Regularly performed exercise has remarkably beneficial effects with regard to chronic disease and aging. The body adaptively responds to exercise, and it has been demonstrated that a substantial decrease in all-cause mortality results from a moderate amount of increased physical activity.1-3 Researchers have also reported results of a randomized controlled trial involving a home-based program of physical activity in older adults with memory problems.4 It has been demonstrated that a 6-month program of physical activity provided a modest improvement in cognition over an 18-month follow-up period.4
However, the experience of pain upon exercise, such as that from osteoarthritis, may create a barrier to participation in beneficial activities. This article discusses the role of exercise in the management of chronic conditions and how pharmacists can encourage older patients to exercise by helping them manage pain.
Aerobic and Strength Training Exercise
Physical activity is anything that gets your body moving.5 Adults need to do two types of physical activity—aerobic and muscle-strengthening (TABLE 1)—each week to improve their health. Currently, the CDC recommends that for important health benefits, adults and older adults need at least 2 hours and 30 minutes (150 minutes) of moderate-intensity aerobic activity (i.e., brisk walking) every week and muscle-strengthening activities on 2 or more days a week.5,6 A recent study looking at whether a lower level of activity is beneficial found that at least 15 minutes per day or 90 minutes per week of moderate-intensity exercise might be of benefit, even for individuals at risk of cardiovascular disease.1 Key to this point regarding exercise for successful aging is that a thoughtful and appropriate pre scription of exercise for any geriatric patient should be the standard of care.7
Exercise: A Self-Management Strategy
Exercise is considered a self-management strategy for many chronic conditions commonly seen in the elderly, including arthritis, diabetes mellitus, and cardiovascular disease. Self-management is a term used for educational programs having the goal of teaching skills needed to carry out medical regimens specific to the disease, guide health behavior change, and provide emotional support for patients to control their disease and maintain functional ability.8 The Chronic Disease Self-Management Program (see Resources for the Patient), developed at Stanford University, is one example. Using workshops facilitated by two trained leaders, one or both of whom are non–health professionals with a chronic disease themselves, groups meet in community settings for 2½ hours per week for 6 weeks. Participants in this program have demonstrated significant improvements in exercise and the ability to do social and household activities; lower levels of depression, fear, and frustration or worry about their health; a reduction in symptoms like pain; and increased confidence in their ability to manage their condition. The Institute of Medicine has identified self-management as a means to promote health care system improvements in the United States.9
Exercise for Pain Management
Currently, exercise is also a major component of most pain management programs, either alone or in association with pharmacologic and other nonpharmacologic interventions.10 Exercise can lead to decreased pain, functional improvement, and elevation of mood.11 Even frail and institutionalized elderly people may benefit.10 Ironically, however, despite the role of exercise in the self-management of pain and pain-associated chronic conditions (e.g., osteoarthritis), pain itself can be a barrier to exercise. Furthermore, for many reasons, pain remains undertreated in older adults.10 One study found that ineffectiveness of pain-relief strategies and avoidance of activity because of fear of pain exacerbation are two of the barriers to pain self-management.12 For a discussion on the psychological approaches to pain management (i.e., behavioral and cognitive strategies for coping with pain), including encouraging the patient to take an active role and accept responsibility for pain management, see Reference 10.
A reduction of the impact of pain on
daily life can often be achieved by simple adjustments in posture and
daily routines (e.g., preparing meals while seated, dividing up
housework, use of a walking aid).10
To ease the pain and discomfort of lumbar spinal stenosis, the use of a walking frame will provide a mild degree of lumbar flexion.10 Other modalities include transcutaneous electrical nerve stimulation (TENS) for symptom relief (i.e., for painful conditions in seniors such as low back pain, osteoarthritis, and postherpetic neuralgia).10,13 Some physical therapies used for a wide range of painful conditions may include massage, cold and heat treatments, and acupuncture.10,13
Other self-management strategies such as yoga and tai chi show promise in reducing pain and increasing function in older adults.13-16 Tai chi, a form of dynamic balance training that requires no new technology or equipment, has been demonstrated to reduce the risk of falling in older people by almost 50%.17
Some key points to remember in managing pain in older adults are: Patients should be evaluated for comorbidities affecting assessment, function, and treatment selection; the presence of radiologic abnormalities does not prove causality; and the unexplained change in symptoms warrants reassessment to exclude serious pathology.10 Joint replacement surgery can alleviate the suffering of seniors with degenerative joint disease who have experienced inadequate control of symptoms with conservative management.10
A course of prescribed physical therapy may be necessary in some individuals (e.g., those with sarcopenia) to carefully and appropriately strengthen targeted muscles before a self-management exercise program is attempted. For a discussion on sarcopenia, the age-related loss of muscle mass in older adults that can result in a 50% loss of skeletal muscle by age 75 years, and the safe use of medication during exercise, see Reference 18. Pharmacists are encouraged to incorporate self-management strategies in pharmaceutical care plans while also remaining up-to-date with recent nonpharmacologic and pharmacologic guidelines for the management of pain.
Guidance for Pharmacists:
Pain Management Recommendations
Persistent pain interferes with enjoyment of life and has deleterious effects on mood, social interaction, function, mobility, and independence.10 The American Geriatrics Society (AGS) recommends that nonpharmacologic management modalities, either alone or in combination with pharmacologic interventions, should be an integral part of the plan of care for seniors with persistent pain.19 Updated guidelines, from the AGS Panel on Persistent Pain in Older Adults: Pharmacological Management of Persistent Pain in Older Persons, were published in 2009.20
Since persistent pain commonly affects seniors and is most frequently associated with musculo-skeletal disorders such as arthritis and degenerative spine conditions, pharmacists are encouraged to become familiar with the recently published American College of Rheumatology 2012 Recommendations for the Use of Nonpharmacologic and Pharmacologic Therapies in Osteoarthritis of the Hand, Hip, and Knee (see Reference 13).13,20,21-23
It is important for pharmacists to acknowledge that while the approach to pain management in older persons differs from that for younger individuals, pain can usually be effectively managed in this population.20 Familiarity with these guidelines can help pharmacists embrace general principles and specific nuances related to pain management in seniors that can guide their professional interactions and clinical recommendations.
1. Wen CP, Wai JP, Tsai MK, et al.
Minimum amount of physical activity for reduced mortality and extended
life expectancy: a prospective cohort study. Lancet. 2011;378(9798):1244-1253.
2. Blair SN. Physical activity, physical fitness, and health. Res Q Exerc Sport. 1993;64:365-376.
3. Blair SN, Kohl HW, Paffenbarger RS, et al. Physical fitness and all-cause mortality. JAMA. 1989;262:2395-2401.
4. Lautenschlager NT, Cox KL, Flicker L, et al. Effect of physical activity on cognitive function in older adults at risk for Alzheimer disease: a randomized trial. JAMA. 2008;300(9):1027-1037.
5. How much physical activity do adults need? Centers for Disease Control and Prevention. Updated December 1, 2011. www.cdc.gov/physicalactivity/everyone/guidelines/adults.html. Accessed April 19, 2012.
6. How much physical activity do older adults need? Centers for Disease Control and Prevention. Updated December 1, 2011.www.cdc.gov/physicalactivity/everyone/guidelines/olderadults.html. Accessed April 19, 2012.
7. Evans WJ. Exercise for successful aging. In: Fillit HM, Rockwood K, Woodhouse K, eds. Brocklehurst’s Textbook of Geriatric Medicine and Gerontology. 7th ed. Philadelphia, PA: Saunders Elsevier; 2010:859-864.
8. Effing T, Monninkhof EM, van der Valk PD, et al. Self-management education for patients with chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2007;(4):CD002990.
9. Adams K, Corrigan, JM Eds. Priority areas for national action: transforming health care quality. Institute of Medicine Committee on Identifying Priority Areas for Quality Improvement. Washington DC: National Academies Press; 2003.
10. Bruckenthal P. Pain in the older adult. In: Fillit HM, Rockwood K, Woodhouse K, eds. Brocklehurst’s Textbook of Geriatric Medicine and Gerontology. 7th ed. Philadelphia, PA: Saunders Elsevier; 2010:965-972.
11. Christmas C, Andersen RA. Exercise and older patients: guidelines for the clinician. J Am Geriatr Soc. 2000;48(3):318-324.
12. Bair MJ, Matthias MS, Nyland KA, et al. Barriers and facilitators to chronic pain self-management: a qualitative study of primary care patients with comorbid musculoskeletal pain and depression. Pain Med. 2009;10(7):1280–1290. www.ncbi.nlm.nih.gov/pmc/articles/PMC2884223/. Accessed April 19, 2012.
13. Hochberg MC, Altman RD, April KT, et al. American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee. Arthritis Care Res (Hoboken). 2012; 64(4):465-474.
14. Hickey T, Sharpe PA, Wolf FM, et al. Exercise participation in a frail elderly population. J Health Care Poor Underserved. 1996;7:219-231.
15. Nelson ME, Dilmanian FA, Dallal GE, et al. A one-year walking program and increased dietary calcium in postmenopausal women: effects on bone. Am J Clin Nutr. 1991;53:1304-1311.
16. Bassey EJ, Fiatarone MA, O’Neill EF, et al. Leg extensor power and functional performance in very old men and women. Clin Sci. 1992;82:321-327.
17. Wolf SL, Barnhart HX, Kutner NG, et al. Reducing frailty and falls in older persons: an investigation of Tai Chi and computerized balance training. Atlanta FICSIT group. Frailty and Injuries: Cooperative Studies of Intervention Techniques [see comments]. J Am Geriatr Soc. 1996;44:489-497.
18. Zagaria ME. Sarcopenia: loss of muscle mass in older adults. US Pharm. 2010;35(9):24-30.
19. AGS Panel on Persistent Pain in Older Persons. The management of persistent pain in older persons. American Geriatrics Society. J Am Geriatr Soc. 2002;50:S205-S224.
20. AGS Panel on Persistent Pain in Older Adults: Pharmacological management of persistent pain in older persons. American Geriatrics Society. J Am Geriatr Soc. 2009;57:1331-1346.
21. Donald IP, Foy C. A longitudinal study of joint pain in older people. Rheumatology (Oxford). 2004;43:1256-1260.
22. Helme RD, Gibson SJ. The epidemiology of pain in elderly people. Clin Geriatr Med. 2001;17:417-431, v.
23. Thomas E, Peat G, Harris L, et al. The prevalence of pain and pain interference in a general population of older adults: cross-sectional findings from the North Straffordshire Osteoarthritis Project (NorStOP). Pain. 2004;110:361-368.
To comment on this article, contact email@example.com.