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It's never too late for weight training.

It had to be one of the more startling studies the Journal of the American Medical Association had ever published: Nine nursing home residents in their 90s, after eight weeks of weight training involving their legs, nearly doubled their leg strength, added 9% to their muscle mass, and improved tandem (heel-to-toe) gait speed by 48%. What's more, these people were no healthier to begin with than other nursing home residents tend to be at that age -- i.e., not very. It made one wonder: What happened to the stereotypical "frail elderly" fading into the sunset?

Lead investigator Maria A. Fiatarone, MD, assistant professor in Harvard Medical School's Division on Aging, and Acting Chief of the Physiology Laboratory at the USDA Human Nutrition Research Center on Aging at Tufts University, was having none of it. As far as she and her research team were concerned, if physical weakness was hampering mobility in these elderly, and weight training was known to promote physical strength, the need for the experiment was obvious. Dr. Fiatarone's team has since completed more work further confirming their findings and, in the process, dramatically reversing the standard "wisdom" concerning the physical capabilities of the very elderly. Recently she offered an update in an interview with Nursing Homes Editor Richard L. Peck.

Peck: What led you to this idea in the first place?

Dr. Fiatarone: There had been several epidemiological studies indicating that muscle weakness was one of the main contributors to falls in the elderly. No one, though, had ever done a muscle strengthening study in the very old age group; it was generally thought to be unsafe, and that older people's muscles wouldn't respond to strength training. We thought that if muscle weakness was a problem for these residents, and the literature showed that the only way to strengthen muscles was weight training, it made sense to give it a try.

Peck: How did you select the 90-something nursing home residents for this study?

Dr. Fiatarone: They were very typical nursing home residents, with the expected burden of osteoarthritis, osteoporosis, high blood pressure, heart disease, diabetes, depression, a history of falls and hip fractures, and even moderate cognitive impairment. The only excluding factors were acute or unstable cardiac or metabolic conditions, severe joint pain and severe dementia.

Peck: So these findings are generalizable to the very elderly nursing home population?

Dr. Fiatarone: Well, the original study was a pilot study. Recently, however, we completed a randomized, controlled study of 100 nursing home residents, mean age 88 with some as old as 100, who had all the physical problems we've discussed. Once again, we found that weight training was very effective in increasing their strength and mobility; they were able to walk faster and more frequently and to climb stairs better. Now we are expanding the study further to 18 nursing homes, comparing them with non-weight training facilities and focusing on long-term functional changes in these residents. So, at this point, I would say that these findings are very generalizable.

Peck: What sort of weight training exercises do the residents perform?

Dr. Fiatarone: We use machines with either weight stacks or compressed air resistance. The residents exercise both their legs and their arms -- specifically, knee extension, hip extension and chest press, which is a bench press type exercise done from a sitting position and pushing outward. They start with weights at 80% of the maximum they can lift and do 24 repititions of a particular exercise at 6 seconds per repitition, gradually increasing the weights, as tolerated. They work out three days a week.

Peck: Before you mentioned that even the cognitively impaired are able to participate. What sort of problems does this pose?

Dr. Fiatarone: If the training is done one-on-one or one-on-two, as in our case, and the residents are behaviorally willing to work through the repititions, there is no reason that the moderately cognitively impaired can't benefit. Larger, less personally supervised groups would, of course, have to be more cognitively intact.

Peck: You also mentioned that you expanded your research to include upper body strength building. How did that work out?

Dr. Fiatarone: We found improved arm strength, though this is more difficult to demonstrate functionally than improved leg strength. Based on our results, though, one would expect to see improved ability to dress oneself and to get in and out of chairs.

Peck: What overall improvements did you see in these residents' health status?

Dr. Fiatarone: As far as actual fall prevention is concerned, there are no data as yet. This would require a long-term study involving a large number of people for at least a year to track any changes. However, the risk factors for falling are measurable -- muscle strength, balance and gait -- and in these we have seen significant improvements, so one might reasonably expect to see fewer falls.

Interestingly, there have been studies of walking as an approach to fall prevention, and walking has been found to be ineffective for this. This is probably because there is no reason to suspect that improving a resident's endurance, as walking does, would lead to fewer fails. The walking studies don't address all of the underlying problems.

Other research groups have looked at the effect of strength training on such things as cardiovascular receptor profiles, blood pressure, glucose metabolism, cholesterol and GI transit time, and have found improvements in all of these.

Peck: Based on what has been learned thus far, should nursing homes consider getting involved in strength training of the very elderly?

Dr. Fiatarone: Yes. The problem now is that often exercise programs in this setting tend to take the path of least resistance, if you will, rather than most resistance. The exercises are safe and easy but, in fact, are not very successful. As part of our randomized, controlled study, non-weight-lifting residents attended a variety of exercise activities, including seated calisthenics, cycling, walking groups, or throwing balls. They ended up with no change in muscle strength or walking ability after the study. Most activities prescribed in nursing homes may be good for socialization, but they are not therapeutic exercise. It may be time for nursing homes to start considering substituting fitness-promoting exercise for a portion of their recreational activities.

Peck: Is there any particular type of apparatus that they would need?

Dr. Fiatarone: We use machines, but just about anything can be used -- sand- or steel-filled portable weights, sand bags, elastic tubing, rubber stretch bands -- so long as it provides high enough resistance. The key is to provide enough resistance to make the muscle overcome something it does not usually encounter, otherwise strength will not increase. So, the apparatus can be anything, just so long as it provides sufficient resistance.

Peck: What about isometric training?

Dr. Fiatarone: Pushing against an immobile object is not something that is commonly done in real life. It is preferable to have the body move through space against resistance. This translates into improved function.

Peck: Would strength training apply to the wheelchair bound elderly as well?

Dr. Fiatarone: Yes, this will promote independence in transfering and wheelchair mobility. This is something that we see in young paraplegics -- they develop tremendous upper body strength to maintain function, and we accept this as normal. But we don't often see the need as clearly in the very elderly, even though they need upper body strength just as much, perhaps more. This is a very underexploited area in all exercise programs, and it's unfortunate, because the result can be a very different quality of life for these people.
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Title Annotation:exercise and the aged
Author:Peck, Richard L.
Publication:Nursing Homes
Article Type:Interview
Date:Oct 1, 1993
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