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The Benefits of Exercise in Geriatric Women

Barbara J. George, RN, MSN; Nieca Goldberg, MD, Lenox Hill Hospital, Women's Heart Program, New York, NY
Originally published in AJGC 10(5):260-263, 2001

Abstract and Introduction

Abstract

Women 65 years of age and older are the fastest growing segment of the population. As women age, physical inactivity is the leading cause of morbidity and mortality due to coronary heart disease, diabetes mellitus, and hypertension. There is also a loss of both physiologic and psychological capabities that contributes to an overall reduction in function and independent living. Regular physical activity in geriatric women has been shown to reduce cardiovascular morbidity and all-cause mortality. Further research needs to be done to evaluate the role of regular physical activity in the management of diabetes and hyperlipidemia.

Introduction

As we enter the twenty-first century, we are faced with the reality that the fastest-growing segment of the population is women aged 65 and older. Within this age group, women significantly outnumber men,1 with the average woman living to 76.7 years of age.2 As women age, physical inactivity is recognized as contributing to the increases in morbidity and mortality due to coronary heart disease (CHD), diabetes mellitus, hypertension, and obesity.3,4

Inherent in the natural aging process is the loss of both physiologic and psychological capabilities, which contributes to a reduction in overall function and independent living.5,6 During the past 30 years, studies have shown that exercise and physical activity improve functional capacity,7,8 reduce risk of illness,9,10 improve health, and ultimately enhance quality of life.11 However, much of the literature in support of regular physical activity has been obtained from studies in young and middle-aged men.

Cardiovascular Benefits of Physical Activity

Research related to the benefits of exercise in women,12 particularly older women,13-15 is limited. Both the Framingham Heart Study16 and the Jerusalem 70-Year-Olds Longitudinal Study15 found that male and female septuagenarians who engaged in regular, moderate physical activity had similar reductions in mortality. Studies of healthy middle-aged and senior women show a 24%-38% relative risk reduction in all-cause mortality17 and a 50% risk reduction in myocardialinfarction18 with participation in moderate leisure-time physical activity.

By age 25, most women begin to exhibit a decrease in maximal oxygen consumption (VO2max), which continues to decrease by as much as 15% per decade.19 Contributing to this age-associated decline in functional capacity is a decrease in physical activity.

Regular aerobic exercise training has been shown to confer a 10%-30% improvement in VO2max in healthy seniors, independent of gender.12,20,21 However, in women this improvement appears to result from peripheral adaptations, such as a large arteriovenous oxygen difference (a-VO2), rather than from improvements in central adaptations more commonly associated with men.22

Women with CHD can also improve exercise tolerance and physical fitness23 with appropriately prescribed exercise training. For these individuals, participation in a cardiac rehabilitation exercise program can raise the angina threshold and onset of ST segment depression during higher absolute exercise intensities. One study24 demonstrated up to 40% improvement in endurance for women with CHD between 62 and 82 years of age. The greatest improvement in endurance appears to occur in women who are most sedentary and with moderate to high exercise intensities.25

Physical Inactivity and CHD Risk Factors

During the last decade, 36% of women between the ages 65 and 74 and one half of women 75 and older reported no leisure-time physical activity.26,27 In this time, the death rate due to cardiovascular disease in women has increased.4 The physiologic changes associated with physical inactivity and increased CHD morbidity include increases in percent body fat and glucose intolerance, hyperlipidemia, and an increase in peripheral vascular resistance, resulting in hypertension.

The National Health and Nutrition Examination Survey (NHANES)-III[28] revealed that 34 million adult American women are considered obese, with body mass indices of >27.3, and nearly two thirds of men and women are considered sedentary. Endurance exercise training has been shown to reduce overall percent body fat in older women by as much as 4%.21 Resistance training, when combined with endurance training, requires even greater increases in energy expenditure, thereby further reducing percent body fat.29

Sedentary lifestyle and obesity contribute to the steady increase in type 2 diabetes with age. Seals and associates30 found significant improvement in insulin sensitivity following 6 months of high-intensity endurance training in healthy older women. This high-intensity training consisted of 30-45 minutes of aerobic activity at least 3 days per week, at 80%-90% of maximum heart rate. However, the initial 6-month, low-intensity training did not elicit this significant improvement. Further research is needed to identify the exercise intensity requirements for both risk reduction and optimal management of diabetes mellitus among older women.

As with diabetes, the incidence of hyperlipidemia increases with age in sedentary women.31,32 Women who maintain a physically active lifestyle do not exhibit the unfavorable age-associated changes in plasma lipids and lipoproteins.33 Although data from recent studies34-36 have indicated that adopting an exercise and diet modification program is the most effective means of managing plasma lipid and lipoprotein abnormalities in women, limited data are available specifically for senior women. In a recent gender study involving middle-aged and senior subjects,37 both men and women had increased high-density lipoprotein (HDL) cholesterol following a 1-year cardiac rehabilitation exercise program (10% and 7%, respectively), but only in the women was this benefit extended, with a 20% increase in HDL cholesterol over a 5-year period. In addition, relative to the men, these women experienced significant improvements in low-density lipoprotein (LDL) and total cholesterol and in the ratio of total to HDL cholesterol. These benefits remained after adjustment for percent body fat and metabolic equivalents. More research is necessary to further understand the role exercise plays in improving hyperlipidemia in senior women.

Recent clinical data38-40 provide evidence in support of regular aerobic exercise as a nonpharmacologic means of reducing resting blood pressures in women aged 50-69 years. Regular aerobic exercise has been shown to reduce resting systolic and diastolic blood pressures by as much as 10 mm Hg and 6 mm Hg, respectively.20,38,39 These changes occurred within as few as 8 weeks of aerobic activity and without increased aerobic capacity, weight reduction, or a change in diet.37

Physical Activity and Musculoskeletal Benefits

Changes in the musculoskeletal system and body composition of aging women have been well documented. Muscle mass and strength decline in women by as much as 15% per decade until the eighth decade, when this age-related decline doubles.41 The loss of muscle strength and lean body mass results in an overall state of physical frailty.42

Epidemiologic and interventional studies43-45 have shown that older women exhibit significant increases in muscle strength and mass by utilizing a combination of endurance and resistance exercise training. Senior women (mean age, 71.6 years) who participated in a 12-month, comprehensive program of resistance and endurance training showed significant improvements in all strength measurements when compared with non-exercising control subjects.46 Resistance training in older women results in increases in muscle mass, muscle strength, and aerobic capacity and reduces weight and body fat density.44,47,48 These improvements in strength are associated with a reduced risk of falls and increased flexibility and range of motion,45 which are of particular concern in this patient population.

Safety of Physical Activity

The risk of cardiac events among sedentary older women during exercise training is somewhat greater than that in younger individuals; however, exercise is considered relatively safe and low-risk.49 An overview of randomized, controlled exercise trials confirms a very low rate of myocardial infarction and cardiovascular complications.50 One concern is the possibility of an exaggerated increase in blood pressure during resistance exercises. Large changes in blood pressure during exercise can be avoided if older women are instructed to maintain normal breathing patterns and avoid the Valsalva maneuver.51

The most common injuries for older women are musculoskeletal (e.g., falls and joint injuries) and do not usually require medical attention.52 These minor injuries can be avoided with inclusion of a 5-10 minute warm-up and similar cool-down in the exercise prescription.51

Conclusions

A number of studies support the benefit of endurance and resistance training in the prevention of cardiovascular disease and improvement of CHD risk factors in senior women. However, in the majority of these studies, the role of exercise was evaluated in mixed populations of middle-aged and older women. The incorporation of physical activity programs in the clinical management of senior women has been shown to mitigate postural instability and orthopedic limitations, and can lead to greater physical independence. Further studies are needed to evaluate the effects of exercise interventions on diabetes and lipid levels in geriatric women.

Benefits of Physical Activity

References

  1. Population Estimates Program, Population Division, US Census Bureau. US Population 1990 Statistical Data.Washington, DC: US Census Bureau; 1999.
  2. National Center for Health Statistics, United States, 1991. National Vital Statistics Report. Hyattsville, MD: Public Health Service; 1998.
  3. NIH Consensus Development Panel on Physical Activity and Cardiovascular Health. Physical activity and cardiovascular health. JAMA. 1996;276:241-246.
  4. American Heart Association. 2001 Heart and Stroke Facts. Dallas, TX: American Heart Association National Center; 1990.
  5. Buskirk ER, Hodgson JL. Age and aerobic power: the rate of change in men and women. Fed Proc. 1987;46:1824-1829.
  6. Ogawa T, Spina R, Martin W III, et al. Effects of aging, sex and physical training on cardiovascular responses to exercise. Circulation. 1992;86:494-503.
  7. Paffenbarger RS Jr, Hyde RT, Wing AL, et al. Physical activity, all-cause mortality, and longevity of college alumni. N Engl J Med. 1986;314:605-613.
  8. Stevenson ET, Davy KP, Seals DR. Maximal aerobic capacity and total blood volume in highly trained middle-aged and older female endurance athletes. J Appl Physiol. 1994;77:1691-1696.
  9. Leon AS, Connett J, Jacobs DR Jr, et al. Leisure-time physical activity levels and risk of coronary heart disease and death. The Multiple Risk Factor Intervention Trial. JAMA. 1987;258:2388-2395.
  10. Blair SN, Kohl HW, Paffenbarger RS, et al. Physical fitness and all-cause mortality. JAMA. 1989; 262:2395-2401.
  11. Oldridge NB. Outcome assessment in cardiac rehabilitation. Health related quality of life and economic evaluation. J Cardiopulm Rehabil. 1997;17:179-194.
  12. Kohrt WM, Malley MT, Coggan AR, et al. Effects of gender, age, and fitness level on response of VO2 max to training in 60-71 yr olds. J Appl Physiol. 1991;71:2004-2011.
  13. Spina R, Ogawa T, Miller T, et al. Effects of exercise training on left ventricular performance in older women free of cardiopulmonary disease. Am J Cardiol. 1993;71:99-104.
  14. Spina R, Miller T, Bogenhagen W, et al. Gender-related differences in left ventricular filling dynamics in older subjects after endurance exercise training. J Gerontol A Biol Sci Med Sci. 1996;51:B232-B237.
  15. Stessman J, Maaravi Y, Hammerman-Rosenberg R, et al. The effects of physical activity on mortality in the Jerusalem 70-Year-Olds Longitudinal Study. J Am Geriatr Soc. 2000;48:499-504.
  16. Sherman SE, D'Agostino RB, Cobb JL, et al. Does exercise reduce mortality rates in the elderly? Experience from the Framingham Heart Study. Am Heart J. 1994;128:965-972.
  17. Kushi LH, Fee RM, Folsom AR, et al. Physical activity and mortality in postmenopausal women. JAMA. 1997;277:1287-1292.
  18. Lemaitre RN, Heckbert SR, Psaty BM, et al. Leisure- time physical activity and the risk of nonfatal myocardial infarction in postmenopausal women. Arch Intern Med. 1995;155:2302-2308.
  19. Heath G, Hagberg J, Ehsani A, et al. A physiological comparison of young and older endurance athletes. J Appl Physiol. 1981;51:634-640.
  20. Hagberg JM, Montain WH, Martin WH III, et al. Effect of exercise training in 60- to 69-year-old persons with essential hypertension. Am J Cardiol. 1989;64;348-353.
  21. Hagberg JM, Graves M, Limacher DR, et al. Cardiovascular responses of 70- to 79-yr-old men and women to exercise training. J Appl Physiol. 1989; 66:2589-2594.
  22. Christmas C, Anderson RA. Exercise and older patients: guidelines for the clinician. J Am Geriatr Soc. 2000;48:318-324.
  23. Lavie C, Milani R, Littman A. Benefits of cardiac rehabilitation and exercise training in secondary coronary prevention in the elderly. J Am Coll Cardiol. 1993;22:678-683.
  24. Ades PA, Waldman ML, Poehlman ET, et al. Exercise conditioning in older coronary patients: submaximal lactate response and endurance capacity. Circulation. 1993;88:572-577.
  25. Seals DR, Hagberg JM, Hurley BF, et al. Endurance training in older men and women. I. Cardiovascular response to exercise. J Appl Physiol. 1984;57:1024-1029.
  26. Pate RR, Pratt M, Blair SN, et al. Physical activity and public health: a recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. JAMA. 1995;273:402-407.
  27. Centers for Disease Control and Prevention. 1994 BRFSS Summary Prevalence Report. Atlanta, GA: US Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion; 1994.
  28. Kuczmarski RJ, Flegal KM, Campbell SM, et al. Increasing prevalence of overweight among US adults: The National Health and Nutrition Examination Surveys, 1960 to 1990. JAMA. 1994;272:205-211.
  29. Campbell WW, Crim MC, Dallal VR, et al. Increased protein requirements in the elderly: new data and retrospective reassessments. Am J Clin Nutr. 1994;60:167-175.
  30. Seals D, Hagberg J, Hurley B, et al. Effects of endurance training on glucose tolerance and plasma lipid levels in older men and women. JAMA. 1984;252:645-649.
  31. Kannel W, Hjortland MC, McNamara PM, et al. Menopause and risk of cardiovascular disease: the Framingham Study. Ann Intern Med. 1976;85:447-452.
  32. Stevenson JC, Crook D, Godsland AF. Influence of age and menopause on serum lipids and lipoproteins in healthy women. Atherosclerosis. 1993;98:83-90.
  33. Stevenson ET, DeSouza CA, Parker Jones P, et al. Physically active women demonstrate less adverse age-related changes in plasma lipids and lipoproteins. Am J Cardiol. 1997;80:1360-1364.
  34. Binder EF, Birge SJ, Kohrt WM. Effects of endurance exercise and hormone replacement therapy on serum lipids in older women. J Am Geriatr Soc. 1996;44:231-236.
  35. Stefanick M, Mackey S, Sheehan M, et al. Effects of diet and exercise in men and postmenopausal women with low levels of HDL cholesterol and high levels of LDL cholesterol. N Engl J Med. 1998;339:12-20.
  36. National Cholesterol Education Program Expert Panel. Second Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel). Circulation. 1994;89:1333-1445.
  37. Warner JG, Brubaker PH, Ying Zhu MS, et al. Long-term (5-year) changes in HDL cholesterol in cardiac rehabilitation patients: do sex differences exist? Circulation. 1995;92:773-777.
  38. Ishikawa K, Ohta T, Zhang J, et al. Influence of age and gender on exercise training-induced blood pressure reduction in systemic hypertension. Am J Cardiol. 1999;84:192-196.
  39. Tanaka H, Reiling MJ, Seals DR. Regular walking increases peak limb vasodilatory capacity of older hypertensive humans: implications for arterial structure. J Hypertens. 1998;16:423-428.
  40. American College of Sports Medicine position stand: Physical activity, physical fitness, and hypertension. Med Sci Sports Exerc. 1993;25:i-x.
  41. Imamura K, Ashida H, Ishikawa T, et al. Human major psoas muscle and sacrospinalis muscle in relation to age: a study by computed tomography. J Gerontol. 1983;38:678-681.
  42. Lawrence RC, Helmick CG, Arnett FC, et al. Estimates of the prevalence of arthritis and selected musculoskeletal disorders in the United States. Arthritis Rheum. 1998;41:778-799.
  43. American College of Sports Medicine position stand. Osteoporosis and exercise. Med Sci Sports Exerc. 1995;27:i-vii.
  44. Cohen RA, Van Nostrand JF. Trends in the health of older Americans: United States, 1994. Vital Health Stat. 1995;3:3-7.
  45. Ostchega Y, Harris TB, Hirsch R, et al. Reliability and prevalence of physical performance examination assessing mobility and balance in older persons in the US: data from the Third National Health and Nutrition Examination Survey (NHANES III). J Am Geriatr Soc. 2000;48:1136-1141.
  46. American College of Sports Medicine position stand. Exercise and physical activity for older adults. Med Sci Sports Exerc. 1998;30:992-1008.
  47. King PA, Savage P, Ades PA. Home resistance training in an elderly woman with coronary disease. J Cardiopulm Rehabil. 2000;20:126-129.
  48. Fiatorone MA, Marks EC, Ryan ND, et al. High-intensity strength training in nonagenarians. Effects on skeletal muscle. JAMA. 1990;263:3029-3034.
  49. Fletcher GF, Balady G, Blair SN, et al. Statement on exercise: benefits and recommendations for physical activity programs for all Americans. A statement for health professionals by the committee on exercise and cardiac rehabilitation of the council on clinical cardiology, American Heart Association. Circulation. 1996;94:857-862.
  50. Wenger NK, Hellerstein HK. Rehabilitation of the Coronary Patient. 3rd ed. New York, NY: Churchill Livingstone, Inc.; 1992.
  51. American College of Sports Medicine position stand. The recommended quantity and quality of exercise for developing and maintaining cardiorespiratory and muscular fitness, and flexibility in healthy adults. Med Sci Sports Exerc. 1998;30:975-991.
  52. Coleman EA, Buchner DM, Cress ME, et al. The relationship of joint symptoms with exercise performance in older adults. J Am Geriatr Soc. 1996;44:14-21.

Address for correspondence/reprint requests: Nieca Goldberg, MD, Lenox Hill Hospital-Women's Heart Program, 178 East 85th Street, 2nd Floor, New York, NY, 10028

Copyright © 2001 by Cardiovascular Reviews & Reports, Inc.