Age shouldn't be barrier to exercise for heart patients, experts say
Older adults with heart disease would benefit from emphasis on physical activity, said a new statement from the American Heart Association.
March 23, 2017 4:05 PM
Jack Waclawski, 71, of Glenshaw exercises on a treadmill at the Allegheny Health Network Wexford Health + Wellness Pavilion in Wexford on Friday, March 24, 2017. Waclawski had a stem heart procedure in 2017.
Nancy McLaughlin, 63, of Mt Washington shares a laugh with J.D. Waechter of cardiac rehabilitation program at Allegheny Health Network's Wexford Health + Wellness Pavilion while rehabbing on Friday, March 24, 2017. McLaughlin had an open heart surgery in August 2016. American Heart Association scientific recommended for more physical activity guidance for older adults with heart disease, to become more independent and heart healthy.
Dr. Michael Hagerty, medical director of the cardiac rehabilitation program at Allegheny Health Network's Wexford Health + Wellness Pavilion chats with his patient Lorraine Kobert, 67, of Allison Park while rehabbing at the Wexford Wellness Pavilion on Friday, March 24. Kobert had an open heart surgery in November 2016. American Heart Association scientific recommended for more physical activity guidance for older adults with heart disease, to become more independent and heart healthy.
By Jill Daly / Pittsburgh Post-Gazette
As people with heart disease live longer, a new emphasis on physical activity will improve the quality of their lives, especially as they get into their 80s and 90s, according to a statement published Thursday by the American Heart Association journal Circulation.
How patients function is traditionally measured by how well the heart and lungs work to supply oxygen to the body’s muscles during physical activity. But in older adults other factors are involved, said geriatric cardiologist Daniel E. Forman at UPMC, who chaired the panel that wrote the scientific statement.
“There are other things, like balance, strength, cognition and vision that really impact on function,” Dr. Forman said. “This paper emphasizes that as cardiology providers, we have to think about functional outcomes.”
A broader focus is called for, he said. “Longevity is relevant: People live 30 years longer than people did a century ago. There is now a whole set of challenges as part of their living to that age.”
Pills can’t do it all, Dr. Forman said, and in some patients they can even make physical activity difficult.
“The irony is, when giving someone beta blockers, it can really impair function. It slows the heart down,” he said. In someone who is older, that can have an unintended effect. Loss of strength and disability after hospital stays is common in older patients with heart disease.
“We have to think about it holistically,” said Dr. Forman, chair of geriatric cardiology at UPMC and director of cardiac rehabilitation at the VA Pittsburgh Healthcare System. “It’s a growing area. Issues of function, frailty — all of these complexities are very challenging to cardiologists.”
There’s a great need for more research involving older patients, said Srinivas Murali, medical director of Allegheny Health Network's Cardiovascular Institute.
“Much of the evidence we have in respect to treatment and procedures for people with heart disease have all been based on studies of people under the age of 75,” he said. “Can you translate the evidence to older age groups? Obviously it is not very straightforward.”
He said he would welcome new guidelines for the care of older patients from the American Heart Association and the American College of Cardiology.
The journal statement outlined three areas for healthcare professionals to consider as they treat older patients with heart disease: 1., the biological effects of aging on disease and non-disease factors that both lessen physical function; 2., methods of assessing function (and the importance to check them regularly); and 3., ways to improve physical function with exercise training.
Loss of muscle mass and strength with disease and age contributes to problems with balance and flexibility that older adults have, for example, and medications for multiple conditions can make that worse, the statement said. Heart disease is also associated with inflammation throughout the body that can add to the risk of cognitive decline and depression, and further impair a person’s capacity for daily activities.
Both normal aging and disease are associated with low-level inflammation, which may be caused by changes within the body’s cells and in the immune system. It increases risks of frailty, a condition which is generally characterized by unintentional weight loss, increased tiredness, increased muscle weakness, slower walking and lower levels of activity. When an older adult is frail, heart disease and functional reductions are usually worse.
“No matter who you are, you’re not the same at 85 as you were at 45,” Dr. Forman said.
The statement outlines the usefulness of various tests to assess an older patient’s functioning in areas like strength, balance, frailty, cognition and physical activity.
“This notion of recovery or resiliency is changing in a fundamental, biological way,” Dr. Forman said. Traditional cardiac tests that measure a patient’s cardiorespiratory fitness may not be enough. Older adults may be frail, as well as orthopedic or neurological conditions that get in the way of being able to exercise and build up aerobic strength, according to the statement.
The journal statement outlines different approaches to improve function for patients with coronary artery disease, heart failure, stroke and peripheral artery disease. When appropriate, cardiac rehabilitation is encouraged.
“Among older-age patients, the more frail they are, the more risk they have for complications and bad outcomes,” Dr. Murali said. “Addressing frailty in these patients is important — good nutrition, physical therapy, building strength, restoring balance, improving their gait. We overlay that with cardiac rehabilitation to improve their functional capacity.”
Cardiac rehab has benefits for all ages, Dr. Forman said. Although it’s underused, the benefits tend to increase with someone who is older and more frail, he added.
Guidance on increasing daily physical activity should be tailored individually for older patients, according to the statement.
“The focus has to broaden to involve muscle function,” Dr. Forman said. Patients should be asked what their own goals are, what their preferences for treatment and rehabilitation are, at each transition of care, he said, whether in the doctor’s office, in the hospital, or in a skilled nursing facility. In particular, however, the statement says cardiac rehab in skilled nursing facilities has poor outcomes.
For some patients the goal might be longevity, Dr. Forman said, for others, it’s independence.
An informal exercise program, the article said, might include daily walking, resistance and balance training and doing more chores around the house.
“Even someone who is frail is not too frail,” Dr. Forman said, to benefit from strength training or other exercise. They might want to learn to make a bed, for example.
“Despite [the fact that] someone has heart failure, we are trying to strategize in a very tailored way for each patient. … Cardiac rehab is more than [an activity tracker]; it’s help with vision, medications, depression — all of these things have an impact.”
He said cardiologists can work with a health care team to make this happen.
“We have to coordinate with other doctors and caregivers and try to listen to the patient. These geriatric precepts are really important as someone gets older. They’re not straightforward. … It takes a lot of listening, thoughtfulness and clinical judgment.”
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