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Exercise Prescriptions: Cardiac Rehab and Frail Adults

Exercise Prescriptions: Cardiac Rehab and Frail Adults. Brian K. Unwin, M.D. Colonel, Medical Corps, USA Uniformed Services University. Cardiac Rehab. Only 15-25% of eligible patients participate!. The Evidence Fewer events, reduced all cause mortality 20-34%.

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Exercise Prescriptions: Cardiac Rehab and Frail Adults

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  1. Exercise Prescriptions:Cardiac Rehab andFrail Adults Brian K. Unwin, M.D. Colonel, Medical Corps, USA Uniformed Services University

  2. Cardiac Rehab Only 15-25% of eligible patients participate! Am Heart J 2006; 152:835-841

  3. The Evidence Fewer events, reduced all cause mortality 20-34% Am Heart J. Nov. 2006. 152(5):835-41

  4. 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

  5. Effects of Exercise

  6. 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 Heart 2007; 93: 862-864

  7. 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

  8. 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

  9. 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

  10. General RecommendationsHeart Failure • All (almost) CHF patients should be considered • Elderly not excluded • Intensity initially = “talk test” • Duration and Frequency = 30 min most days Heart, Lung and Circulation 2007; 16: S83-S87

  11. American Association of Cardiovascular Rehabilitation (AACVPR) (Card Clin 2001; 19: 415-431) Lowest Risk Moderate Risk High Risk American Heart Association (Circulation 2001; 104:1694-1740) Class A Class B Class C Class D Risk Stratification AHA Guidelines include activity guidelines and supervision requirements See handout…

  12. Returning to work Many factors Non-exercise variables are important Gradual exposure to outdoor exercise program See ACSM Guide Appendix E

  13. Notes on total dose and volume for cardiac patients ACSM Guide to Exercise Rx 7th Edition 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 <300kcal per session and <200 on non-program days 19-43% of patients in rehab programs reach these levels Traditional exercise rx falls short of this goal!

  14. 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

  15. 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

  16. 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

  17. 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

  18. Exercise considerations for the CABG and PTCI patient CABG PTCI Aerobic and resistance after access site healed May progress rapidly if no myocardial damage • 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

  19. Exercise and Frail Elders

  20. Why push our frail elders? People live longer with chronic diseases. 10% of nondisabled adults 75 years+ lose independence in 1 or more ADL’s each year. Exercise and physical activity can improve health, functional capacity, QOL, and independence.

  21. 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.

  22. Frailty in Relation to Other End of Life States Lunney et al. JAMA; 289:2387-92, 2003

  23. 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

  24. 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, 1994;49(3):M109-15

  25. Aging Decreased taste Poor dentition Dementia and depression Chronic illness Multiple hospitalizations Aging Weight loss Chronic inflammation Illness Chronic Malnutrition Frailty Cycle Decreased appetite Sarcopenia Osteopenia Decreased strength Immobility Dependency Impaired balance and falls Chronic illness Hospitalization Medications Stressful life events Falls Decreased metabolic rate and activity AM J Med. 2007. 120(9):748-753

  26. 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 Overall: 2,762 subjects with comorbidity and/or disability and/or frailty

  27. Pathways to Frailty Genetic Factors, atherosclerosis, chronic inflammation Prevention Low level of exercise, malnutrition Clinical Disease Primary Frailty Palliation Secondary Frailty Disability Lancet. 2007. 369: 1328-29

  28. 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

  29. How to Quantify Frailty: From the Cardiovascular Health Study, three or more of the following: Shrinking >10 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 Fried. J Gerontol. 2001. 56A(3): M146-156

  30. Quantifying Frailty: Frailty 3 or more criteria met Pre-frailty 1-2 criteria met Fried, Tangen, et al. Frailty in Older Adults: Evidence for a Phenotype. J of Gerontology. 2001: 56A(3): M146-M156.

  31. Criteria #1: Weight loss • Weight loss • Patients asked if they experienced 10 pounds of unintentional weight loss in last one year

  32. 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

  33. Criteria #3: Walk time Time to walk 15 feet: 6.5 secs

  34. Criteria #4: Grip strength MEN: WOMEN: <30 Kg <18 Kg

  35. Criteria #5: Low activity • Leisure-time physical activity • Males < 383 kcal/week • Females < 270 kcal/week Perspective: 159# person walking at 5kph burns 280kcal/HOUR

  36. Frailty: An operational definition The aged person with unintended weight loss Weakness Self-report of exhaustion Slowness Low activity WASTING SYNDROME

  37. 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.

  38. 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

  39. 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

  40. Exercise History What is the patient’s lifelong pattern of activities and interests? Patient’s investment in plan What has been the patient’s activity level in the past 2-3 months? Determines current baseline What are the patient’s concerns and perceived barriers regarding exercise? Opportunity for education

  41. 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

  42. 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

  43. 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

  44. Disease Specific Exercise Rx’s 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

  45. The “MD FITT” Prescription (for the older adult) • Mode: Aerobic+Strength +Balance+Flexibility • Duration • Frequency • Intensity: • Touch > No Touch > Eyes Closed for balance • 5-6/10 self-perceived exertion • Timely Follow Up • Therapy (Preventive and/or Therapeutic)

  46. TOOL TIME!

  47. REHAB TOOLS! • The Kansas City Cardiomyopathy Questionnaire • The Patient Knowledge Questionnaire • Medical Outcomes Study: 36-Item Short Form Survey Instrument • 6 Minute Walking Test • ACSM’s Guidelines for Exercise Testing and Prescritpion (7th Edition)

  48. Vulnerable Elder SurveyVES-13 Saliba et al. JAGS ; 49: 1691-99, 2001

  49. Timed Up and Go“TUG” 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 >15 seconds higher risk for fall

  50. PPT Reuben DB, Siu AL. JAGS; 38(10): 1105-12, 1990

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