Paul Oh MD MSc FRCPC FACP Medical Director & GoodLife Fitness Chair Cardiac Rehabilitation Program

1. Exercise and Seniors: Your Health Depends on it! Paul Oh MD MSc FRCPC FACP Medical Director & GoodLife Fitness Chair Cardiac Rehabilitation Program University Health Network

2. CFPC CoI Templates: Slide 1 – used in Faculty presentation only. Faculty/Presenter Disclosure • Faculty: Dr. Paul Oh • Relationships with financial sponsors: • Grants/Research Support: CIHR, HSF, Amgen, AstraZeneca, Bayer, Roche, sanofi • Speakers Bureau/Honoraria: None • Consulting Fees: None • Patents: None • Other: Employee of University Health Network

3. CFPC CoI Templates: Slide 3 Mitigating Potential Bias • Discussion of efficacy and safety of products and interventions will be based on published scientific evidence

4. Outline • Decline in fitness with age • Poor fitness associated with loss of independence, frailty and chronic disease • Exercise is the “best medicine” • Guidelines and evidence • Case study – cardiovascular rehab

5. Introduction • Ageing is associated with declines in: • Cardiorespiratory function (VO2peak) • Muscle mass • Strength • Flexibility • ~10% per year of community dwelling elderly over age 75 lose independence Cunningham 1997; Lexell 1998; Vandervoort 1986; Bassey 1989; Manton 1993; Paterson 2004

6. Introduction Function Fitness and Strength Independence Morey 1998; Brill 2000; Woo 1999

7. What is Fitness or “VO2 ”? O2 O2 CO2 CO2 VO2 = O2 delivery x extraction = C.O. x (A – V) O2

8. Fitness Declineswith Age Fitness (VO2) (mL/kg/min) Age TRI Analysis n=6,164

9. Muscle Loss with Age Muscle Mass 20 40 60 80 Age Janssen et al., 2000

10. Determinants of future dependence • 8 yr follow up of 441 healthy community dwelling volunteers in London, ON • Mean age 67 • 15% became dependent walking aid NH/LTC homecare Paterson JAGS 2004;52:1632-1638

11. Determinants of dependence Paterson JAGS 2004;52:1632-1638

12. Determinants of Dependence – which of these is modifiable?? • Older age • Comorbidity • Lower fitness Paterson JAGS 2004;52:1632-1638

13. Fitness and dependence Odds Ratio for Dependence VO2 peak at baseline 1 mL/kg/min = 14% risk Paterson JAGS 2004;52:1632-1638

14. Circulation Nov 2016

15. Population Attributable CVD Risk Associated with Risk Factors 13,500 women in Australia Physical Inactivity is the most important risk in seniors Brown WJ, et al. Br J Sports Med 2014;0:1–8. doi:10.1136/bjsports-2013-093090

16. Canadians Meeting Physical Activity Guidelines (2012-2013) 88% of seniors don’t get enough! % 60-79 yrs Canadian Health Measures Survey 2012-2013

17. “Exercise is the medicine to reverse or mitigate frailty, preserve quality of life, and restore independent functioning in older adults at risk of frailty.” Appl. Physiol. Nutr. Metab. 41: 1112–1116 (2016)

18. Exercise Recommendations • Older adults can be classified as non-frail, pre-frail, or frail. Non-frail adults should follow the Canadian Physical Activity Guidelines for Older Adults (CSEP 2011) as a basic exercise recommendation. 
 Appl. Physiol. Nutr. Metab. 41: 1112–1116 (2016)

19. www.csep.ca/CMFiles/Guidelines/CSEP_PAGuidelines_older-adults_en.pdfwww.csep.ca/CMFiles/Guidelines/CSEP_PAGuidelines_older-adults_en.pdf

20. Exercise Recommendations • Both pre-frail and frail older adults should perform various exercise modalities that includes aerobic, resistance, balance, and flexibility activities. 
 Appl. Physiol. Nutr. Metab. 41: 1112–1116 (2016)

22. Balance Exercise

23. Proprioceptive Neuromuscular Facilitation • flexibility training that involves both the stretching and contraction of the muscle group being targeted

24. Exercise and frailty status Appl. Physiol. Nutr. Metab. 41: 1112–1116 (2016)

25. Exercise Recommendations • Pre-frail older adults (exhibit 1–2 physical deficits) should exercise 3 times a week for 45–60 min per session. • Frail older adults (exhibit ≥ 3 physical deficits) should exercise 3 times a week but for a shorter duration, 30–45 min. 
 Appl. Physiol. Nutr. Metab. 41: 1112–1116 (2016)

26. Exercise Recommendations • Pre-frail older adults should dedicate 30 – 40 min of their training time to resistance and balance-training activities • Frail older adults should emphasis aerobic training (10–20 min). 
 Appl. Physiol. Nutr. Metab. 41: 1112–1116 (2016)

27. For aerobic exercise, both pre-frail and frail older adults should work at an intensity that is “moderate–vigorous”, equivalent to a 3–4 (somewhat hard) on the Borg CR10 point scale. Appl. Physiol. Nutr. Metab. 41: 1112–1116 (2016)

28. Exercise Recommendations Resistance training intensity is established from an individual’s 1RM, starting light (i.e., 55%) for beginners and progressing to heavier resistances (i.e., >80%). 
 Appl. Physiol. Nutr. Metab. 41: 1112–1116 (2016)

29. Canadian Sedentary Time Minutes per day 10 hrs per day 60-79 yrs Canadian Health Measures Survey 2012-2013

30. Watching TV is Deadly!!AARP Health Study Prolonged sitting doublesCV death…even in regular exercisers Cardiovascular Mortality

31. Advice for All

32. Low physical activity has been shown to be one of the most common components of frailty • Review of 9 relevant papers de Labra et al. BMC Geriatrics (2015) 15:154

33. Exercise and Frailty • Improvements in: • Falls • Mobility • Balance • Functional ability • Strength • Body composition • Frailty de Labra et al. BMC Geriatrics (2015) 15:154

34. “Exercise therapy, applied pre-, or post-operatively, was associated with significant improvements in functional outcomes and improved quality of life” PLOS ONE | https://doi.org/10.1371/journal.pone.0190071 Dec 2017

35. we need to start looking for frailty in elderly patients entering cardiac rehab • we need to better understand whether exercise may change frailty in CV patients.

36. Due to the aging and increasingly complex nature of our patients, frailty has become a high-priority theme in cardiovascular medicine. JACC 2014;63(8):747–62

37. The prevalence of frailty ranges from 10% to 60%, depending on the CVD burden • frailty carries a relative risk of >2 for mortality and morbidity across a spectrum of stable CVD, acute coronary syndromes, heart failure, and surgical and transcatheter interventions. JACC 2014;63(8):747–62

38. Fitness and Survival in CAD High VO2> 22 • Toronto Rehab Study • n=12,169 men • 30 yr follow up Low VO2< 15 Fitness αSurvival • Kavanagh Circulation 2002;106:666-671 • Myers NEJM 2002;346;793-801 • Gulati Circulation 2003;108:1554-1559 Kavanagh Circulation 2002;106:666-671

39. How to Safely and Effectively Improve Fitness 2 x week 3-5 x week 150-240 min/wk

40. Preserving Independence Across the Ages p<.001 p<.001 p<.001 VO2peak (mL kg min-1) Independence threshold Age

41. Rehab and “Real World” Outcomes Mean follow up 5.2 years • Mortality: • CR – 2.6% • Control – 5.1% • Adjusted Hazard ratio: 0.47 (0.32 – 0.68) • p<0.001 Proportion Surviving 50% reduction in death Days Since Index Event EJCPR Feb 2009

42. Summary • Seniors may have high risk profiles and poor baseline fitness • Fitness does improve significantly and importantly regardless of age • Important for longevity and independence • Exercise training is safe and readily available