National physical activity recommendations for older Australians: Discussion Document

9.4 People with comorbidities

The National Ageing Research Institute was commissioned by The Department of Health and Ageing to review the evidence and develop physical activity recommendations for older people.

Page last updated: 01 February 2011

9.4.1 Cardiovascular disease

Older people with - or at risk from - CVD can benefit from physical activity adoption. Given the greater risk associated with vigorous activity, lower intensity activity seems preferable for older people in the prevention of heart disease. A meta-analysis found that vigorous activity is generally less effective than lower intensity activity in reducing blood pressure, particularly diastolic blood pressure (Whelton, Chin et al. 2002). Whilst heart disease may still occur in the physically active, it tends to present at a later age and be less severe (Haskell, Leon et al. 1992). The Iowa study reported that active women had better cardiovascular risk profiles than the sedentary i.e. lower blood pressure (BP), body mass index (BMI) and low density lipoprotein (LDL)-cholesterol (Kushi, Fee et al. 1997).

Several commentary reviews suggest that physical activity may be effective in the secondary prevention of heart disease and stroke (Kohl 2001). Various types of physical activity can aid the management of CVD. Crucially, there have been no significant complications or adverse outcomes reported. Older people with clinically stable heart failure can safely participate in low to moderate aerobic exercise (Witham, Struthers et al. 2003; Briffa, Maiorana et al. 2006). Progressive resistance training (PRT) has also produced health gains amongst those with chronic heart failure (CHF) (Witham, Struthers et al. 2003). The generalisability of exercise training findings for CHF remains limited. Witham and colleagues note that the evidence comes from research studies where the samples were highly selected in terms of age and overall health status (Witham, Struthers et al. 2003). Before this specialised rehabilitation training can be routinely used in the clinical setting, there is a need for further studies to test the transference of the findings to more disabled older people. Maintenance of physical activity is also important: the studies have tended to report on post-training effects, with follow-up studies showing a reversal of benefits once training ceases (Witham, Struthers et al. 2003).

In addition to the physiological improvements reported, clinically relevant benefits to symptomology, such as fatigue and dyspnoea, have been noted, plus improved quality of life. Older men with coronary heart disease have achieved improved mental health and functional capacity from regular exercise programs (Briffa, Maiorana et al. 2006).

The National Heart Foundation of Australia recommendation for older people with CVD is for low to moderate intensity physical activity, with multiple shorter episodes daily. As they progress, the duration of episodes can increase. A similar recommendation was made for those with peripheral vascular disease (PVD) and stroke survivors. Further details concerning physical activity and CVD can be obtained from this useful evidence based resource (Briffa, Maiorana et al. 2006)
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9.4.2 Diabetes

Many of the diabetes prevention programs have been multifaceted, making it difficult to discern the unique impact of physical activity. A meta-analysis of exercise interventions, including exercise alone and exercise plus dietary modifications, reported a clinically significant improvement in HbA1c levels, of a similar level to drug treatments (Boule, Haddad et al. 2001). Crucially, the improvement was not mediated by exercise volume or intensity, nor was weight loss needed to produce the positive outcome. Both aerobic and resistance exercise were effective. The authors note that exercise therapy may offer additional benefits to cardiovascular risk reduction beyond those afforded by drugs alone. The review included people from a variety of ethnic backgrounds, increasing the generalisability of the findings. However, the meta-analysis contained only one study where the sample were solely older people. This study did not find a significant difference in HbA1c between intervention group and controls (Tessier, Menard et al. 2000). There was a significant decrease in glucose excursion during the glucose tolerance test, improved attitudes towards diabetes and more capacity for sustained exercise in the intervention group compared to controls. The impact on insulin resistance seemed more marked amongst females, the obese and those with higher HbA1c levels.

Exercise has a role as an adjuvant drug treatment for people with type 2 diabetes, although a clinical review of diabetes in older people commented on the equivocal evidence for exercise in the management of diabetes in older people (Meneilly and Tessier 2001). Several subsequent trials of type 2 diabetes management have included older adults (Castaneda, Layne et al. 2002; Di Loreto, Fanelli et al. 2003; Brown, Ford et al. 2005; Dunstan, Daly et al. 2005). A recent trial that focused on older people used high intensity PRT and a moderate weight loss program and compared this with the moderate weight loss program alone (Daly, Dunstan et al. 2005). There was 6 months gym based then 6 month home based exercise. Weight and fat mass (FM) decreased at 6 months in both groups, but at 12 months follow up, weight and FM had significantly increased again (from the 6 month levels) in both groups. Crucially, although strength increases were maintained, improvements in glycaemic control and insulin were not maintained by the home-based program. This emphasizes the need for continued adherence to physical activity at sufficient volume and intensity to sustain the benefits seen with a closely supervised program.

Chapter 5 referred to the importance of motivating people in order to maintain physical activity behaviour. Pedometers have been used for some time as outcome measurement instruments, but are currently popular as motivating tools, although the evidence base for their use in this regard is limited. A coaching trial for sedentary overweight older people with type 2 diabetes examined the impact of pedometers on walking and physiological outcomes (Engel and Lindner 2006). Contrary to expectations, time spent walking was greater in the coaching only group. There were improvements in weight, waist circumference and cardiovascular fitness for both groups.

9.4.3 Obesity

It is accepted that physical inactivity and obesity are both important mortality risk factors. The few studies that have looked at stratified levels of physical activity within BMI categories tend to support the fact that inactivity is a risk factor across all categories. Preventive measures are particularly scarce: the focus is usually on weight reduction in conjunction with the management of a chronic condition. In reviewing whether physical activity prevents weight gain in Caucasian adults, Fogelholm and Kukkonen-Harjula (2000) noted that the overall evidence for physical activity was modest - not least because of limitations noted elsewhere in this document - that the volume of physical activity used often being insufficient and adherence being less than optimal. Many of the interventions for obesity include exercise as part of a multifaceted program. The evidence generally suggests that diet and physical activity are more effective in combination than physical activity alone. To sustain weight loss, maintenance strategies such as professional mentoring or self help groups can play a role. Older people have been included in studies, but there is limited evidence for this sub-group alone.

9.4.4 Cancer

Chapter 4 referred to the evidence for the role of physical activity in the prevention of certain types of cancer. The search conducted to produce this document did not identify any intervention studies in the cancer field.
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9.4.5 Mental health

Qualitative evidence indicates that physical activity contributes to mental health through “maintenance of a busy and active life, mental alertness, positive attitude toward life, and avoidance of stress, negative function, and isolation” (Stathi, Fox et al. 2002) pg 76, but the actual mechanisms have not yet been established. There is no consistent association between mood and physical activity, possibly because of the transient nature of many mood states (Emery and Blumenthal 1991). For clinical conditions, there is increasing evidence for the benefits of physical activity in their management.

Depression

Depression often co -exists with other health problems and can be a side effect of certain medications, such as some of those used in the management of arthritis (Leon, Ashton et al. 2003). Whilst antidepressants may be effective, they can have significant side effects, such as increased risk of hip fracture (Fiatarone Singh 2002). Depression is debilitating to the individual and incurs both social and economic costs. There are many trials where people with a variety of conditions (e.g. coronary heart disease, chronic obstructive pulmonary disease, cancer, arthritis, multiple sclerosis, chronic fatigue syndrome), have demonstrated reduced levels of depressive symptoms following a physical activity program. Interpretation of these findings has to be sensitive not only to methodological constraints, but also to the fact that not all participants were clinically depressed at the time of the physical activity intervention (Paluska and Schwenk 2000). To posit a clearer association, studies using clinically depressed people are required.

Level 1 evidence suggests that physical activity is preferable to no treatment or social contact alone and that it has a similar effect to standard antidepressant drug or psychological treatments for both adults (North, McCullagh et al. 1990; Craft and Landers 1998; Lawlor and Hopker 2001; Brosse, Sheets et al. 2002) and older adults (Frazer, Christensen et al. 2005; Palmer 2005). Recent meta-analytic and experimental studies show a significant antidepressant effect for physical activity in older adults with clinical depression, supporting the use of physical activity in the management of depression in older people (Taylor, Cable et al. 2004; Frazer, Christensen et al. 2005). Reviewers have been critical of the quality of studies (Lawlor and Hopker 2001) particularly where physical activity failed to improve on the effectiveness of medications (Blumenthal 1999). Common methodological weaknesses include a lack of a standard diagnostic process for identifying depression in participants and a short follow up period (Dunn, Trivedi et al. 2001; Lawlor and Hopker 2001).

Aerobic and resistance training have both produced benefits. Both moderate and vigorous levels of exercise shows efficacy in reducing depressive symptoms (Dunn, Trivedi et al. 2001). Singh et al. (2001; 2005) have reported positive effects following progressive resistance training (PRT) in older people with depression. Their most recent research highlights the importance of exercise intensity, with the high intensity group being significantly more likely to reduce their depressive status (61% versus 29% in the low intensity group and 21% in the usual care group) (Singh, Stavrinos et al. 2005). The reduction was associated with actual strength gain, suggestive of an underlying biological mechanism. There were indications that vitality and sleep quality were particularly improved in the high intensity PRT group. Research is ongoing to elucidate the role of social contact in exercise programs for older people with depression. In Singh et al’s study socialization did not seem to explain the impact of PRT: only the high intensity group achieved clinically significant benefits (Singh, Stavrinos et al. 2005). Belief in the perceived gains from the program seemed to produce a placebo effect for the low intensity group, whereas efficacy belief did not predict outcome in the high intensity group.

Physical activity may reduce the risk of depression relapse, but the evidence is scarce (Babyak, Blumenthal et al. 2000). In a trial with major depressives, aerobic exercise was found to be of similar benefit to the antidepressant sertraline (Blumenthal 1999). Given the poor adherence to antidepressant medication, it is interesting to note that at six months follow-up, relapse rates were lower in the exercise group (Babyak, Blumenthal et al. 2000). One study focused on people who had not responded to antidepressant treatment (Mather, Rodriguez et al. 2002). Aerobic exercise was of short-term benefit as an adjunct treatment. Secondary analyses in an osteoarthritis trial found improvements in depressive symptoms and disability at 18 months post aerobic, but not resistance, training (Penninx, Rejeski et al. 2002).

Other affective disorders

There is limited evidence for physical activity in the management of other psychological conditions. For example, a small pilot with a before after design indicated some gains for adults with post traumatic stress disorder (Manger and Motta 2005) in terms of reductions in anxiety, depression and post traumatic stress disorder (PTSD symptoms). Although the evidence base is small, gains similar to those from meditation and relaxation have been found for anxiety and panic disorder, with acute anxiety responding better to physical activity therapy. Several trials have shown that progressive resistance training delivered over 10 weeks improves mood in the short term and, in one trial, to 12 months (Singh, Clements et al. 2001; Mather, Rodriguez et al. 2002; Penninx, Rejeski et al. 2002). Other trials successfully tested aerobic activity (Blumenthal 1999; Babyak, Blumenthal et al. 2000; Singh, Clements et al. 2001) and less intensive activity such as walking (McNeil, LeBlanc et al. 1991).
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Cognitive health

Various aspects of cognition have been improved by physical activity but the evidence base is limited by small studies and weak designs (Hogan 2005). In nursing home residents with cognitive impairment and incontinence, the Functional Incidental Training program (incorporating additional walking / transfers together with a prompted toileting regime) achieved significant improvements in mobility, as well as reduced agitation (the prompted toileting program in isolation also reduced agitation) (Schnelle, Macrae et al. 1995). In contrast, a structured exercise program (walking or wheelchair mobility training, together with work on a rowing machine) in a cognitively impaired, physically restrained sample of nursing home residents had a high dropout rate (54% over 9 weeks), but did achieve significant improvements in injury risk and upper body strength and endurance (Schnelle, MacRae et al. 1996). There were no significant changes in lower body strength. This study highlights that despite the range of difficulties encountered in implementing physical activity programs for older people with marked cognitive impairment, that positive outcomes can be achieved in those who are able to participate.

There is some evidence that physical activity can help in the management of people with dementia, by improving disruptive behaviour, functional health, sleep patterns and alertness. For people who require medication or physical restraint, physical activity affords a potentially safer and cheaper alternative treatment approach. In a quasi- experimental study, Holliman et al. (2001) piloted a 30 minute interactive group activity for people (n =14) with moderate to severe dementia, designed to enhance purposeful upper limb activity and social interaction. The intervention produced acute behavioural benefits, but these were not sustained beyond the sessions themselves. Given the low cost of running such sessions (staff or volunteers could be trained to run them), it may be worth trialling such an intervention with a larger sample over a longer period than this two-week pilot, to assess the ongoing impact.

9.4.6 Injury prevention

Physical activity has been shown to be effective in reducing falls either as a single intervention or as part of a multifaceted intervention (Hill, Vrantsidis et al. 2004; Sherrington, Lord et al. 2004). Examples of successful community-based programs include:
    • Targeted home exercise programs incorporating balance and strengthening exercises, developed by a physiotherapist or another trained health professional following an assessment (Robertson, Campbell et al. 2002);
    • Group exercise programs incorporating a combination of balance, strength, mobility and fitness exercises (Rubenstein, Josephson et al. 2000; Day, Fildes et al. 2002; Barnett, Smith et al. 2003);
    • Group exercise programs using an abbreviated set of forms from the 24 form Tai Chi Quan (Wolf, Barnhart et al. 1996).
In contrast to the community setting, there is relatively little level I or II evidence regarding effective falls and falls related injury prevention programs in residential care settings. Randomised controlled trials have reported significant reduction in falls rates in residential care settings using a group exercise program (retirement village setting) (Lord, Castell et al. 2003). In addition, a program incorporating frequent toileting and increased incidental activity (such as walking / transferring), called the Functional Incidental Training (FIT) program, was shown to reduce falls (Schnelle, Kapur et al. 2003). Multifaceted interventions which have incorporated exercise approaches together with a range of other falls prevention activities (such as assessment, staff training, environmental modification, and hip protectors) have also been shown to reduce falls (Jensen, Lundin-Olsson et al. 2002; Becker, Kron et al. 2003).
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9.4.7 Musculoskeletal health

Arthritis and musculoskeletal conditions are the chief causes of disability in Australia: around 1.2 million Australians (about 32% of all persons with a disability) have a disability due to these conditions. There are associated activity restrictions, notably in mobility and self-care. Arthritis and musculoskeletal conditions were estimated to account for 4% of the disease burden in Australia in 1996, in terms of disability-adjusted life years (DALYs). The direct costs of arthritis and musculoskeletal conditions were estimated at $4.7 billion in 2000-1 (Australian Institute of Health and Welfare 2005).

In Keysor and Jette’s review of disability (2001), three of the five studies that found positive effects on both function and disability involved people with arthritis (Minor, Hewett et al. 1989; Kovar, Allegrandte et al. 1992; Ettinger, Burn et al. 1997). Notably, people with musculoskeletal conditions may find it difficult to do land-based aerobic physical activities because of the impact on joints. There is evidence that water-based exercises can be helpful for those with osteo- and rheumatoid arthritis. There have been four randomised controlled trials of water exercises/hydrotherapy for older people with musculoskeletal problems, with positive outcomes in terms of functional reach (Simmons and Hansen 1996), muscle endurance, work capacity (Ruoti, Troup et al. 1994), muscle strength, cardiorespiratory fitness, body fat and total cholesterol (Takeshima, Rogers et al. 2002), and muscle strength, distance walked and self rated health (Foley, Halbert et al. 2003). An Australian implementation trial, using local aquatic facilities with an existing program reported improved balance and shoulder range of motion compared to a control group (Lord, Tiedemann et al. 2005).

An increasingly popular type of Tai Chi in Australia and internationally is ‘Tai Chi for Arthritis’, which is a gentle combination of forms for people with more limited mobility. Tai Chi for Arthritis has been shown to improve balance, leg strength, and function in older people with arthritis (Song, Lee et al. 2003; Verhagen, Immink et al. 2004). Two RCTs have reported the effectiveness of Tai Chi in the management of people with osteoarthritis. One reported improvements in arthritic symptoms, balance and self perceived function (Song, Lee et al. 2003). The other found improvements in self efficacy for arthritis symptoms, satisfaction with general health and trends for improved mobility and standing up from a chair (Hartman, Manos et al. 2000).

A UK group recently produced the MOVE consensus report, evidence based recommendations regarding exercise in the management of osteoarthritis of the hip or knee (Roddy, Zhang et al. 2005). The recommendations are shown in Figure 9.1 below.
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Figure 9.1 Recommendations for physical activity in the management of osteoarthritis of the hip or knee.

Both strengthening and aerobic exercise can reduce pain and improve function and health status in those with knee OA (1B evidence) but there is only level 4 evidence for hip OA

There are few contraindications to the prescription of strengthening and aerobic exercise in those with knee or hip OA: the number of contraindications is small (level 4 evidence)

Prescription of both general aerobic and local strengthening exercises is an essential, core aspect of management for every patient with knee or hip OA (level 4 evidence)

Exercise therapy for knee or hip OA should be individualized and patient -centred, taking into account factors such as age and overall comorbidity (level 4 evidence)

To be effective, exercise programs should include advice and education to promote a positive lifestyle change with an increase in physical activity: Level 1B evidence for strategy effectiveness, but only level 4 evidence that such techniques are needed for exercise programs to be effective</quote>]

Group exercise and home exercise are equally effective and patient preference should be considered (level 1A evidence for both)

Adherence is the principal predictor of long-term outcome from exercise in those with knee or hip OA: level 1 evidence supports adherence, but only level 4 evidence supports it as the principal predictor

Strategies to improve and maintain adherence should be adopted e.g. long-term monitoring/review and inclusion of spouse/family in exercise: 1 B evidence extrapolated from general literature. Only level 4 for specifically for knee or hip OA

The effectiveness of exercise is independent of the presence or severity of radiographic findings: the current evidence does NOT support this recommendation.

Improvements in muscle strength and proprioception gained from exercise programs may reduce the progression of knee and hip OA: this is based solely on level 4 evidence.

Key

Level 1A metaanalysis of RCT

Level 1B at least 1 RCT

Level 4 Expert committee reports/opinions and /or clinical opinion of respected authorities.
Source: Roddy 2005
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9.4.8 Respiratory disease

A systematic review of the benefits of exercise (‘physical training’) for asthmatics included 13 studies, all with children as participants (Ram, Robinson et al. 2005). The findings indicated that maximum oxygen consumption and expiratory ventilation could be increased without any adverse impact on pulmonary function or wheezing. Whether these findings are generalisable to older people is not known. As noted in Chapter 4, much of the respiratory disease literature focuses on asthma. Use of physical activity in the management of respiratory conditions has not been extensively researched. Acute episodes of asthma or unstable chronic obstructive pulmonary disease (COPD) are contraindications for physical activity. However, where the condition is stable, the use of physical activity as part of the management can confer benefits additional to those obtained from pharmacological intervention alone (Mazzeo, Cavanagh et al. 1998).

The benefits of physical activity for COPD patients is recognised and rehabilitation programs include both aerobic and resistance exercises. The challenge is to maintain the gains beyond the rehabilitation program. Spruit and colleagues (2004) note that the benefits wane with time and call for strategies to maintain physical activity behaviour beyond the intensive, supervised rehabilitation programs. In a trial of physical activity maintenance for older people with COPD, Wadell and colleagues found that whilst weekly training was insufficient to maintain improvements observed following an initial high frequency training program (Wadell, Henriksson-Larsen et al. 2005), such low frequency training can prevent deterioration in physical capacity and health related quality of life. The importance of monitoring was demonstrated by Katsura et al. (2004), who found that exercise capacity, dyspnoea and quality of life gains were maintained up until one year follow up in a group who had monthly outpatient visits. They noted that the gains were sustained for both the younger old people and those aged over 75 years. Interestingly, the gains were greater in the old old group, who were more debilitated at baseline. The findings may not be wholly generalisable, since these were people chosen on the basis of being well motivated at baseline, as indicated by their average adherence of 82% to a post-rehabilitation home exercise program. A review of five earlier studies failed to find consistent improvements in dyspnoea and quality of life (Chavannes, Vollenberg et al. 2002).

There is no consensus on the optimal dose for COPD rehabilitation. The review evidence suggests that a high intensity program is preferable for the initial rehabilitation. Thereafter, adherence may be more important. It is better to do some activity consistently than to try to continue to maintain high intensity activity, fail and stop altogether.

As noted in Chapter 5, self-efficacy influences compliance to physical activity programs. Self efficacy has been shown to be strongly associated with physiological status (e.g., pulmonary function, exercise tolerance, diffusing capacity) in COPD patients (Kaplan, Atkins et al. 1984; Toshima, Kaplan et al. 1990). Self efficacy can both predict the uptake of physical activity and be sustained by engagement in physical activity, producing comprehensive health benefits. Kaplan and colleagues found self efficacy to be a significant predictor of survival in people with COPD (Kaplan, Atkins et al. 1984): this trait may be enhanced by physical activity uptake.
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