1. Exercise Interventions For Successful Aging Miriam C. Morey VA and Duke Medical Centers Durham, NC

2. Objectives General overview of PA guidelines Overview of VA/ Duke PA programs Thoughts about implementation

3. National Physical Activity Guidelines ACSM, AHA Recommendations: Aerobic ≥ 30 min or 3 bouts of ≥10 min/day ≥ 5 days/week moderate intensity = 5-6 on a 10-point scale in addition to routine ADL’s Or, 20 minutes of vigorous activity 3 days / week Strength 8-10 exercises (major muscle groups), 10-15 repetitions ≥2 nonconsecutive days/week moderate to high intensity = 5-8 on a 10-point scale Circulation:2007;116

4. Guidelines Recommendations: Flexibility ≥ 10 min ≥2 days/week flexibility to maintain/improve range of motion (i.e. stretching of major muscle/tendon groups, yoga) Balance Balance exercises for those at risk for falls (i.e. Tai Chi, individualized balanced exercises)

5. Guidelines Recommendations : Plan create a single physical activity (PA) plan that integrates preventive and therapeutic treatment of chronic conditions Benefit Exceed the minimum recommended amount to accrue greater benefits

6. Exercise Interventions For Successful Aging If you do it, it will work

7. Exercise Interventions For Successful Aging If you do it, it will work The devil is in the details

8. 2005 National Average: Recommended Physical Activity 65+Strength Training (2001) Recommended40%10% Insufficient35% Inactive25%

9. From CDC website

10. Exercise program for older veterans Clinical research program with focus on the older adult Provider training in physical activity for older adults Exercise rotation for medical students and fellows in geriatric training program Pepper Center Aging Center/ Duke Medical Center GEROFIT Durham VA Medical Center

11. Gerofit Program Facility-based exercise and health promotion program established in 1986 as a GRECC clinical demonstration project. Developed in response to Veterans Health Care Amendment of 1983 mandating implementation of preventive medicine in VA’s. Fitness programming identified as a targeted area of need. Individually tailored to meet needs of older veterans with chronic conditions and physical impairments, many as a result of military service.

12. Veterans ages 65 and over have access to facility- based supervised exercise program (treadmills, stationary bicycles, stair machine, weight training machines, floor exercises, tai chi, water aerobics) -Over 1200 patients referred -Average daily census + 60 patients Referred by primary care providers and other health care specialists Special consultative services available as needed Telephone counseling offered to: -Patients who live too far to attend the facility- based program - Patients under age 65

13. Key published clinical outcomes Veterans participating in Gerofit report significant improvements in exercise capacity, cardiovascular risk factors and psychological well-being. JAGS (37):1989; J Appl Ger (10):1991. Examination of impact of burden of disease (no disease vs. 1 disease vs. 2 diseases) on exercise parameters and 5-year trajectories of performance. JAGS (44):1996. Older veterans with chronic diseases experience a long-term beneficial mortality effect from participation in facility-based program. JAGS (50):2002. Older veterans enrolling in Gerofit have significantly poorer physical performance than national normative data. And, veterans participating in Gerofit for 6 months or more have physical performance on par or higher than reported national norms. JRRD (41):2004.

14. Transition to Funded Research Aerobic vs. Axial/Aerobic Training: Improvement in Function (PI: Morey, 1992-1995) (facility to home-based) Duke Pepper Center Phoning for Function: Promoting Health After Cancer (PI: Demark, 1997-2003) (home-based) Duke Pepper Center Improving Fitness and Function in Elders (LIFE 1) (PI: Morey, 2001- 2004) (home-based): VA Rehabilitation Research Service Learning to Improve Fitness and Function in Elders (LIFE 2) (PI: Morey, 2004-2008) (home-based): VA Rehabilitation Research RENEW: Reach Out to Enhance Wellness in Older Survivors (PI Demark 2004-2008) (home-based) National Cancer Institute

15. Aerobic vs. Axial/Aerobic Training: Improvement in Function (facility to home-based) Randomized clinical trial Three months of supervised exerciseThree months of supervised exercise Followed by six months of home-based exercise Followed by six months of home-based exercise with telephone follow-up with telephone follow-up Intervention (3 days per week) Axial/Aerobic group Axial/Aerobic group 20 minutes axial mobility exercises 20 minutes axial mobility exercises 20 minutes aerobic exercise 20 minutes aerobic exercise Aerobic group Aerobic group 40 minutes aerobic exercise 40 minutes aerobic exercise

16. Change in Aerobic Capacity Findings: Significant overall improvement, both groups, p=0.0001 0-3 mos. group*time interaction, p=0.0014 (dose response) 0-9 mos: p=0.07 Months VO 2 Pea k ml/kg/min Morey et al., J Geron Med Sci 1999 54A M335-M342.

17. Change in Physical Function Findings: Significant overall improvement, both groups, p=0.0016 0-3 mos. p=0.004 0-9 mos. p=0.68 No between group differences Months PhysFunction Score Morey et al., J Geron Med Sci 1999 54A M335-M342.

18. Secondary Improvements Health Related Quality of Life, p= 0.0009 Total Number of Symptoms Reported, p=0.0001 Effect of Symptoms on Functional Limitations, p=0.0001 Morey et al., J Geron Med Sci 1999 54A M335-M342.

19. What did we learn and where do we go from here? Facility-based have more robust outcomes; but most people choose home-based exercise How can we successfully apply these approaches to home-based intervention? How can we enhance adherence in the home- based setting?

20. Predictors of adherence Number of diseases Body mass index Physical function Pain **Weekend adherence Weeks Morey, et al. J Aging Phys Act 2003, 11,351-368

21. Functional Outcomes by Level of Adherence: SF-36 Physical Function Findings: Change in physical function scores between 3 and 9 months differed by level of adherence. (Chi sq. = 5.67, 1 df, p= 0.017) Adherents maintained gains Non adherents declined to baseline functional score. Months Function

22. Project LIFE 1 And 2 Use state of the art counseling methods to enhance adherence Desire to include primary care providers as part of counseling team Needed to involve more functionally limited elders

23. Project Life 1 Six-month feasibility trial Primary care providers endorsed PA one-time in clinic Health counselor gave baseline PA counseling to everyone prior to randomization High intensity group had 3 months bi-weekly PA counseling and 3 months monthly PA counseling

24. Project LIFE 1 One-time counseling had short-term benefit that was not sustained Patients valued primary care provider involvement More frequent telephone contact was needed Morey, et al. J Aging Phys Act 2006 14 324-343

25. Project LIFE 2 12-month multi component PA trial comparing counseling to usual care –One-time in person –Provider endorsement –Sustained telephone counseling –Sustained provider endorsement by automated telephone messaging –Mailed quarterly progress report Goal: 30 min 5 days/week aerobic 15 min strength training 3 days/wk

26. Project LIFE 2 Counseling must be sustained It takes one year to get close to recommended PA guidelines Provider involvement is highly acceptable These changes are accompanied by very modest improvements in physical function

27. New approaches to enhance PA adherence SMART Design

28. From Physical Activity to Physical Function Data from 2 clinical trials (Life 1 and Phoning for Function) Both 6 months w telephone PA counseling Examined impact of 150 minutes PA Pooled data from several studiesPooled data from several studies

29. From Physical Activity to Physical Function Pooled data from several studiesPooled data from several studies >150 min/wk PA to < 150 min/wk 150 min/wk

30. Physical Activity to Physical Function Benefits are more easily achieved among adults of higher physical function Exercise modality is not crucial – any exercise is better than being sedentary Among more impaired adults and those with multiple morbidities results are more tenuous. New health events occur frequently.

31. Partnering with Specialists to Enhance PA in Special Populations Innovative use of advances in Telemedicine Health Buddy for monitoring PA adherence in stroke patients (Chumbler and Hoenig, Co-PI’s)

32. Provider Education All VA primary care providers trained in PA counseling using PACE methods and materials Gerofit rotation offered to all geriatric fellows; observe nurse-based physical activity counseling and follow new patient for 6-8 weeks Modified rotation offered to medical students (fourth year, geriatric intern rotation, and others). Establish link between exercise prescription and physical function

33. Partnering with Specialists to Enhance PA in Special Populations Telemedicine for Intensive Care Rehab (Ely and Hoenig, Co-Pi’s)

34. Conclusions Physical activity interventions of diverse content can be implemented across multiple settings Integration of clinical, research and educational programs have expanded the successful implementation of PA programs at our medical centers