John M. Heath, MD, and Marian R. Stuart, PhD

Disclosures

J Am Board Fam Med. 2002;15(3) 

In This Article

Benefits of Exercise for Frail Elders

Many studies have examined the benefits of exercise in frail elders living in skilled nursing facilities, where it is convenient to conduct and assess the effect of group-centered interventions.[8,9,10,11] These institutionalized populations, who often have varying degrees of cognitive impairment, can be challenging both when trying to establish motivation for exercise and when creating opportunities for group reinforcement and participation. Study variables on which exercise interventions have had an impact include those directly related to the exercise itself -- changes in mobility or strength. More indirect but perhaps more functionally relevant benefits also accrue from exercise, such as improved sleep, physical function, and overall well-being of the participants.[12]

One major intervention study used daytime arm and leg exercises, conducted in a supervised group setting, as a means to improve the sleep of nursing home residents. The investigators found that participants' quality and quantity of sleep improved by about 40% during subsequent nighttime observations.[13] Another institutionally based study examined the effect of weight-training on strength and stair climbing in a selected group of very old (mean age 87 years) nursing home residents.[14] Participants assigned to the intervention group had enhanced overall mobility compared with the control group, for whom only a socialization intervention was provided. This study provides the best evidence that exercise can produce short-term, highly relevant improvements for even the oldest frail elder. In another group of nursing home patients for whom stair climbing was considered well beyond their functional capacity, a structured strength-training program using resistance exercise of upper extremities dramatically improved spontaneous activity.[15]

Although some of the same outcomes for institutionalized frail elders have been found in studies of exercise in community-based frail elders -- notably improved sleep derived from a modest aerobic exercise routine[16] -- many more exercise studies reporting effectiveness have centered on disease states. Osteoarthritis is a major morbidity factor for frail elders for which exercise is a specific therapeutic intervention.[17] Exercise intervention trials for knee osteoarthritis have shown significant reductions in disability using resistance training that focused on increasing muscle strength and modest aerobic exercise that centered on motion.[18,19] The positive effects of either exercise modality speaks to the positive effects that any form of exercise can have if sustained even for a relatively short time. Specifically, for underlying conditions such as osteoarthritis, increased mobilization of the affected joints, when done in a safe manner, has resulted in the same pain reduction and enhanced mobility as has physical hydrotherapy.[20]

The FAST study -- Fitness and Seniors Trial -- was a landmark study examining the effects of three forms of exercise intervention compared with a sedentary intervention for four groups of older adults with osteoarthritis.[21] An important feature of this study, which examined pain and disability as well as radiographic changes, was its 18 months' duration. No form of exercise was clearly superior, but when compared with the sedentary group, all exercise groups did show strong improvements to their well-being and in their arthritis outcome markers. An important message from this study was that any form of exercise -- general aerobic activities, muscle strengthening using resistance training, range-of-motion activities focused across an affected arthritic joint -- can produce important therapeutic benefits in an elderly population. The particular form of exercise in arthritis patients appears less important than that exercise has occurred.

Exercise is highly relevant to prevention of falls among frail community-dwelling elders. A collaborative intervention study, Frailty and Injuries: Cooperative Studies of Intervention Techniques or FICSIT,[22] was developed in an attempt to assess the impact of exercise in reducing falls. Many of the eight clinical FICSIT trials assessed the efficacy and feasibility of exercise intervention strategies, including exercise and balance training, for noninstitutionalized elders through either home-based or group-supervised exercise. Collectively the FICSIT trials were successful in achieving significant reductions in the incidence of falls.[23] Incorporating specific balance training into fall-prevention exercises was believed to be important. Tai chi, a popular Asian mode of exercise that emphasizes balance as well as psychological and spiritual factors, has been studied as a particularly successful strategy for fall prevention. In addition to reducing the frequency of falling, participants in tai chi programs enhanced their lower extremity strength, increased their overall physical activities, and had positive cardiovascular responses.[24,25] Greater daily mobility could be critical for the prevention of future falls, and increasing activities requiring some degree of mobility is an important lifestyle modification to enhance the health and well-being of frail elders.[26]

Strengthening the quadriceps might also be important in reducing the number of falls.[27] Even in 90-year-old participants, resistance training leads to enhanced muscle mass, doubling of strength, and greater independence in activities of daily living. It has been suggested that the benefits of exercise in fall prevention might be related in part to enhanced proprioception in the lower extremities, which has been found to occur after an exercise regimen.[28]

The previous discussion has focused on the physical benefits of exercise that are directly relevant for older frail patients. The many physiologic advantages of preventing cardiovascular disease, reducing insulin resistance, reducing blood pressure, and improving hyperlipidemia in the general population can also benefit frail elders.[29,30] Most medical conditions, however, are treated with pharmacotherapy for maximal improvement. Interventions directed toward improving functional capabilities, such as avoiding falls or increasing upper extremity range of motion (which enhances dressing and bathing), would have a more direct impact on the daily well-being of frail elders. Studies showing that exercise reduces disability in this target population are limited, in part because of the short duration of most intervention trials, and in part because of the need to address environmental and psychological factors that, when combined with physical health, determine disability.[31]

Regular exercise has been shown to provide such psychological benefits as preserving cognitive function, alleviating depression, and improving a sense of personal control and self-efficacy.[32] Studies in older adults have found psychological benefits from exercise at a variety of intensity levels and settings.[33] Both high-intensity and moderate-intensity strength training have been shown to improve mood significantly and reduce symptoms of anxiety.[34] Whereas exercise improves functional fitness (flexibility, coordination, agility, strength and endurance, and cardiorespiratory endurance) and overall psychological well-being, in a randomized controlled trial of 124 community-living postmenopausal women, exercise was shown specifically to lower the intensity of back pain.[35]

In a randomized controlled study of major depression in 156 older patients, 16 weeks of exercise treatment was as effective in relieving symptoms as was treatment with antidepressants.[36] In a careful follow-up study, patients who were exercising had a relapse rate that was significantly less than for patients receiving medication with the exercise intervention.[37] The implication from this study, which advocates the integrative treatment of geriatric depression, is that symptomatic improvement in depression can be enhanced through exercise. Exercise-enhanced improvement in quality of life also occurs in normal states of psychological health in which exercise and leisure activity are predictive of perceived better health and greater life satisfaction.[38]

A common misconception is that exercise must be performed at high intensity for therapeutic benefit.[32] Although a substantial body of literature has been written on the intensity of aerobic activity and the corresponding degree of fitness, this approach to exercise does not apply to outcomes of greatest relevance to frail elders. A sedentary older person need not achieve an arbitrary degree of oxygen consumption to improve standing ability from a lower leg-strengthening exercise. The resting heart rate does not need to be elevated for a bed-bound frail nursing home patient to improve dressing and bathing abilities from a range-of-motion and stretching routine. Even for the noninstitutionalized, ambulatory elder who wishes to begin an aerobic exercise program to improve cardiovascular conditioning, the intensity of the exercise program should focus on long-term sustainability and enjoyment to achieve an optimal overall outcome.[39]

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