Fitness and Function at the End of Life

In this issue of JAGS, a novel clinical intervention is described by Schnelle and colleagues.1 Seventy-six nursing home residents selected for incontinence were enrolled in a randomized trial of prompted voiding (PV) compared with an experimental “FIT” protocol consisting of standing and ambulating to tolerance 4 times per day. The subjects in this study were unlike participants in previously published trials of exercise in the nursing home2-14 in regard to their nearly bed-bound state, severity of dementia, high short-term mortality (9% in just 4 weeks), and extreme exercise intolerance. Under the instruction of the nursing staff, residents in the experimental program were assisted to a standing position up to a maximum goal of 16 times throughout the day and walked or propelled their wheelchair up to a maximum goal of 20 minutes per day. Over the course of the 8-week study period, the FIT group increased their daily walking time from 4.3 minutes per day to 7.9 minutes per day, whereas the prompted voiding (PV) group walked only 1.5 minutes per day at both time points. Similarly, FIT subjects stood 10 times per day (compared with 3.4 at the beginning of the intervention), whereas the control group stood 2.3 times per day, on average, without improvement over time. When tested at the end of 8 weeks, FIT subjects performed better on walking, wheelchair, and standing endurance tests compared with controls. What is the significance of these results? On average, an additional 3.6 minutes per day were spent walking or propelling a wheelchair, with no adverse events (falls, increased agitation, musculoskeletal injuries, or cardiovascular events) reported. What are the clinical benefits of this amount of increase in time out of chair or bed? It is not clear that this change would be of sufficient magnitude to result in decreased postural hypotension, reduced decubitus ulcer risk, improved depressive symptoms, improved glucose tolerance, less muscle atrophy and weakness, reduced skeletal demineralization, or any of the other hazards described in conditions of complete immobilization or severe deconditioning.15, 16 The authors state that incontinence and agitation improved equally in both groups, so that the clinical significance of the change in exercise capacity and mobility achieved is not certain. Although the intervention was relatively cheap and easy to administer, it did require approximately 6 minutes more nursing time per session (a total of 18 minutes per day), more than required by prompted voiding alone. However, mobility is a worthy enough goal of its own, and preserving or improving this ability may provide overall quality of life benefits even at the very end of life when the traditional health benefits associated with walking or aerobic exercise (longevity, prevention of cardiovascular disease/risk factors, maintenance of normal weight, improved glucose regulation, etc.) may no longer apply. Mobility may be impaired because of physiologic deficits in aerobic capacity, muscle strength, or balance, and the specificity of the response to various exercise modalities should be kept in mind. For maximal efficiency, therapeutic exercise should be prescribed so as to achieve multiple outcomes at once if possible. Resistance training (weight lifting) interventions2-4 in the frail nursing home resident have been shown to improve strength, muscle mass, overall activity levels, depressive symptoms, and nutrient intake, as well as performance on mobility tests. In other populations, resistance training has been shown to improve strength,17 balance,18 and aerobic capacity,19 thus addressing multiple physiological deficits thought to contribute to frailty simultaneously. By contrast, endurance training such as walking does not improve strength or balance in general.20 It should be kept in mind that encouraging increased ambulation without addressing the underlying impaired balance or muscle weakness may, in fact, predispose frail older people to fall, or may exacerbate arthritic symptoms, and those outcomes should be included in future analyses of exercise trials in the nursing home. There are several lessons that may be drawn from this and other studies of exercise in this unique and vulnerable population. First, it is feasible to encourage increased physical activity patterns in the most deconditioned of individuals, and the potential for improved function does not appear to be limited by extreme age or fragility. Second, cognitive impairment is not a deterrent to improved fitness as long as behaviorally the individuals are able and willing to follow simple commands or mimic the movements of their instructors. Third, it remains to be demonstrated conclusively that the physiological and functional benefits observed after exercise in frail older people will translate into improved clinical outcomes or decreased costs of healthcare delivery, and such outcomes will require longer term observation of larger populations, which is the focus of current ongoing clinical trials. Fourth, as geriatricians and researchers, we should keep an open mind about the plasticity of physiological reserves in the very old and design nursing home, long-term care, home environments, and caregiver training protocols that serve to encourage and enable fitness and mobility rather than discourage or ignore this remarkable potential of our oldest old. It is the least that we can do for our parents and our future selves.