Exercise Combats Frailty: Physical Exercises as a therapy to combat Frailty

Population ageing is one of the most discussed global phenomena in the present century. Countries with a large population like India have a large number of people now aged 60 years or more. The population over the age of 60 years has tripled in last 50 years in India and will relentlessly increase in the near future. According to census 2001, older people were 7.7% of the total population, which increased to 8.14% in census 2011. The projections for population over 60 years in next four censuses are: 133.32 million (2021), 178.59 (2031), 236.01 million (2041) and 300.96 million (2051).

Frailty is a state of vulnerability that carries an increased risk for adverse outcomes. It can be viewed as a transition phase in older people between good health and poor health. Frail older adults are less capable of tolerating the stress of medical illness, hospitalization, and immobility. Common signs and symptoms are fatigue, weight loss, muscle weakness, and progressive decline in function. Frailty is more prevalent in older people and in those with multiple medical conditions. Frail in Elderly is usually manifested as weakness, impaired mobility, balance and minimal reserve. It is seen in the older population as unintentional weight loss, fatigue, exercise intolerance, weakness, slowed motor performance and low physical activity.

Concomitant with age, there is decline in voluntary physical activity which is associated with decrease in numerous measures of exercise capacity including peak oxygen consumption (VO₂pea), muscle strength, and fatigability which ultimately leads to frailty. Recently it has been recognized that older adults who are obese also meet criteria for frailty because of decrease muscle mass and strength that occurs with aging (sarcopenia) and a need to carry greater body mass due to obesity. This is associated with an increased risk of fall, ADL disability, hospitalization and death and at times with Chronic Health diseases like Osteoarthritis, Diabetes Mellitus, Hyper Tension, angina, Congestive Cardiac Failure, pulmonary disease or Cancer.

Frailty due to alteration in multiple physiological systems (including inflammatory, skeletal muscle, endocrine, clotting, and haematological) and dysregulation of mechanisms between these systems to maintain homeostasis

With increasing age, there is a well-described decline in voluntary physical activity which is associated with decreases in several measures of exercise tolerance including maximal aerobic capacity, muscle strength, and fatigueability, leading to an increase risk of frailty.

Frailty increases the risk for loss of functional independence and decrease in quality of life, the identification of cost-effective interventions to prevent or ameliorate frailty is one of the most important public health challenges.

In recent years, increased physical activity or regular exercise training has been proposed as preventive strategies for frailty and its adverse outcomes, as it can target four of the frailty criteria: weakness, low physical activity, slowed motor performance, and exercise intolerance. Epidemiological studies suggest that regular physical activity is associated with a decreased risk of ADL disability in older adults, which is an adverse outcome of frailty.

Frailty is not a contra-indication to physical activity, rather it maybe one of the most important indications to prescribe physical exercise. Longitudinal studies have demonstrated that regular physical activity extends longevity and reduces the risk of physical disability. In fact, cardio-respiratory fitness has been found to be a significant mortality predictor in older adults, independent of overall or abdominal obesity

Benefits of Exercises:

With age, there is a decline in the muscle mass and strength and it is even more distinct in frailty. Studies show that exercise is favourable in older adults, even in the frailest subset benefit from it. The benefits of exercise in the elderly are numerous and include increased mobility, improved performance of activities of daily living (ADL), better gait, less incidence of falls, increased bone mineral density, and improvements in overall wellbeing.

Aerobic/endurance exercise training

Aerobic capacity often measured as VO₂peak declines with age and contributes to a decrease in the older adult’s ability to perform activities of daily living. This is largely due to three major causes:

1) A decline in the ability of the cardiopulmonary system to deliver O₂

2) A decline in the ability of the working muscle to extract O₂, and

3) A decline in metabolic muscle mass and parallel increase in metabolically inactive fat mass.

Indeed, probably one of the most notable effects of endurance training is on VO₂peak which is an important determinant of frailty in older adults. The improvement in VO₂peak with endurance exercise training would be thought to reduce frailty in older adults and thus counter the decline in VO₂peak with aging and physical inactivity. There are two mechanisms by which aerobic exercise is thought to alter the frailty phenotype: improvement in the maximal oxygen uptake (VO₂ peak) and increased muscle mass. VO₂ peak is defined as the maximum rate of oxygen consumption measured during vigorous exercise and is closely related to sub-maximal endurance exercise capacity and exercise tolerance. Another important adaptation to endurance exercise training is an increase in muscle oxidative capacity, which results in fatigue resistance or increased muscle endurance.

Progressive Resistance exercise training

There is well-documented evidence that muscle strength and mass decreases with advancing age.

Muscle strength decreases approximately 12% to 15% per decade after the age of 50 years in both males and females going up to a 30% decrease by 70 years age. Most of the decline in strength can be explained by selective atrophy of type II muscle fibres and the loss of neuronal activation.

Despite these age-related effects on muscle, resistance exercise training still has been found to increase strength in older adults. Motor performance in older adults has also been shown to improve after resistance training. Several studies have shown that resistance exercise training increases muscle mass and thus muscle strength in both younger and older adults. However, the response to resistance training appears to be attenuated in older adults with mobility limitations or other co-morbidities. In healthy older adults, four months of progressive resistance training increased muscle mass by 16 to 23%, whereas it increased muscle mass by 2.0–9% in frail older adults

Combined aerobic and resistance exercise

Given the beneficial results seen with aerobic or resistance exercise alone and that both types of exercise target specific distinct features of frailty, there has been recent interest in whether an intervention with both components is beneficial for frail older adults. Therefore, the few exercise interventions conducted in frail older populations have mostly used combined aerobic and resistance exercise and found to have a much promising effect than isolated aerobic or resistance training alone.

Effect of exercise interventions on the adverse outcomes of frailty

Several studies have examined the effect of exercise on falls, a common adverse outcome of frailty. After a single fall, the risk of skilled nursing facility placement in older adults increases three-fold, after adjustment for cognitive, psychological, social, functional and medical factors. In addition to falls, ADL disability is of major concern in frail individuals as it is associated with higher rates of mortality. Combined resistance exercise training with balance training and home safety and assistive device evaluations, rates of ADL disability decreased only in those with moderate frailty, but not in those with not in those with severe frailty. Moderate frailty was defined as either the inability to perform a rapid gait test (requiring more than 10 seconds to walk a 3 meter course) or stand up from a chair with arms folded, and severe frailty was defined as having both characteristics

Adverse outcomes of exercise

Most exercise intervention trials studied the effects on features of frailty and the adverse outcomes of frailty.  Physical exercise can reverse frailty (frail reverse to non-frail) or if older adults can convert from a greater state of frailty to a lesser state of frailty with exercise suggesting that it is possible to successfully “treat” frailty.

Molecular and cellular mechanisms underlying exercise training

Aging and physical inactivity are associated with increased levels of chronic inflammation. Inflammatory cytokines have direct catabolic effects on skeletal muscle. These cytokines also induce insulin resistance, which contributes to sarcopenia and frailty by reducing muscle protein synthesis. Accordingly, an important mechanism by which exercise training reduces frailty is by suppressing muscle inflammation and promoting anabolism which leads to an increase in muscle protein synthesis

Future Directions

Exercise and physical activity are promising interventions for frailty, and several studies are currently underway to examine their impact. Adherence to an exercise regimen is key to its beneficial effects, and strategies to overcome this barrier need to be developed before exercise as treatment modality is implemented on a wide scale.

Although exercise uniformly had a positive impact on functional measurements, exercise seemed to be more beneficial in frail people living in long-term care facilities compared to the community (probably due to floor and ceiling effects of some outcome measurements) and in the earlier stages of frailty compared to the later stages of frailty (probably due to less ability to exercise with greater degree of frailty). With respect to specific type of exercise program, a multi-component training was found to have a more positive effect on the functional ability and adverse health consequences of the frail people. Interventions lasting longer than five months seemed to result in greater benefits on the adverse health consequences of the frail people. The duration for each session of exercise that was most beneficial was 30–60 minutes, which is less than what is usually recommended for healthier older adults. In addition, cognition is a factor that should be considered. A significant proportion of older adults are cognitively impaired, which may impact their ability to properly adhere to a regular exercise regimen. However, if caregivers are involved, this may not be such a barrier.

Based on currently available evidence, a multi-component exercise program that includes aerobic activity, strength exercises, and flexibility is recommended in frail older adults

Recommendations:

In older adults of the 60 years and above age group, physical activity includes leisure time physical activity, transportation (e.g. walking or cycling), occupational (if the individual is still engaged in work), household chores, play, games, sports or planned exercise, in the context of daily, family, and community activities.

The recommendations in order to improve cardio-respiratory and muscular fitness, bone and functional health, reduce the risk of NCDs, depression and cognitive decline are:

1. Older adults should do at least 150 minutes of moderate-intensity aerobic physical activity throughout the week or do at least 75 minutes of vigorous intensity aerobic physical activity throughout the week or an equivalent combination of moderate- and vigorous-intensity activity.

2. Aerobic activity should be performed in bouts of at least 10 minutes duration.

3. For additional health benefits, older adults should increase their moderate intensity aerobic physical activity to 300 minutes per week, or engage in 150 minutes of vigorous-intensity aerobic physical activity per week, or an equivalent combination of moderate-and vigorous-intensity activity.

4. Older adults, with poor mobility, should perform physical activity to enhance balance and prevent falls on 3 or more days per week.

5. Muscle-strengthening activities, involving major muscle groups, should be done on 2 or more days a week.

6. When older adults cannot do the recommended amounts of physical activity due to health conditions, they should be as physically active as their abilities and conditions allow.

Inactive people should start with small amounts of physical activity and gradually increase duration, frequency and intensity over time. Inactive adults and those with disease limitations will have added health benefits when they become more active.

Exercise Recommendations for frail older adults:

Aerobic exercise: Moderate to vigorous activity enough to raise the pulse rate to 70–80% of the maximum heart rate. Activity performed for a minimum of 20–30 minutes at least three days per week

Resistance exercise: The progressive resistance program should involve all major muscle groups of the upper and lower extremities and trunk. One set of 8 to 10 different exercise, with 10 to 15 repetitions per set, performed 2–3 non-consecutive days per week. Moderate-high intensity training is recommended, in which moderate intensity is 5 or 6 on a 0 to 10 scale.

Flexibility and balance exercise: Stretching to the point of tightness and holding the position for a few seconds. Flexibility activities are performed on all days that aerobic or muscle strengthening activity is performed. Balance training exercise 2–3 times per week.

Modified Wall Suryanamaskar: Hypothesised to be a good exercise for improving balance and reaction time in the community dwelling elderlies. Also can be a good combination of aerobic and resistance training for improving strength, endurance, flexibility and aerobic capacity in this population.

Virtual Reality Training: Virtual reality game exercise have been found to improve balance and gait of elderly individuals in community dwelling elderlies.

Conclusion: An exercise “prescription”

Majority of studies suggest that clinicians should recommend regular physical activity or exercise training to frail older adults. All adults over 60 years should participate in 150 minutes (2 hours and 30 minutes) of moderate aerobic exercise per week. Although most trials studied resistance exercise training, we would encourage frail older adults to start with an aerobic activity such as walking, as it is more accessible. If possible, resistance exercise training should be added. Depending on the degree of frailty, supervision may or may not be required. For individuals with severe frailty, evaluation by a rehabilitation profession is recommended.

The majority of evidence shows that regular physical activity or exercise is beneficial for older adults who are frail or at high risk of frailty. Studies have shown the number adverse events are minimal, and the gains of regular exercise clearly outweigh the risks.

References:

1.   Liu CK, Fielding RA. Exercise as an intervention for frailty. Clin Geriatr Med. 2011 Feb;27(1):101-10. doi: 10.1016/j.cger.2010.08.001. Review. PubMed PMID:21093726; PubMed Central PMCID: PMC3005303.

2.   Aguirre LE, Villareal DT. Physical Exercise as Therapy for Frailty. Nestle Nutr Inst Workshop Ser. 2015 November; 83: 83–92. doi:10.1159/000382065.

3.   Ministry of health and family welfare. New Delhi: Director General of Health Services, MOHFW, Government of India; 2011. National Program for Health Care of the Elderly (NPHCE): Operational Guidelines 2011.

4.   Central Statistics Office. New Delhi: Central Statistics Office Ministry of Statistics and Programme Implementation, Government of India; 2011. Situation Analysis of the Elderly in India.

5.   Verma R, Khanna P. National Program of Health-Care for the Elderly in India: A Hope for Healthy Ageing. International Journal of Preventive Medicine, 2013;4(10): 1103–1107.

6.   Morley JE, Malmstrom TK, Miller DK. A simple frailty questionnaire (FRAIL) predicts 

outcomes in middle aged African Americans. J Nutr Health Aging. 2012 Jul;16(7):601-8. 

PubMed PMID: 22836700; PubMed Central PMCID: PMC4515112.

7.   Shaheen M, Puri S, Tandon S. An Overview of Frailty in Elderly. Journal of The Indian Academy of Geriatrics, 2016; 12:58-65

8.   World Health Organization (WHO). Global Recommendations on Physical Activity for Health. Viewed on http://www.who.int/dietphysicalactivity/pa/en/ [Viewed on 2017 March 30]

9.   Park EC, Kim SG, Lee CW. The effects of virtual reality game exercise on balance and gait of the elderly. J. Phys. Ther. Sci. 27: 1157–1159, 2015

10.              Shaikh A, Shimpi A, Rairikar S. Effectiveness of Modified Wall Suryanamaskar Training for enhancement of Balance and Reaction time in community dwelling elderlies. (AoP)