabetes mellitus, coronary artery disease, hypertension, heart failure, chronic obstructive pulmonary disease, mood disorders, sleep disturbance, and cognitive dysfunction (6-10). Of greatest importance, perhaps, is that overall functional quality of life, balance, strength, and independence are enhanced by physical fitness and activity, while risk of falls is reduced, such that self-care and activities of daily living are maintained (1,11). On page 79 of this issue, Robert J. Petrella, MD, PhD, explains the benefits of exercise for a number of conditions and outlines programs appropriate for those who are afflicted.
Overall, exercise patterns in middle and late adulthood predict future total medical disability: The onset of disability is postponed by more than 5 years in low-risk patients as measured by self-reported daily energy expenditure (12). Total disease burden is reduced through "squaring off" of the age-function curve. That is, the seemingly inevitable decline in function with age is forestalled through physical activity, irrespective of actual increases in fitness (13,14). Beyond the obvious benefits to individual patients, these improvements have significant implications for the cost of medical care (15), particularly given the increasing numbers of elderly people in the United States and other developed countries (12% of the US population was over age 65 in 1993; projections indicate 22% by 2030).
The opportunity for physicians to promote exercise among their elderly patients is almost unlimited. As noted above, the number of older patients is increasing; in addition, the typical elderly patient visits the physician's office regularly. Also, there's a great deal of room for improvement: Regular physical activity was reported by only 37% of older men and 24% of older women in the 1990 National Health Interview Survey (16). Similarly, the Centers for Disease Control and Prevention reported that the prevalence of doing no leisure-time physical activity was 38.5% among patients over age 65 in 1992 (17). While this was a slight improvement from 43.2% in 120217 (17), the rate of change has been too slow to reach the Healthy People 2021 (18) objective of 78% of elderly adults having at least some leisure-time physical activity.
Still, no matter how convinced each of us is that promoting exercise is critical, we must deal with the practical issues: How? What motivates patients? What exactly should they be doing?
While promoting exercise to elderly patients is not necessarily different from encouraging younger ones, some of the barriers seniors face require special attention. Older patients may be embarrassed or unsure of exercise techniques, or afraid of injury or pain; they may need social support and a social network that supports exercise, require specific and realistic goals, and need access to low-cost and convenient exercise programs. James Dunlap, MD, and Henry C. Barry, MD, MS, identify many of these barriers and suggest practical ways to help patients overcome them on page 69; more tips from the journal's editorial board and other authors can be found in a special edition of our "Pearls" department, page 27. In addition to being realistic, though, the exercise prescription must also be safe, effective, and individualized. Evan W. Kligman, MD, et al, provide details of the preparticipation history and physical examination and recommend prescription specifics, starting on page 42.
Above all is the importance of physicians actually believing that promoting exercise among the elderly is an important and laudable healthcare goal, worthy of their professional time, expertise, and energy. By providing solutions to the special problems related to exercise in patients with chronic disease, addressing the many barriers that prevent elderly patients from exercising, and suggesting effective forms of aerobic and resistance training for elderly patients, we hope to help you help them improve functional status, decrease the burden of chronic disease, and enhance independence. It has been my great pleasure to be involved with this effort, and I hope you'll contact me with questions, concerns, and suggestions for follow-up in the future.
Dr Schwenk is professor and chair in the Department of Family Medicine at the University of Michigan Medical Center in Ann Arbor.