Exercise and Elderly Persons
The US Agency for Health Care Policy and Research and the National Heart, Lung, and Blood Institute's Clinical Practice Guideline Cardiac Rehabilitation recommended the incorporation of cardiac rehabilitative services (exercise training and education, counseling and behavioral interventions) as a component of the comprehensive care of patients with coronary heart disease and with heart failure. The greatest benefits of exercise training, per this evidence-based document, occurred in individuals with a low exercise capacity at baseline. Elderly patients are less fit following a coronary event, in part owing to their lesser fitness prior to the event. A limitation of the data supporting the beneficial effect of exercise training on mortality in older patients with coronary heart disease is that few elderly patients, and even fewer elderly women, were included in the randomized clinical trials that buttressed this statement.

The rehabilitative goals for exercise training at elderly age are to improve the physical function (mobility and self-sufficiency) needed for an active lifestyle. Highlighted in the Cardiac Rehabilitation Guideline was the underutilization of exercise training for elderly patients in general and elderly women in particular. This was evident despite the documentation of comparable benefits from exercise training in younger and older coronary patients and for men and women. An unmet need was the lessening of barriers to participation in cardiac rehabilitation for these underserved populations. The first is physician referral and the recommendation to participate; the latter is a major contributor to patient enrollment. However, physicians habitually underestimate the exercise capacity and routine physical activity levels of their elderly patients and, in a variety of clinical settings, recommend excessive activity limitation. Other barriers to participation include transportation issues, timing of formal exercise rehabilitation sessions, insurance reimbursement, and physical activity regimens suitable for elderly individuals. A potential remedy is home-based rehabilitation guided by a health professional, which has the advantages of convenience and decreased cost. Home-based rehabilitation is documented in the Guideline to provide benefits comparable to formal, supervised rehabilitation. Although all seven randomized, controlled trials of home-based rehabilitation included patients 65-75 years of age, no study compared outcomes in older and younger patients. However, the population studied did not include very elderly or higher-risk cardiac patients, for whom the safety and efficacy of home-based rehabilitation have yet to be established.

Exercise training of patients with heart failure and left ventricular systolic dysfunction is specifically addressed in the Cardiac Rehabilitation Guideline. Improvement in exercise tolerance is documented for both supervised and unsupervised exercise, without deterioration of ventricular function and with the benefit in exercise capacity additive to that attained with angiotensin-converting enzyme inhibitor therapy. Again, however, although heart failure predominates at elderly age, few elderly patients were included in the studies establishing the safety and benefit of exercise training in patients with heart failure. Clearly, additional studies of exercise training in elderly patients with heart failure are requisite to delineate optimal exercise regimens, including modalities of exercise, intensity, duration, and needs for surveillance.

This issue of The American Journal of Geriatric Cardiology, ably coordinated by Guest Editor Dr. Edgar Lichstein, surveys the benefits of exercise for healthy seniors as well as for those with hypertension, coronary heart disease, and heart failure. Currently, about one half of individuals in the United States older than age 60 describe themselves as sedentary, and this sedentary lifestyle is responsible for a substantial component of the decreased functional capacity at elderly age.

There seems little doubt that a moderate to high level of physical exercise in healthy elderly people is associated with many favorable outcomes, including lowered blood pressure; reduced rates of diabetes, insulin resistance, and falls; improvement in depressive symptoms, perceived general health status, and life satisfaction; and reduced cardiovascular morbidity and mortality. However, one must be careful about inferring causality. Many prior studies cited in this issue are old, underpowered, and/or not truly randomized, or they are meta-analyses, and it is possible that many attributes of a healthful lifestyle that tend to be more common in older persons who have the will and capability for moderate to vigorous exercise also play a role in favorable outcomes.

Taken together, these articles emphasize that exercise in cardiovascular medicine is no longer solely an attempt at rehabilitation following a serious clinical event, but rather a systematic approach to treat critical risk factors and to enhance the physical and emotional well-being of people who have cardiovascular disease or are susceptible to it. It is becoming abundantly clear that positive outcomes of exercise can be demonstrated in the elderly, as in middle-aged or younger people.

These articles are intended to be practical and to provide useful ideas for clinicians. How often should older people exercise, and for how long? How might prescriptions for exercise be influenced by underlying diseases? What sort of exercise is best, and what should be done when conditions such as arthritis or poor vision make it difficult to undertake more conventional aerobic or resistance exercise programs? For many years, exercise has been encouraged as an approach for controlling hypertension, but it may also be of value in the presence of other common risk factors of the elderly, particularly diabetes.

Several articles in this issue provide excellent innovative summaries of the physiology and pathophysiology of exercise and exercise intolerance in elderly patients with various cardiac conditions, and the cardiovascular benefits of exercise in older people. They also provide several important cautions: some sicker, older patients with congestive heart failure may not tolerate an exercise program, and the antihypertensive effect of exercise is probably modest and likely not applicable to those with more than mild hypertension.

Throughout the issue, evidence is presented that exercise in an elderly population is safe, that modest levels of exercise are probably effective, and that simple exercise, such as walking, may suffice. There are probably multiple benefits of exercise in addition to cardiovascular enhancement. Indeed, several promising topics are not included in this issue. One is exercise and lung function: several studies have suggested benefit from guided exercise in patients with significant pulmonary disease. At a time of increasing lifespan and skyrocketing numbers of postmenopausal women, the anti-osteoporosis effects of regular exercise may well be among the most important reasons to increase its use. And, given what is known about effects of exercise on depressive symptoms, one might hope that regular exercise can play a role in reducing loneliness and social isolation among elderly persons, both "nontraditional" but very powerful risk factors for cardiac disease and death in a number of clinical studies.

Unfortunately, it also seems clear that many elderly persons get far too little exercise. Since recommendations of the primary physician appear to play an important role in motivating patients to exercise, this issue of our journal provides an excellent opportunity to our readers to redouble their efforts to encourage elderly patients to be physically active.

Nearly a half-century ago, Dr. Paul Dudley White advocated exercise for elderly patients: ". . .exercise of almost any kind, suitable in degree and duration. . . can and does play a useful role in the maintenance of both physical and mental health of the aging individual . . ." A growing body of scientific evidence echoes this wise observation.

Last year, Dr. J. Willis Hurst gave a stimulating presentation at the Annual Meeting of the Society of Geriatric Cardiology. Fortunately, Dr. Hurst agreed to turn his remarks into an article and we are now able to make his ideas available to an even larger audience. In one sense, this is a very practical document, for Dr. Hurst has selected a dozen or more common conditions and issues arising in the management of cardiovascular problems in the elderly, and provides succinct and focused explanations and recommendations -- clearly based on his own clinical experience -- that are truly helpful to his clinical colleagues.

This article also says a great deal about attitudes toward aging itself, and the fact that even the greatest of physicians must recognize that their skills cannot extend life indefinitely. This article allows us to share the approaches to teaching that have been employed by an individual who is not only a renowned cardiologist but who, for many years, was the Chairman of Medicine at a major medical school. He emphasizes how important it is to be structured in one's teaching activities and to use systematic approaches, such as written problem lists and patient databases. He argues that young physicians -- and probably all others as well -- must be meticulous in reconciling what they really know about an individual patient and what they can then validly conclude.

Students and other trainees who have been taught by Dr. Hurst doubtless can tell many stories of how this teacher's use of Socratic and didactic techniques has helped them understand the importance of integrating the complex mix of contemporary science, clinical knowledge, and humanistic doctrine. For the rest of us, this article provides a fascinating insight into the ideas of a distinguished clinical scholar.