Onder

Physical activity and cardio-vascular prevention

Graziano OnderCentro Medicina dell’InvecchiamentoUniversità Cattolica del Sacro Cuore

Rome - Italy

Factors for successful aging Male and female aging

Social factorsEducation, social support, prevention, abuse

Personal factorsBiology, genetic factors

Social and Health servicesPromotion of health, primary and secondary prevention, long-term care

Environmental factors Metropolitan/rural area, personal environmental, injuries

Economical factorsType of work.

Life style Physical activity, nutrition, smoke, alcohol, drugs abuse

Successful aging

0NU 2002

EXERCISE IN THE ELDERLY

THE ROLE OF EXERCISE IN THE ELDERLY

a) In the young-old, exercise has much the same function as in the young:

- prevention of disease - maintenance of aerobic capacity

- maintenance of muscle strength - psychological well-being

b) In the old-old, exercise is still used for its preventive effects, but more often for:

- secondary or tertiary prevention - rehabilitation from pre-existing chronic conditions

c) Some of the most important goals of exercise in the frail elderly are:

- the improvement of muscle strength and endurance capacity to allow increased functional independence

Characteristics of study poplulation according to physical activity

Risk of disability according to physical activity

- the prevention of falls and fall- related injuries

- maintenance of fat-free mass

- cardiovascular reconditioning, treatment of peripheral vascular

- adjunctive treatment of depression, anxiety, isolation, insomnia, dementia

- rehabilitation from neurologic diseases

- increased survival

Crude and adjusted relative risk of mortality

Adjusted for gender and for all other possible risk factors for death (gender, physical and cognitive disability, cardiovascular diseases, pneumonia, cancer, stroke, diabetes, chronic obstructive pulmonary disease, renal failure, Parkinson’s disease, depression, delirium, and arthritis).

Preventive Medicine 47 (2008) 422–426

Crude and adjusted relative risks (RRs) of mortality in the Italian cohorts of the ilSIRENTE study, examined at baseline between 2003

and 2004 and after 24 months

Sedentary: subjects walking less than 1 h per day; Active: subjects walking 1 h or more per day.Adjusted for age, gender and for other possible risk factors for death (functional and cognitive disability, congestive heart failure, hypertension, osteoarthritis, depression, number of medications, body mass index, cholesterol and C reactive protein).

Incidence of Coronary Heart DiseaseHonolulu Heart Program

2678 active menAge: 71-93 yearsFU: 2 to 4 years

Hakim et al. Circulation 1999

Vigorous Moderate Vigorous Moderate0

102030405060

75-79 years 80-84 years >=85 years

AMI r

ate

per 1

mill

ion

pers

on-h

ours

Estimated rates of AMI

Mittleman et al. NEJM 1993

Men WomenMen Women

Sacco et al. Stroke 1998

Association between physical activity and stroke

Case control study1047 men and womenAge: 70 years

Mediators ?

Physical activity - Lipids

Total Cholesterol LDL HDL Triglycerides-20

-10

0

10

20

30

40

Active Sedentary

% c

hang

e

Petrella et al. Diabetes Care 2005

Observational study380 men and womenAge: 68 yearsFU: 10 years

Irwin et al. JAMA 2003

Physical activity – Body composition

173 women Age: 55-70 years

Physical activity – Diabetes

Knowler et al. NEJM 2003

3234 non-diabetic Age: 50 years FU 2.8 years

Physical activity – Glucose intolerance

Van Dam et al. Med Sci Sports Exerc 2002

424 men Age: 74 years FU 5 years

Physical activity and inflammation

Gaffken et al. Am J Epidemiol. 2001

Physical activity – Hypertension

Whelton et al. Ann Intern Med 2002

Mediators

1. Antiatherogenic effects2. Antithrombotic effects

↓plasma fibrinogen levels↑ plasminogen activator↑ active tissue plasminogen activator↓ plasminogen activator inhibitor

3. Endothelial function alterationrelease of endothelium-derived relaxing (NO)

Fletcher et al. Circulation 2002

Mediators

4. Autonomic functional changes↑ parasympathetic activity

5. Anti-ischemic effects↓ myocardial work (↓ BP and HR)

6. Antiarrhythmic effectsimproved myocardial oxygen supply-demand balance↓ in sympathetic tone and catecholamine release↑ ventricular fibrillation during strenuous exercise


Which type of intervention?

1. Dynamic aerobic (endurance) exercise – running or walking

2. Dynamic resistance anaerobic (strength) exercise – weight lifting

Endurance

Endurance

Resistance

Resistance

Endurance training

Cornelissen et al. Hypertension 2005

Blood pressure

Cardiac output

Heart rate

Stroke volume

Vascular resistance

Resistance training

Cornelissen et al. J Hypert 2005

Williams et al. Circulation 2007

Resistance and endurance trainingEndurance Resistance

Body fat ↓↓ ↓

Lean mass 0 ↑↑

Strength 0↑ ↑↑↑

Insulin sensitivity ↑↑ ↑↑

HDL 0↑ 0↑

LDL 0↓ 0↓

HR ↓↓ 0

Stroke volume ↑↑ 0

Cardiac output (maximal) ↑↑ 0

SBP ↓ 0↓

Basal metabolic rate 0↑ ↑

Quality of life 0↑ 0↑

For persons at moderate to high risk of cardiac events, RT can be safely undertaken with

proper preparation, guidance, and surveillance … given the extensive evidence of the benefits of aerobic exercise training on the modulation of cardiovascular risk factors, RT should be viewed as a complement to rather than a replacement for aerobic exercise.

Resistance training

Williams et al. Circulation 2007

Training - Guidelines


Frequency Intensity Duration ModalityEndurance training3–5 days/week 50%–70% max HR 20–60 min Lower extremity: walking,

jogging/running,stairclimberUpper extremity: arm ergometryCombined: rowing, cross-country ski machines, combined arm/leg cycling,swimming, aerobics

Resistance training2–3 days/week 1–3 sets of 8–15 RM Lower extremity: leg

for each muscle group extensions, leg curls, leg press, adductor/abductorUpper extremity: biceps curl, triceps extension, bench/overhead press.

Age-Associated Alterations in Physiological Response to Aerobic

Exercise• Reduced aerobic capacity: decline in V˙ O2

max of 8% to 10% per decade in nontrained populations

• Reduced maximal heart rate of 1 beat/min per year

• More rapid increase in systolic blood pressure with exercise

• Attenuated rise in ejection fractionFletcher et al. Circulation 2002

Classification of Physical Activity Intensity


MET=metabolic equivalents

1 MET = resting metabolic rate of 3.5 mL O2 * kg-1 * min-1

If exercise could be packed into a pill, it would be the

single most widelyprescribed, and beneficial,

medicine

Robert N. Butler, M.D. Director, National Institute on Aging

Bottleexercise

PHYSICAL ACTIVITY = MEDICINE

Potential risks

General

• Muscle soreness

• Soft tissue injury

• Falls

• Fractures

Resistance training

• Detached retina

• Hernia

• Hemorrhage

• Lumbar disk hernia

Potential risks Vigorous exercise

• Sudden death

• Acute myocardial infarction

• Hypoglycemia in persons with diabetes

• Orthostatic hypotension

• Arrhythmia

8,58,7

7,57,98,0

6

7

8

9

10

0 6 12

Sco

re

Physical activitySuccessful aging

P<0.001

mo mo

LIFE-P SPPB score

Pahor et al J Gerontol A Biol Sci Med Sci 2006

mo

LIFE-P – Side effects

Pahor et al J Gerontol A Biol Sci Med Sci 2006

Exercise in the Elderly- Screening

• History• Physical• Cardiovascular reserve: get up and down

from the examination table, walking 15 m, climbing 1 flight of stairs, cycling in the air for 1 min while lying down

• ECG

Gill et al JAMA 2000

It is not necessary that all individuals beginning a moderate-intensity and moderately progressive exercise program undergo an exercise stress test, although this issue remains controversial.


Exercise in the Elderly- Screening

Exercise in the Elderly

Pre-exercise period of stretching and light activity involving the large muscle groups for 5-10 minutes

Extended cool-down period after physical activity

Importance of range of motion and flexibility exercises

Evaluation of participant’s footwear

Evaluation of thermoregulatory capacity of participant


Majority of Americansdo not follow healthy lifestyle

0

20

80

1002000 Behavioral Risk Factor Surveillance System, N = 153,805

Respondents(%)

Smokers

Reeves et al. Arch Intern Med. 2005

BMI≥25 kg/m2

Consumesfruits/vegetables

<5x/day

Infrequentexercise

(<5x/week)

60

40

24.0

59.9

76.7 77.8

Conclusions

1. People of all ages, both male and female, benefit from regular physical activity

2. Significant health benefits can be obtained by including a moderate amount of physical activity on most, if not all, days of the week

3. Additional health benefits can be gained through greater amounts of physical activity

Conclusions

4. Physical activity reduces the risk of premature mortality in general, and of coronary heart disease, hypertension, stroke, and diabetes mellitus in particular

5. Both aerobic (endurance) and resistence training may influence health outcomes

6. Potential risks related to physical activity should be always considered

Søren Kierkegaard in 1847 in a letter to his sister in law who had just been ill.

”Do not give up your wish to walk. I walk every day and feel well and walk away from any illness. I have had my best thoughts while walking and I do not know of any thoughts so dark that I can not walk away from them…”

Health & Medicine

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