Exercise Prescriptions: Cardiac Rehab and Frail Adults

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Exercise PrescriptionsCardiac Rehab andFrail
Adults

• Brian K. Unwin, M.D.
• Colonel, Medical Corps, USA
• Uniformed Services University

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Cardiac Rehab
Only 15-25 of eligible patients participate!
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The Evidence Fewer events, reduced all cause
mortality 20-34
Diagnosis Fxnl. Capacity QOL Morbidity Mortality
AMI
CABG
Stable angina
PCI ?
CHF
Cardiac Transplant ? ?
Valve Repl. ? ?
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Core components of Cardiac Rehab

• Patient assessment
• Nutritional counseling
• Lipid management
• Hypertension management
• Smoking cessation
• Diabetes management
• Psychosocial management
• General education (meds, procedures, condition)
• Physical activity counseling
• Exercise training

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Effects of Exercise
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NICE Guidance

• Lifestyle
• Regular activity
• Stop Smoking
• Mediterranean Diet
• 7 gm of Omega-3 fatty acids/week
• Healthy weight
• 14 units of alcohol per week
• No beta-carotene
• No evidence for antioxidants and folic acid

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NICE Guidance

• Cardiac Rehab
• Exercise offered
• Includes exercise, education, stress management
• Involves partners/carers
• Can be home based (Edinburgh Heart Manual)
• Advice for return to activities
• Sexual activity okay
• Consider wider social and health needs

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NICE Guidelines

• Drug Treatment
• ACE
• Aspirin
• Beta-blocker
• Statin
• Clopidogrel x12 months (after non-ST MI), at
  least 1 month after ST elevation MI.
• Aldosterone with CHF and LV dysfunction
• Consider moderate intensity coumadin (INR 2-3)
• Cardiological assessment

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General RecommendationsIschemic Heart Disease

• When stable, regular physical activity
• Contra-indications
• Recent MI
• Unstable angina
• Exercise induced arrhythmia
• Intensity
• Below anginal theshold
• Talk-test
• Duration and Frequency 30 min most days

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General RecommendationsHeart Failure

• All (almost) CHF patients should be considered
• Elderly not excluded
• Intensity initially talk test
• Duration and Frequency 30 min most days

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Risk Stratification

• American Association of Cardiovascular
  Rehabilitation (AACVPR) (Card Clin 2001 19
  415-431)
• Lowest Risk
• Moderate Risk
• High Risk

• American Heart Association (Circulation 2001
  1041694-1740)
• Class A
• Class B
• Class C
• Class D

AHA Guidelines include activity guidelines and
supervision requirements See handout
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Returning to work

• Many factors
• Non-exercise variables are important
• Gradual exposure to outdoor exercise program
• See ACSM Guide Appendix E

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Notes on total dose and volume for cardiac
patients

• For stable cardiac patients progress to
  expenditure of 1000kcal/week over 3-6 months
• Higher level than this is associated with
  atherosclerotic regression (1500-2200kcal/week)
  (15-20 miles per week)
• Typical cardiac program is lt300kcal per session
  and lt200 on non-program days
• 19-43 of patients in rehab programs reach these
  levels
• Traditional exercise rx falls short of this goal!

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Exercise considerations for the angina patient

• Goal increase anginal and ischemic threshold
• Prolonged warm-up cool down (gradual rise)
• Target HR below ischmic level ( 10 bpm)
• Caution with exertion in the cold
• Upper body exercise may precipitate symptoms due
  to higher pressor response
• NTG
• Monitor blood pressures before and after exercise
  (or NTG use)
• Alternative exercise frequent, short,
  intermittent sessions

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Exercise considerations for the CHF patient

• Must be on stable medical therapy
• Monitor hypokalemia and hemodynamic response
• Malignant dysrhythmia
• THR 40-70 VO2max 3-7days per week, 20-40 minutes
  per session
• Long warm-up and cool down
• Interval exercise training
• RPE may be used

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Exercise considerations for the pacemaker/ICD
patient

• Fixed vs. adjustable rate
• Monitor systolic pressures
• Extended warm-up and cool down
• ICD ECG monitoring/pulse to titrate intensity
• Rate modulated pacemakers intensity
• MHRR method of Karvonen
• Fixed percentage of MHR
• RPE
• METs

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Exercise considerations for the cardiac
transplant patient

• 1-3 year survival rates of 86 and 80
• Train wreck physically and metabolically
• Rx from data from testing, graded protocols
• Long warm up cool down
• Denervated heart no angina, low EKG sensitivity
  for ischemia, delayed cardioacceleratory (and
  deceleratory) response
• Stress echo or radionuclide testing
• Intensity
• 50-75 of VO2peak
• RPE of 11-15 on the 6-20 scale
• Dyspnea

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Exercise considerations for the CABG and PTCI
patient

• CABG

• PTCI

• ROM and mobility exercises
• Light hand weights
• Stretching and flexibility
• Avoid resistance training until sternum healed (3
  months)
• Initial aerobic training (resting HR 30bpm)
• Valve patients longer recovery, slower rate,
  more limitations

• Aerobic and resistance after access site healed
• May progress rapidly if no myocardial damage

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Exercise and Frail Elders
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Why push our frail elders?

• People live longer with chronic diseases.
• 10 of nondisabled adults 75 years lose
  independence in 1 or more ADLs each year.
• Exercise and physical activity can improve
  health, functional capacity, QOL, and
  independence.

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Exactly What is Frailty?

• Aging, high burden of chronic disease,
  malnutrition and extreme lack of activity.
• Muscle weakness and low muscle mass (sarcopenia),
  low bone density, cardiovascular deconditioning,
  poor balance and gait.
• Inactivity with low energy intake, weight loss or
  low BMI.

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Frailty in Relation to Other End of Life States
Lunney et al. JAMA 2892387-92, 2003
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Physiology of Frailty

• Sarcopenia decreased quality of muscle
• Strength decline diminished walking speed and
  balance difficulties as a result
• Grip strength inversely related to IADL deficits
• Spinal mobility affects many functional tasks

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Exercise (Activity) Prescription for Older Adults
Fitness and Functional Status
Normal
Healthy Adults
Function
Near Frail
THRESHOLD
Poor
Frail Adults
Strength
Low
High
Established Populations for Epidemiologic Studies
of the Elderly (EPESE) . J Gerontology,
199449(3)M109-15
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Aging Decreased taste Poor dentition Dementia and
depression Chronic illness Multiple
hospitalizations
Aging Weight loss Chronic inflammation Illness
Chronic Malnutrition
Frailty Cycle
Sarcopenia
Decreased appetite
Osteopenia Decreased strength Immobility Dependenc
y Impaired balance and falls
Decreased metabolic rate and activity
Chronic illness Hospitalization Medications Stress
ful life events Falls
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Associations with co-morbidity and disability
If identified as Frail 27 reported
ADL disability 46 had co-morbid disease 22
had ADL disability and com-morbid illness 27
had neither disability or co-morbidity
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Pathways to Frailty
Genetic Factors, atherosclerosis, chronic
inflammation
Prevention
Low level of exercise, malnutrition
Clinical Disease
Primary Frailty
Palliation
Disability
Secondary Frailty
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Frailty Predicted

• Predictor of death within 3 yrs (6x mortality)
• 3x mortality at 7years
• Increased falls, decreased mobility, injury and
  ADL disability
• Hospitalization/institutionalization risk
• Pre-frail had 2x the risk of progression to being
  frail
• Dependency

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How to Quantify Frailty

• From the Cardiovascular Health Study, three or
  more of the following
• Shrinking
• gt10 pounds (or 5) of body weight in prior year
• Weakness
• Lowest 20 adjusted for gender and BMI
• Self report of exhaustion
• Correlates with VO2 max and cardiovascular
  disease
• Slowness
• Slowest 20 based on time to walk 15 feet, gender
  and standing height adjusted
• Low physical activity level
• Weighted score of kcals expended per week, lowest
  20 adjusted to gender

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Quantifying Frailty

• Frailty
• 3 or more criteria met
• Pre-frailty
• 1-2 criteria met

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Criteria 1 Weight loss

• Weight loss
• Patients asked if they experienced 10 pounds of
  unintentional weight loss in last one year

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Criteria 2 Exhaustion

• Self-report of exhaustion
• Two statements provided
• I felt that everything I did was an effort
• I could not get going.
• How often in the last week did you feel this
  way?
• 1 some or a little of the time (1-2 days)
• 2 a moderate amount of time (3-4 days)
• 3 most of the time

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Criteria 3 Walk time
Time to walk 15 feet
6.5 secs
Height Time
Men
173 cm (68) 7 seconds
gt 173 cm (68) 6 seconds
Female
159 cm (62) 7 seconds
gt 159 (62) 6 seconds
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Criteria 4 Grip strength
MEN
WOMEN
lt30 Kg
lt18 Kg
BMI Strength (Kg)
24 29
24.1-28 30
gt28 32
BMI Strength (Kg)
23 17
23.1-26 17.3
26.1-29 18
gt29 21
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Criteria 5 Low activity

• Leisure-time physical activity
• Males lt 383 kcal/week
• Females lt 270 kcal/week

Perspective 159 person walking at 5kph burns
280kcal/HOUR
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Frailty An operational definition

• The aged person with unintended weight loss
• Weakness
• Self-report of exhaustion
• Slowness
• Low activity

WASTING SYNDROME
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Evidence for Exercise

• Regular physical activity reduces age-related
  loss of muscle mass.
• Resistance training increases muscle mass,
  counteracts sarcopenia, and improves function.
• Chronic disease and syndromes respond favorably
  to exercise.
• Small improvements in physiological capacity
  substantial effect on functional performance.

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Studies

• Cochrane Collaboration falls reduction
• Fiatarone et al increased muscle strength
  increased daily function
• FICSIT Trials balance exercises lowered falls
• FAST trial diminished pain and disability in OA
  patients
• NEJM Oct 2002 45 reduction in disability
• Health ABC Study exercise better function

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Exercise Goals for the Frail Elder

• Improve ADL and IADL function
• Improve QOL
• Enhance flexibility, balance/postural stability,
  endurance, coordination, movement speed,
  strength, and bone health
• Prevent/decrease the burden of disease
• Improve patient education

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Exercise History

• What is the patients lifelong pattern of
  activities and interests?
• Patients investment in plan
• What has been the patients activity level in the
  past 2-3 months?
• Determines current baseline
• What are the patients concerns and perceived
  barriers regarding exercise?
• Opportunity for education

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Evaluating Function

• Physical Performance Test (PPT)
• Timed Get Up and Go (TUG)
• Vulnerable Elders Survey (VES-13)
• Functional Status Questionnaire (FSQ)
• EPESE study Physical performance measures
• Others LLFDI, PF-10 and LHS

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Contraindications for Exercise

• Frailty or extreme age is not!
• Caution acute illness unstable CP uncontrolled
  DM, HTN, asthma, CHF musculoskeletal pain,
  weight loss and falling
• Not during treatment hernias, cataracts,
  retinal bleeding or joint injuries
• Stop! enlarging AAA, end stage CHF, malignant
  ventricular arrhythmias, severe AS

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Risks of exercise for the frail elder

• Main risk musculoskeletal injury
• Higher vigorous exercise, higher volume, obesity
• Lower higher fitness, supervision, protective
  gear and well designed exercise environment
• Risk of exercise related MI and sudden death
  greatest in least active elders

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Disease Specific Exercise Rxs

• OA aquatic flexibility training isometric
  exercises
• Osteoporosis weight bearing improve balance
• Obesity rotation to minimize orthopedic injury
• HTN aerobic activity, large muscle groups
• COPD walking PRT of shoulder girdle,
  inspiratory and UE muscles. Bronchodilators
  reduce dyspnea
• CHF aerobic and resistance training improves
  VO2 max, dyspnea, work capacity and LV function
  muscle strength and muscle endurance

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The MD FITT Prescription (for the older adult)

• Mode
• AerobicStrength BalanceFlexibility
• Duration
• Frequency
• Intensity
• Touch gt No Touch gt Eyes Closed for balance
• 5-6/10 self-perceived exertion
• Timely Follow Up
• Therapy (Preventive and/or Therapeutic)

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TOOL TIME!
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REHAB TOOLS!

• The Kansas City Cardiomyopathy Questionnaire
• The Patient Knowledge Questionnaire
• Medical Outcomes Study 36-Item Short Form Survey
  Instrument
• 6 Minute Walking Test
• ACSMs Guidelines for Exercise Testing and
  Prescritpion (7th Edition)

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Vulnerable Elder SurveyVES-13
Saliba et al. JAGS 49 1691-99, 2001
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Timed Up and GoTUG

• Patient sits in a straight-backed high-seat chair
• Instructions for patient
• Get up (without using the armrests)
• Stand still momentarily
• Walk forward (10 ft or 3 m)
• Turn around and walk back to chair
• Turn and be seated
• gt15 seconds higher risk for fall

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PPT
Reuben DB, Siu AL. JAGS 38(10) 1105-12, 1990
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Exercise (Activity) Prescription for Older Adults
http//www.nia.nih.gov/NR/rdonlyres/8E3B798C-237E-
469B-A508-94CA4E537D4C/0/NIA_Exercise_Guide407.pdf
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Useful web sites

• Exercise A Guide from the NIA
  http//www.nia.nih.gov/HealthInformation/Publicati
  ons/ExerciseGuide
• ACSM Fit Society Page http//www.acsm.org
• CDC Physical Activity for Everyone
  http//www.cdc.gov/nccdphp/dnpa/physical/index.htm