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CARDIOLOGY CASEBOOK |
Case 1
A 78-year-old retired man has a 10-year history of essential hypertension and aortic valve regurgitation. Since retirement, he has lived a sedentary life and gained 15 lb (6.75 kg). Lately he has considered starting an exercise program and wisely sought medical advice before beginning a program. He is concerned about his "heart condition" and would like to know what type of exercise he can engage in and the length and frequency of the sessions. On physical examination, the blood pressure was 130/70 mm Hg in both arms; the lungs were normal on auscultation; the heart rate was 80 beats/minute, and a grade 2/6 aortic regurgitant murmur was heard over the aortic area with radiation to the fourth left parasternal inter-costal space. There were S4, S1, and S2 heart sounds. The aortic valve regurgitation was hemodynamically stable; the end-systolic and end-diastolic left ventricular cavity diameters and the aortic root diameter were all within acceptable ranges that would support conservative management. The lipid profile and homocysteine level were within the acceptable range.
Questions
Case 2
A frail 82-year-old woman who lives in a nearby rural community is brought to her doctor’s appointment by her daughter. She has had type 2 diabetes for the past 15 years complicated by neuropathy, is unsteady on her feet, and is afraid of falling. Her greatest concern is that she will fall, break a hip, and become totally dependent on her daughter. As a result, she has restricted her activities and no longer walks outdoors for fear of falling. There was no evidence of congestive heart failure, and results of a neurological examination were normal. Her diabetes is well controlled with diet and oral hypoglycemia agents. She has a history of hypertensive atherosclerotic heart disease that is currently well controlled and asymptomatic. Her weight is 110 lb (49.5 kg); blood pressure is 125/65 mm Hg in both arms; lungs are normal on auscultation. Her heart rate was 66/minute and regular. There were S4, S1, and S2 heart sounds, a grade 2/6 aortic systolic murmur due to aortic valve sclerosis, and a 2/6 mitral regurgitant murmur due to mitral papillary muscle dysfunction. The lipid profile revealed: cholesterol, 180 mg/dL (4.65 mmol/L); high-density lipoproteins, 52 mg/dL (1.34 mmol/L); low-density lipoproteins, 94 mg/dL (2.43 mmol/L); triglycerides, 150 mg/dL (1.69 mmol/L); very-low-density lipoproteins, 28 mg/dL (0.72 mmol/L); high-sensitivity C-reactive protein, 0.2 mg/L; and glycosylated hemoglobin, 5.9%. Medications included aspirin 325 mg daily, enalapril 20 mg daily, metoprolol 100 mg daily, atorvastatin 20 mg, and oral hyperglycemics daily. The patient asks her physician if there is anything she can do to improve her activity level and lessen her risk of falling and getting a skeletal injury.
Questions
ANSWERS
1. b. Regular exercise is often not attempted in older adults because of the frequency of underlying medical problems.
d. Regular exercise can prevent cognitive decline in older adults.
Evidence is growing that in the elderly, as well as in younger persons, effective lifestyle modifications, including regular physical exercise, dietary changes that promote the consumption of well-balanced, healthy nutrients, and stress management can have a significant influence not only on the quality of life, but also on the length of life.1 Unfortunately, physical activity decreases steadily after early adulthood for diverse reasons that include medical problems, lack of motivation, loneliness, and no access to adequate facilities. However, the beneficial effects of moderate and regular physical activity in the elderly are now universally acknowledged. It has been demonstrated that regular physical activity decreases the chances of cardiovascular mortality, including lowering the incidence of ischemic stroke.2,3 Active older adults have a lower incidence of depression and their quality and duration of sleep may be enhanced.4 Research performed in healthy, sedentary older adults has demonstrated that even a superficial exercise program can significantly increase their functional capacity measured by oxygen consumption. After 4 months of aerobic exercise, their functional capacity has been shown to increase by an average of 10% to 15%.5 The same group of older adults also achieved a reduction in total and low-density lipoprotein cholesterol, as well as an increase in high-density lipoproteins. These studies show that senior citizens can and should engage in regular, moderate physical activity (eg, walking for approximately 30 minutes 5 to 6 days a week). Other examples of moderate physical activity include playing (walking) 18 holes of golf once a week, playing tennis twice a week or walking 1.6 kilometers a day.3 The salutary effects of such activity make it one of the most cost-effective interventions that healthcare providers can promote.
Multiple studies have shown that the incidence of dementia increases exponentially with age.6 At least 10% of persons older than 65 years and 50% of those older than 85 years have some form of cognitive impairment.3 This area of research has also shown that physically active older adults perform better in cognitive testing than sedentary older adults. Prospective studies have shown that women with higher levels of physical activity were less likely to develop cognitive decline. In one study, women had 15% lower odds of cognitive decline for every 10 blocks walked per day. Possible mechanisms by which physical activity may influence cognitive function include the following: reduction in the risk of cardiovascular and cerebrovascular disease, stimulation of neuronal growth and increased cerebral blood flow (CBF).3 Regional CBF measurements using 133Xe inhalation are a useful, noninvasive method for measuring cerebral perfusion in older adults.2 A 1990 study showed that retirees who elected to become physically inactive exhibited significant declines in CBF throughout 4 years of follow-up. Those who continued to work or who participated in regular activities sustained more constant CBF levels and scored better on cognitive testing.
2. a. Physical activity is a beneficial component in preventing falls in the aged.
b. Balancing exercises while standing or walking are the best in reducing risks of falling in the elderly.
d. Older urban adults may have a higher level of physical activity than their rural counterparts.
e. Physical activity can lessen osteopenia.
The incidence of falling increases with age. Falling can be particularly problematic in very frail elderly persons because their slower reflexes, poor vision, and osteoporosis make them more susceptible to injuries. Evidence is increasing that participation in regular exercise programs can reduce the risk of falling, particularly when supplemented by education, review of medications, and modification in the home environment.4 Physical activity can improve balance; muscle strength can improve with progressive resistance training. Strength-building programs can improve mobility and balance, aiding in weight maintenance. However, balancing exercises while standing or walking will be more beneficial in reducing the risks of falling and will improve confidence in walking. Flexibility, necessary for daily activities such as climbing stairs, rising from a chair or bed, or walking can be improved with supervised training.
Clinical evidence shows that active older adults have a lower incidence of osteopenia than their sedentary counterparts.4 Frail elderly individuals or those with multiple comorbidities pose a special challenge in shaping an exercise program. A thorough screening and physical assessment are necessary. Often, the poor general condition in the aged and the generalized weakness and gait problems make the exercise prescription difficult but still manageable.
These individuals, however, may benefit from more moderate or light activities with less emphasis on aerobic conditioning. One study reports a lower rate of falls among women over 80 years when working with a physical therapist.7 Interventions that improve mobility, increase strength and improve balance. Examples of interventions that could be implemented are a walking program or a supervised program of gentle exercise at least twice weekly. Exercise classes can be on videotape if classes are not available. Regular physical activity even at moderate levels is beneficial and can prevent many disabling conditions that affect older adults.1
Both national and community studies have shown that physical activity decreases after early adulthood and continues to decline after age 50. One statewide study has shown that rural residents have a higher percentage of sedentary lifestyle than urban residents.8 Living in rural areas may need to be added to screening criteria. Healthcare providers may need to write "exercise prescriptions" rather than give verbal advice to frail older adults. Since older adults (living in rural areas) are less likely to engage in preventative health behavior, a written exercise prescription could influence their health behavior.1,9 Physical activity is one of the most effective preventative strategies that will increase the number of older persons who will remain independent in their ninth and tenth decades of life.
SUMMARY
At all age levels and especially in the elderly population, a sedentary lifestyle and low fitness levels are independent risk factors for all causes of mortality, including cardiovascular mortality. Exercise improves cardiovascular outcomes by increasing vagal activity and attenuating sympathetic hyperactivity. The risk of diabetes mellitus type 2 developing is reduced by 40% in men of normal weight and 60% in overweight men when on a regular exercise program. Physical activity in the elderly sustains cerebral perfusion, maintaining cognitive function. Isolation, which is not uncommon among the elderly, fosters cognitive decline. Stimulating mental activity can protect against dementia.
ACKNOWLEDGMENT
Supported in part by a grant from the Applebaum Foundation, in loving memory of Joseph Applebaum.
Reprint requests: Louis Lemberg, MD, University of Miami School of Medicine, Division of Cardiology (D-39), P O Box 016960, Miami, Fla 33101.
Bonzheim KA, Franklin BA. Women and heart disease: role of exercise-based cardiac rehabilitation. Women Heart Dis. May/June 2001:135–144.
Christensen H, Korten A, Jorm AF, et al. Activity levels and cognitive functioning in an elderly community sample. Age Ageing. 1996;25:72–80.
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  A. S. Slingerland, F. J. van Lenthe, J. W. Jukema, C. B. M. Kamphuis, C. Looman, K. Giskes, M. Huisman, K. M. V. Narayan, J. P. Mackenbach, and J. Brug Aging, Retirement, and Changes in Physical Activity: Prospective Cohort Findings from the GLOBE Study Am. J. Epidemiol., June 15, 2007; 165(12): 1356 - 1363. [Abstract] [Full Text] [PDF]
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 K. B. Keller and L. Lemberg Secondary prevention of coronary artery disease in elderly persons: a treatise on a report by the american heart association. Am. J. Crit. Care., September 1, 2006; 15(5): 514 - 518. [Full Text] [PDF]
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