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10 Articles in Volume 16, Issue #9
Health and Economic Benefits of Exercise Programs for Seniors
Role of Physical Activity in Managing Chronic Pain in Older Adults
Levorphanol: An Optimal Choice for Opioid Rotation
Incorporating Functional Medicine Into Chronic Pain Care
Expanded Use of EMG-NCV Helps Guide Treatment of Lower Extremity Neuromuscular Disorders
Application of Acupuncture to Treat Low Back Pain
People With Sickle Cell Trait at Greater Risk of Rhabdomyolysis
A Case of Statin Therapy in a Patient With Rhabdomyolysis
Overview of Exertional Rhabdomyolysis
Benzodiazepines and Opioids: Only Trained Pain Practitioners Should Prescribe

Health and Economic Benefits of Exercise Programs for Seniors

Promoting regular physical activity promises to optimize functional and cognitive status, which may in turn lead to a reduction in healthcare costs for our aging population.

The role of regular strength and conditioning exercises for seniors has been studied by many different groups and for many different reasons. The senior demographic under consideration includes individuals who are 50 years old and older, unless otherwise specified.

Seniors who exercised were once considered somewhat of an anomaly; after all, we tend to think of our golden years as a time of rest and relaxation, not necessarily a time to seek out physical stress, engage in strength and conditioning, or want to “go for the burn.” Yet, it turns out that there are a number of health benefits associated with regular physical activity,1 as well as economic advantages at both the individual level and the societal level.2

This article will explore the potential benefits of exercise on achieving optimal functional status, cardiovascular (CV) health, fall prevention, and cognitive function, which will in turn, prompt a reduction in prescription medication use, 30-day readmission rates, and social isolation.

Aging and Impairment/Disability

Before we examine some of the health benefits that regular physical activity might bring to the aging public’s ability to function, a good place to start is consideration of the age-related changes that advancing time can bring to the human condition. Even in the absence of discernable disease, both structural and functional deterioration occurs in all our physiological systems.3

Declines in maximal aerobic capacity (VO2max) and skeletal muscle mass (sarcopenia) are examples of age-related losses that can significantly impair physical independence and are representative of physiological aging.4 Both of these measures are determinants of exercise tolerance and functional abilities.5,6 There is evidence to suggest that baseline values for VO2max and sarcopenia are predictive of future disability,7,8 chronic disease,9 and death.10,11

The aging process is also associated with changes in anthropometry; specifically, there is a shift in body composition with advancing age that may lead to a greater proportion of body fat to lean body mass. This change in body composition has implications for both metabolic and CV health in terms of disease risks.12,13 As the aging body gradually takes on a greater percentage of body fat to lean muscle, the most significant change is a reduction in metabolic capacity to burn calories, which may manifest in weight gain.

As well, there is often a selective loss of fast-twitch, white muscle fibers. This matters since white fibers are the glycolytic units responsible for powerful anaerobic and explosive-type movements as opposed to the slow-twitch, red fibers that are more oxidative and facilitate longer (endurance-type) activities. Preferential muscle fiber loss, specifically type 2a and 2b white fibers, occurs in certain pathologies, such as Parkinson’s disease and hemiparesis secondary to cerebrovascular events or stroke.

Movement specialists who create exercise programs for these challenged populations need to keep the physiological changes in muscle fibers in mind when formulating effective exercise programs. Whether caused by aging or disease, a selective muscle fiber population decay that is also consistent with clinical observations suggests that strength loss is actually not the main problem: in many cases it is lack of muscle power, or the patient’s inability to generate forces fast enough to accomplish a task or activity of daily living (ADL). The muscle parameter that needs attention is not peak force generation, but rather peak torque at the right time (sequence) and within a specified duration of time. Exercise programs that focus on eccentric movements and higher-velocity muscle actions have been shown to be beneficial.14

Other aging-related functional deficit observations that can be improved through exercise include joint mobility, muscle flexibility and endurance, balance deficits, cardiac and hemodynamic functions, oxygen extraction, gas exchange/ventilation, cognitive declines, walking kinematics, stair climbing ability, lactate thresholds, and bone density—most of which adversely impact height and weight—and therefore body mass index or body weight.15

Economic Benefits of Exercise for Seniors

Recent research shows that in terms of predicting an anticipated escalation in health problems, health care costs, and 30-day all-cause hospital readmission in Medicare patients, functional impairment is a critical predictor to understand and consider monitoring.16

Severe functional impairment is defined as a person needing help in at least 2 ADLs. Thus, there is an important predictor of outcomes, both health and economic, in functional status; yet Medicare does not mandate measuring this factor in acute care patients discharged from skilled nursing facilities (SNFs) or hospitals. According to data presented at the Society of Hospital Medicine 2014 annual meeting [preceding publication], Medicare would save billions of dollars annually if the policy were changed to recognize the value of functional impairment as an important predictor of outcomes.17

The irony is that hospitals and SNFs already have the mechanism in place to assess functional status, which is typically performed by physical therapists (PTs) and occupational therapists (OTs). Since PTs and OTs routinely assess functional status in acute rehabilitation facilities, nursing homes, and the outpatient sector, the system to collect and analyze the data already exists and is ready to be tapped. Only the policy directive is missing.

In another cost comparison study, the total cost of care after hospital discharge was the primary outcome assessed through Medicare claims (adjusted for inflation).18 The authors also adjusted for age, gender, race, marital status, income, education, number of morbidities (Elixhauser index), and number of hospitalizations in the previous year. They found a linear relationship between functional level and cost at 1 year that ranged from $21,263 for those with no functional impairment to $39,705 for patients with severe impairment (needing assistance with 2 or more ADLs).18 An assessment of the data reflected a $221 billion difference in cost between patients with no impairment and those with severe impairment.18

Exercise and CV Health

The process of aging is known to affect the CV system in many ways. In the heart, there is myocyte loss with a concomitant increase in fibroblasts and collagen deposition, leading to decreased ventricular compliance.19 In the vessel walls, there is stiffening and thickening that occurs due to collagen deposition, loss of elastin, and hypertrophy of the smooth muscle cells.19 In addition, there is endothelial dysfunction caused by nitric oxide─mediated relaxation.

The overall effects of aging on human CV physiology may lead to reduced exercise capacity, tolerance, and cardiac responses. Both aerobic training (AT) and resistance training (RT) have demonstrated benefits in an older CV physiology. In particular, AT improved age-related diastolic function at rest and left ventricular diastolic and systolic exercise reserve.20 Similarly, RT has been shown to improve blood pressure, dyslipidemia, and glycemic control.20 The evidence regarding exercise benefits in the elderly points to high-intensity exercise training programs as being optimal to reduce risks of developing chronic diseases, such as diabetes, depression, osteoporosis, sarcopenia, and muscle weakness.13

The critical point to drive home is that the type of exercise is less important than simply being active and participating in some form of physical activity that includes strength training, aerobics, or a combination of activities. Physical activity itself is the risk modifier to achieve the largest increment in mortality benefit when comparing sedentary adults with those in the next-highest physical activity level.21 (See related article)

Avoiding Sarcopenia, Protecting Muscle Mass

It is generally accepted that humans deteriorate with advancing age and the musculoskeletal system is not immune to this decline. Sarcopenia consists of loss of muscle fibers (mostly type 2 fast twitch) that are replaced with fatty deposits and is characterized by the breakdown of the neuromuscular junctions, leading to reduced neuromuscular integrity. The expected rate of sarcopenia is about 0.5% to 2% a year after age 50.22 Sarcopenia is generally considered physiologic, not pathologic, although varying rates of sarcopenia have been observed.22 Strength studies in older populations have consistently demonstrated the benefits of regular training or at least staying active in reducing the rate of sarcopenia.23

Restoration of muscle mass (primarily type 2 fibers) and increased strength, power, and endurance are characteristic responses or adaptations in senior RT-type training. The mechanisms behind these findings are thought to be an increased motor unit recruitment or discharge rates, or possibly a decreased activation of antagonist muscle groups, or alterations in muscle architecture and tendon stiffness.24,25

Since work and daily function are arguably defined from a movement standpoint as consisting of low-resistance and high-repetition scenarios (ie, stairs, laundry, walking, light lifting), muscular endurance is an important functional attribute. The ability to repeatedly produce muscular forces over an extended period of time is important for human function since this defines how work is generally performed. It is thought that strength and power-training adaptations tend to transfer into the domain of muscular endurance since adaptations in endurance are seen as a byproduct of strength and conditioning training in general.26

Maintaining Balance for Fall Prevention

Older individuals have a higher risk of falling. This concern derives from an increased weakness (frailty) due to sarcopenia, accumulated comorbidities, musculoskeletal disease from past injuries, polypharmacy, visual impairment, and gait and balance disorders. Any and all of these can play a role in a medical fall—a fall leading to serious injury requiring medication or hospitalization.

According to the US Centers for Disease Control and Prevention, over 28% of Americans age 65 or older fall each year.27 Falls also result in more than 2.8 million injuries treated in the emergency department annually, including over 800,000 hospitalizations and more than 27,000 deaths, with a cost burden of over $34 billion in 2014 and an estimated increase to over $67 billion by 2020.27

The literature is quite consistent when it comes to the role of exercise in fall prevention in senior populations, and it appears to be a nonspecific effect, in that it doesn’t appear to matter whether it is Tai Chi, strength training, home exercises, or a multimodal exercise program—they all seem to work.28 Since fall risks are apportioned by a constellation of variables, it is not surprising that no 1 type of exercise stands out over and above the rest. There is, however, a dose response, in that a minimal threshold for intensity and duration need to be met.29

Social Isolation, Depression, and Cognition

There is now an abundance of evidence that supports improved mental health and well-being as a result of sustained and regular exercise in the elderly.30-32 Higher physical fitness levels and participation in an aerobic exercise program are associated with a decreased risk of clinical depression or anxiety.32 Exercise and physical activity also play into constructs such as self-efficacy and self-esteem, which tend to counteract the common feeling of loss of control that comes along with aging.32

According to a 2013 study, both social isolation and loneliness are associated with a higher risk of mortality in adults aged 52 and older.33 Physical activity is positively associated with quality-of-life measures, including self-efficacy, and since exercise is usually performed with a group of people, it becomes a viable strategy to combat social isolation. Fitness centers have a social component to the training experience, and participants have reported a reduced feeling of isolation and loneliness as a result of their exercise programs.30

Improvements in overall well-being and quality-of-life measures such as vitality, social functioning, and sleep quality have been reported among seniors engaged in moderate-to-higher intensity exercise programs.15,24,30

The positive effect of physical activity on cognition has been extensively studied.34-38 For example, a meta-analysis involving 29 randomized clinical trials of healthy adults without dementia found that aerobic exercise improved memory, attention, processing speed, and executive functions.34 Another meta-analysis of 30 randomized controlled trials of mostly aerobic exercise involving over 2,000 subjects with dementia or mild cognitive impairment (MCI) showed that exercise improves fitness, physical function, and cognitive function.35 The reasons for this have been hypothesized; it may be that exercise increases the expression of genes and factors that are responsible for neuroplasticity.36 Both cross-sectional and prospective cohort studies have linked participation in regular physical activity with a reduced risk for dementia or cognitive decline in older adults.35,37,38

Conclusion

Regular exercise appears to spare many seniors from the burden of falls, injury, healthcare costs, added morbidity, and in some cases death. There is no amount of exercise that can stop the biological aging process; however, regular exercise at moderate to high intensity has a multitude of benefits, only some of which were briefly discussed in this report. There does not appear to be a more cost-effective and all-encompassing risk and healthcare cost reduction strategy for seniors than a daily exercise program. The American College of Sports Medicine had it right when it trademarked “Exercise Is Medicine” as a campaign slogan.39 While the term senior could encompass a couple of generations and is a vague description relative to fitness, health status, and functional capacity, in general, it is recommended to practitioners who provide exercise programming to the senior population that individual capacity—both physical and cognitive—should be considered in designing effective exercise strategies.

While a portion of the aging population may have physical limitations that preclude a moderate activity program, there are still merits to any non-sedentary efforts, including strength and functional improvements. Therefore, any type of activity, regardless of intensity, can be of benefit to individuals as they age. With regard to the impact factor of exercise, conventional wisdom points to reducing the level of musculoskeletal forces on the aging body, which is consistent with the recommendations presented by several national agencies on aging and orthopedic health. Yet emerging research suggests that this approach is not as absolute as some may think, with recent evidence (animal and human) supporting the concept that higher-impact activities may be more beneficial to positively affect both osteoarthritis and osteoporosis, with the caveat or modifying factor being degree of disease severity.40,41 One aspect of human movement that all can agree with is that if you don’t use it, you will lose it. We see this truism reveal itself most prominently in the aging process, so it is imperative that exercise in its many forms be part of medical prescriptions of all practitioners.

Last updated on: November 10, 2016
Continue Reading:
Role of Physical Activity in Managing Chronic Pain in Older Adults

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