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Caring for the aging athlete
NGNA
Feature Article
Caring for the Aging Athlete Catherine Hill, RN, MSN, CS, ONC, CEN
T
he myth of the “golden years” as a time of inactivity and confinement is no longer valid with 85% of elders 65 and older reporting their health as good, very good, or excellent.1 Eighty percent of seniors also reported no difficulty with any activities of daily living (ADL).1 Exercise, leisure physical activities, and competitive sports are an important part of the life of many retired elders. Although chronic conditions, such as arthritis (47.7% of seniors) and heart disease (59.8% of seniors), frequently occur in this age group, they are not contraindications to regular activity, especially the continuation of modified forms of prior exercise. Long-term exercise does not appear to cause excessive degenerative joint disease, reduces systolic and diastolic blood pressure, and improves blood lipid profiles. Fall risk and injury are lower in elders who participate in resistance training, according to the President’s Council on Physical Fitness and Sports. Leisure activity and sports injury trends in the aging athlete are similar to younger adults—20% are strain/sprain in nature, and 15% are skin problems. Today, we define and monitor senior exercise regimens as aerobic or strength, endurance, and flexibility training in addition to the traditional measures of ADL and instrumental ADL. Aerobic exercise includes light, moderate, or vigorous physical activity for at least 30 minutes per day five or more times per week. In 1985, 12% of seniors met this definition;2 currently, that figure is 20% to 30%.3 Strength, endurance, and flexibility training include a combination of components that improve ADL performance, functional independence, and social integration. Although weight training can increase muscle strength and endurance, other activities can accomplish the same goals. Technically, leisure physical activities are a subset of general exercise patterns. A review of 1992 data from
Geriatric Nursing 2001 • Volume 22 • Number 1
the Healthy People 2000 report reveals that more than 60% of adults 65 and older engage in leisure-time physical activity. Leisure activities are affected by strength, endurance, flexibility, and personal interest. The intensity of participation tends to be less than in exercise and competitive sports but helps maintain fitness nonetheless. Physically active hobbies, surveyed in the 19901991 Health Promotion and Disease Prevention supplement to the National Health Interview Survey, included gardening, dancing, golf, hunting, fishing, woodworking, tennis, bowling, biking, and swimming. The variability of senescence and the range of physical activity levels seen in elder athletes make aging physiology important in their assessment and treatment. Cardiopulmonary and musculoskeletal systems have intrinsic changes related to aging, some of which are slowed by fitness activities, whereas others may increase or affect speed of recovery from injury. The interplay of these systems often is measured by maximum oxygen consumption (VO2 max) to quantify cardiopulmonary endurance as a marker of fitness. As people age past their 30s, their maximum work capacity declines at a rate of about 1% per year.4 A person’s highest level of conditioning influences his or her final level of decline. Therefore, athletes and untrained or sedentary seniors will have very different functional abilities. Unfortunately, the inactive senior will decline twice as fast as his physically active counterpart.4 Table 1 summarizes the cardiopulmonary changes that affect physical exercise. Musculoskeletal changes, like cardiopulmonary changes, can be minimized by fitness training. However, given the physical loading forces, musculoskeletal injuries are the most common in the aging athlete. Here we need to understand the structural changes that affect the balance of fitness activity versus injury risk. In 1998, the U.S. Consumer Product Safety Commission (CPSC) reported a 54% increase in the number of active sports-
43
NGNA
Table 1. Physiological Changes of the Cardiopulmonary System that Affect Exercise Cardiovascular changes Decline in cardiac output (approximately 30%) Decline in maximum heart rate (max 10 beats/min/decade) Decline in VO2 max (9%/decade after age 25) Decreased capillary-to-muscle peripheral blood flow Decreased myocardial muscle mass Increased time for return to resting heart rate Pulmonary changes Decreased lung compliance Decreased static and dynamic lung function Decreased vital capacity (50%) Increased forced residual capacity (30%)
Table 2. Physiogical Changes in Musculoskeletal System that Affect Exercise after Age 50 Decreased collagen water content (decreased flexibility) Decreased glycosaminoglycan in tendons (stiffer) Decreased intervertebral spinal disc water/cells/proteins Decreased lean body/muscle mass (up to 35%/decade) Decreased ligament tensile strength (by 50%) Decreased strength (10%/decade) Decreased Type II (fast twitch) muscle fibers (by 50%) Decreased Type XI articular cartilage Increased body fat Increased muscle collagen (decreased flexibility) Loss of bone mass (men: 0.4%/year, women: 1%-7%/year) Lower articular cartilage chondrotin sulfate/chonodrocyte content (decreased strength)
related injuries to people 65 and older between 1990 and 1996. This increase occurred with an age-specific population growth of only 8%. Injuries associated with aerobics and weight training were up 173%, whereas less active sports, such as golf and bowling, showed very little increase.5 These statistics have prompted the CPSC to team up with the American Academy of Orthopedic Surgeons to promote a sensible approach to physical activity. Table 2 summarizes the physiologic changes that affect exercise. The musculoskeletal declines of aging can be minimized—and in some cases eliminated—by sensible strength and endurance training. The difference be-
44
tween Gordie Howe, a hockey star playing exhibition games in his 70s, and your typical nursing home resident is the result of not only good genetics but life choices in fitness activities.6 According to a 1990 report from the CPSC that samples the National Electronic Injury Surveillance System, Americans are remaining physically active into their 70s, 80s, and 90s. In actual numbers, 34,000 sports injuries occurred in the 65 and older age group, which rose to 53,000 in 1996. This 54% increase is quite a contrast to the 18% increase in sports injuries among 25- to 64-year-olds. Interestingly, sports injuries occurred not only among the youngest of the 65-plus population but increased by 29% for people 75 and older. Although more injuries are occurring, on the average, they are less costly and severe. Injuries from leisure activities have remained relatively constant. A fascinating but small number of injuries have been seen for the first time in 1996 involving such “extreme” sports as snowboarding and in-line skating. Most (60%) geriatric sports injuries in both 1990 and 1996 occurred in men. Overuse injuries (62%) are most common, often involve the lower extremities, and frequently compound pre-existing arthritis in the 50- to 80-year-old population,7 according to private practice physician Warren A. Scott. No evidence exists that moderate exercise like bicycling, skiing, rowing, swimming, or golf increases the risk of developing osteoarthritis, but research on runners reveals an acceleration of pre-existing disease with continued running.8 Likewise, previous joint injury or abnormal joint alignment increases the risk of degenerative joint disease. Given that 40% to 60% of elders have some arthritis of the hip or knee activity and 81% of aging athletes injure themselves, moderation is critical to injury avoidance. Golf and tennis are the most common sports played by American elders. These sports produce many of the rotator cuff injuries and meniscal tears encountered in ambulatory care.6 Because aging is associated with progressive changes in cardiopulmonary function, many health care providers are concerned about appropriate recommendations and monitoring of recreational and competitive athletics in elders. Research has shown exercise training can delay and partially reverse some of the age-related decline in cardiac functional capacity.9 Although the magnitude of benefit is related to baseline status and activity frequency and intensity, increased blood flow and shear stress actually inhibit athrogensis.10 In patients with coronary heart disease, exercise has similar benefits in exercise tolerance, muscle strength, decreased blood pressure, improved blood lipids, decreased cigarette smoking, enhanced psychologic well-being, and stress reduction.11 In older athletes, the primary focus is on individual efforts instead of team sports, such as long distance run-
Geriatric Nursing 2001 • Volume 22 • Number 1
NGNA
Table 3. Guidelines for Exercise Training
Exercise Type
American Heart Association
American College of Sports Medicine
Centers for Disease Control
American Association for Cardiovascular and Pulmonary Rehabilitation
AEROBIC Frequency per week
≥3
3-5
Daily
3-5
Intensity
50%-60% heart rate
55%-90% heart rate
Moderate
50% VO2 max
Duration
30 minutes
15-16 minutes
30 minutes
30-45 minutes
Activity
8-10 reps
8-12 reps
No recommendation
12-15 reps
Frequency
2-3
≥2
Most days
2-3
RESISTANCE
ning. A 5-year retrospective study conducted on 155 YMCAs and Jewish Community Centers throughout the United States concluded that the greatest risk of cardiovascular complications occurred in racquetball, handball, squash, and jogging.12 Swimming, basketball, calisthenics, soccer, and walking, on the other hand, had much lower cardiovascular risk. The most important variable associated with risk of cardiovascular event was the person’s normal activity pattern. This research has spawned the evaluation emphasis of previously sedentary older adults—men older than 40 and women older than 50—before they begin a vigorous physical activity program. In patients older than 65, an energy expenditure greater than 500 calories over basal requirements per week should be the goal. Rhythmic activities, such as walking or swimming, performed three to four times per week for 5 to 30 minutes at intensities of 50% to 60% of maximum heart rate is safe and easily maintained by most elders. Table 3 summaries the guidelines for fitness and rehabilitation for adults that have been developed and published by the American Heart Association, American College of Sports Medicine, the Centers for Disease Control, and the American Association for Cardiovascular and Pulmonary Rehabilitation. Exercise in the elderly is not a single entity but a collection of leisure time activities, sports participation, and conditioning exercise. Older individuals who have remained active throughout their lives maintain much of their strength and stamina. Regardless of age or initial fitness level, these activities should be assessed, encouraged, and monitored because of their physical and psychologic benefits. The benefits and risks of regular exercise in older and elderly adults are similar to those in younger people. Regular exercise not only lengthens the number of years of life but also its quality by ameliorating many age-related declines in the musculoskeletal and cardiovascular systems. An awareness of the prevalence, importance, and guidelines for exercise
Geriatric Nursing 2001 • Volume 22 • Number 1
in older people should be reflected in our assessment and counseling. Seniors generally possess significant time to act on behalf of their health. Their commitment to exercise patterns can be easily reinforced because of the rapid benefits, such as enhanced functional independence and self-esteem. REFERENCES 1. Schick FL, Schick R. Statistical handbook on aging Americans. Phoenix: Oryx Press; 1994. 2. U.S. Department of Health and Human Services. Healthy People 2000: National Health Promotion and Disease Prevention Objectives. Washington (DC): Public Health Service; 1990. p. 97-106. 3. U.S. Department of Health and Human Services. Healthy People 2000: Midcourse Review and 1995 Revisions. Washington (DC): Public Health Service; 1996. p. 23. 4. Williams RA. The athlete and heart disease. Philadelphia: Lippincott Williams & Wilkins; 1999. p. 110. 5. Available from: http://www.nisu.flinders.edu.au/pubs/monitor16/monitor1619.htm. 6. Rodeheffer RJ, et al. Exercise cardiac output is maintained with advancing age in healthy human subjects: cardiac dilatation and increased stroke volume compensate for diminished heart rate. Circulation 1984;69:203-13. 7. Scott WA, Couzens GS. Treating injuries in active seniors. Phys Sports Med 1996;24(5). 8. Krcik JA. Geriatric athlete: musculoskeletal problems. Geriatric Grand Rounds 1999. 9. Hagberg JM. Effect of training on the decline of VO2 max with aging. Fed Proc (1987);46:1830-3. 10. Niebauer J, Cooke JP. Cardiovascular effects of exercise: role of endothelial shear stress. J Am Coll Cardiol 1996;28:1652-60. 11. Wegner NK, Froelicher ES, et al. Cardiac rehabilitation. Clinical practice guideline No. 17. AHCPR Publication No. 96-0672. Washington (DC): U.S. Department of Health and Human Services; 1996. 12. Vander L. Cardiovascular complications of recreational physical activity. Phys Sports Med 1982;10:89-97.
CATHERINE HILL, RN, MSN, CS, ONC, CEN, is a nurse practitioner with the Medical Group of Texas and a faculty member at the University of Texas at Arllington School of Nursing.
Copyright © 2001 by Mosby, Inc. 0197-4572/2001/$8.00 + 0 34/1/114423 doi:10.1067/mgn.2001.114423
45
Feature Article
Caring for the Aging Athlete Catherine Hill, RN, MSN, CS, ONC, CEN
T
he myth of the “golden years” as a time of inactivity and confinement is no longer valid with 85% of elders 65 and older reporting their health as good, very good, or excellent.1 Eighty percent of seniors also reported no difficulty with any activities of daily living (ADL).1 Exercise, leisure physical activities, and competitive sports are an important part of the life of many retired elders. Although chronic conditions, such as arthritis (47.7% of seniors) and heart disease (59.8% of seniors), frequently occur in this age group, they are not contraindications to regular activity, especially the continuation of modified forms of prior exercise. Long-term exercise does not appear to cause excessive degenerative joint disease, reduces systolic and diastolic blood pressure, and improves blood lipid profiles. Fall risk and injury are lower in elders who participate in resistance training, according to the President’s Council on Physical Fitness and Sports. Leisure activity and sports injury trends in the aging athlete are similar to younger adults—20% are strain/sprain in nature, and 15% are skin problems. Today, we define and monitor senior exercise regimens as aerobic or strength, endurance, and flexibility training in addition to the traditional measures of ADL and instrumental ADL. Aerobic exercise includes light, moderate, or vigorous physical activity for at least 30 minutes per day five or more times per week. In 1985, 12% of seniors met this definition;2 currently, that figure is 20% to 30%.3 Strength, endurance, and flexibility training include a combination of components that improve ADL performance, functional independence, and social integration. Although weight training can increase muscle strength and endurance, other activities can accomplish the same goals. Technically, leisure physical activities are a subset of general exercise patterns. A review of 1992 data from
Geriatric Nursing 2001 • Volume 22 • Number 1
the Healthy People 2000 report reveals that more than 60% of adults 65 and older engage in leisure-time physical activity. Leisure activities are affected by strength, endurance, flexibility, and personal interest. The intensity of participation tends to be less than in exercise and competitive sports but helps maintain fitness nonetheless. Physically active hobbies, surveyed in the 19901991 Health Promotion and Disease Prevention supplement to the National Health Interview Survey, included gardening, dancing, golf, hunting, fishing, woodworking, tennis, bowling, biking, and swimming. The variability of senescence and the range of physical activity levels seen in elder athletes make aging physiology important in their assessment and treatment. Cardiopulmonary and musculoskeletal systems have intrinsic changes related to aging, some of which are slowed by fitness activities, whereas others may increase or affect speed of recovery from injury. The interplay of these systems often is measured by maximum oxygen consumption (VO2 max) to quantify cardiopulmonary endurance as a marker of fitness. As people age past their 30s, their maximum work capacity declines at a rate of about 1% per year.4 A person’s highest level of conditioning influences his or her final level of decline. Therefore, athletes and untrained or sedentary seniors will have very different functional abilities. Unfortunately, the inactive senior will decline twice as fast as his physically active counterpart.4 Table 1 summarizes the cardiopulmonary changes that affect physical exercise. Musculoskeletal changes, like cardiopulmonary changes, can be minimized by fitness training. However, given the physical loading forces, musculoskeletal injuries are the most common in the aging athlete. Here we need to understand the structural changes that affect the balance of fitness activity versus injury risk. In 1998, the U.S. Consumer Product Safety Commission (CPSC) reported a 54% increase in the number of active sports-
43
NGNA
Table 1. Physiological Changes of the Cardiopulmonary System that Affect Exercise Cardiovascular changes Decline in cardiac output (approximately 30%) Decline in maximum heart rate (max 10 beats/min/decade) Decline in VO2 max (9%/decade after age 25) Decreased capillary-to-muscle peripheral blood flow Decreased myocardial muscle mass Increased time for return to resting heart rate Pulmonary changes Decreased lung compliance Decreased static and dynamic lung function Decreased vital capacity (50%) Increased forced residual capacity (30%)
Table 2. Physiogical Changes in Musculoskeletal System that Affect Exercise after Age 50 Decreased collagen water content (decreased flexibility) Decreased glycosaminoglycan in tendons (stiffer) Decreased intervertebral spinal disc water/cells/proteins Decreased lean body/muscle mass (up to 35%/decade) Decreased ligament tensile strength (by 50%) Decreased strength (10%/decade) Decreased Type II (fast twitch) muscle fibers (by 50%) Decreased Type XI articular cartilage Increased body fat Increased muscle collagen (decreased flexibility) Loss of bone mass (men: 0.4%/year, women: 1%-7%/year) Lower articular cartilage chondrotin sulfate/chonodrocyte content (decreased strength)
related injuries to people 65 and older between 1990 and 1996. This increase occurred with an age-specific population growth of only 8%. Injuries associated with aerobics and weight training were up 173%, whereas less active sports, such as golf and bowling, showed very little increase.5 These statistics have prompted the CPSC to team up with the American Academy of Orthopedic Surgeons to promote a sensible approach to physical activity. Table 2 summarizes the physiologic changes that affect exercise. The musculoskeletal declines of aging can be minimized—and in some cases eliminated—by sensible strength and endurance training. The difference be-
44
tween Gordie Howe, a hockey star playing exhibition games in his 70s, and your typical nursing home resident is the result of not only good genetics but life choices in fitness activities.6 According to a 1990 report from the CPSC that samples the National Electronic Injury Surveillance System, Americans are remaining physically active into their 70s, 80s, and 90s. In actual numbers, 34,000 sports injuries occurred in the 65 and older age group, which rose to 53,000 in 1996. This 54% increase is quite a contrast to the 18% increase in sports injuries among 25- to 64-year-olds. Interestingly, sports injuries occurred not only among the youngest of the 65-plus population but increased by 29% for people 75 and older. Although more injuries are occurring, on the average, they are less costly and severe. Injuries from leisure activities have remained relatively constant. A fascinating but small number of injuries have been seen for the first time in 1996 involving such “extreme” sports as snowboarding and in-line skating. Most (60%) geriatric sports injuries in both 1990 and 1996 occurred in men. Overuse injuries (62%) are most common, often involve the lower extremities, and frequently compound pre-existing arthritis in the 50- to 80-year-old population,7 according to private practice physician Warren A. Scott. No evidence exists that moderate exercise like bicycling, skiing, rowing, swimming, or golf increases the risk of developing osteoarthritis, but research on runners reveals an acceleration of pre-existing disease with continued running.8 Likewise, previous joint injury or abnormal joint alignment increases the risk of degenerative joint disease. Given that 40% to 60% of elders have some arthritis of the hip or knee activity and 81% of aging athletes injure themselves, moderation is critical to injury avoidance. Golf and tennis are the most common sports played by American elders. These sports produce many of the rotator cuff injuries and meniscal tears encountered in ambulatory care.6 Because aging is associated with progressive changes in cardiopulmonary function, many health care providers are concerned about appropriate recommendations and monitoring of recreational and competitive athletics in elders. Research has shown exercise training can delay and partially reverse some of the age-related decline in cardiac functional capacity.9 Although the magnitude of benefit is related to baseline status and activity frequency and intensity, increased blood flow and shear stress actually inhibit athrogensis.10 In patients with coronary heart disease, exercise has similar benefits in exercise tolerance, muscle strength, decreased blood pressure, improved blood lipids, decreased cigarette smoking, enhanced psychologic well-being, and stress reduction.11 In older athletes, the primary focus is on individual efforts instead of team sports, such as long distance run-
Geriatric Nursing 2001 • Volume 22 • Number 1
NGNA
Table 3. Guidelines for Exercise Training
Exercise Type
American Heart Association
American College of Sports Medicine
Centers for Disease Control
American Association for Cardiovascular and Pulmonary Rehabilitation
AEROBIC Frequency per week
≥3
3-5
Daily
3-5
Intensity
50%-60% heart rate
55%-90% heart rate
Moderate
50% VO2 max
Duration
30 minutes
15-16 minutes
30 minutes
30-45 minutes
Activity
8-10 reps
8-12 reps
No recommendation
12-15 reps
Frequency
2-3
≥2
Most days
2-3
RESISTANCE
ning. A 5-year retrospective study conducted on 155 YMCAs and Jewish Community Centers throughout the United States concluded that the greatest risk of cardiovascular complications occurred in racquetball, handball, squash, and jogging.12 Swimming, basketball, calisthenics, soccer, and walking, on the other hand, had much lower cardiovascular risk. The most important variable associated with risk of cardiovascular event was the person’s normal activity pattern. This research has spawned the evaluation emphasis of previously sedentary older adults—men older than 40 and women older than 50—before they begin a vigorous physical activity program. In patients older than 65, an energy expenditure greater than 500 calories over basal requirements per week should be the goal. Rhythmic activities, such as walking or swimming, performed three to four times per week for 5 to 30 minutes at intensities of 50% to 60% of maximum heart rate is safe and easily maintained by most elders. Table 3 summaries the guidelines for fitness and rehabilitation for adults that have been developed and published by the American Heart Association, American College of Sports Medicine, the Centers for Disease Control, and the American Association for Cardiovascular and Pulmonary Rehabilitation. Exercise in the elderly is not a single entity but a collection of leisure time activities, sports participation, and conditioning exercise. Older individuals who have remained active throughout their lives maintain much of their strength and stamina. Regardless of age or initial fitness level, these activities should be assessed, encouraged, and monitored because of their physical and psychologic benefits. The benefits and risks of regular exercise in older and elderly adults are similar to those in younger people. Regular exercise not only lengthens the number of years of life but also its quality by ameliorating many age-related declines in the musculoskeletal and cardiovascular systems. An awareness of the prevalence, importance, and guidelines for exercise
Geriatric Nursing 2001 • Volume 22 • Number 1
in older people should be reflected in our assessment and counseling. Seniors generally possess significant time to act on behalf of their health. Their commitment to exercise patterns can be easily reinforced because of the rapid benefits, such as enhanced functional independence and self-esteem. REFERENCES 1. Schick FL, Schick R. Statistical handbook on aging Americans. Phoenix: Oryx Press; 1994. 2. U.S. Department of Health and Human Services. Healthy People 2000: National Health Promotion and Disease Prevention Objectives. Washington (DC): Public Health Service; 1990. p. 97-106. 3. U.S. Department of Health and Human Services. Healthy People 2000: Midcourse Review and 1995 Revisions. Washington (DC): Public Health Service; 1996. p. 23. 4. Williams RA. The athlete and heart disease. Philadelphia: Lippincott Williams & Wilkins; 1999. p. 110. 5. Available from: http://www.nisu.flinders.edu.au/pubs/monitor16/monitor1619.htm. 6. Rodeheffer RJ, et al. Exercise cardiac output is maintained with advancing age in healthy human subjects: cardiac dilatation and increased stroke volume compensate for diminished heart rate. Circulation 1984;69:203-13. 7. Scott WA, Couzens GS. Treating injuries in active seniors. Phys Sports Med 1996;24(5). 8. Krcik JA. Geriatric athlete: musculoskeletal problems. Geriatric Grand Rounds 1999. 9. Hagberg JM. Effect of training on the decline of VO2 max with aging. Fed Proc (1987);46:1830-3. 10. Niebauer J, Cooke JP. Cardiovascular effects of exercise: role of endothelial shear stress. J Am Coll Cardiol 1996;28:1652-60. 11. Wegner NK, Froelicher ES, et al. Cardiac rehabilitation. Clinical practice guideline No. 17. AHCPR Publication No. 96-0672. Washington (DC): U.S. Department of Health and Human Services; 1996. 12. Vander L. Cardiovascular complications of recreational physical activity. Phys Sports Med 1982;10:89-97.
CATHERINE HILL, RN, MSN, CS, ONC, CEN, is a nurse practitioner with the Medical Group of Texas and a faculty member at the University of Texas at Arllington School of Nursing.
Copyright © 2001 by Mosby, Inc. 0197-4572/2001/$8.00 + 0 34/1/114423 doi:10.1067/mgn.2001.114423
45