Should Persons Older than 75 Have Exercise Stress Testing Before Starting an Exercise Program?
Should Persons Older than 75 Have Exercise Stress Testing Before Starting an Exercise Program?
abstract & commentary
Synopsis: A set of recommendations is offered regarding precautions to minimize risks of adverse cardiac events among older persons who do not have symptomatic cardiovascular disease and are interested in starting an exercise program.
Source: Gill MT, et al. JAMA 2000;284:342-348.
Gill and colleagues state that while the ben-efits of physical activity and exercise among older persons are becoming increasingly clear, the role of exercise stress testing and safety monitoring for older persons who want to start an exercise program is unclear. Current guidelines regarding exercise stress testing likely are not applicable to the majority of persons 75 years of age or older who are interested in restoring or enhancing their physical function through a program of physical activity and exercise. In addition to being expensive and of unproven benefit, the current policy of routine exercise stress testing potentially could deter many older persons from participating in an exercise program. Research is needed to investigate current physician practices, evaluate the risk of adverse events, determine the role of pharmacological stress testing, and measure and compare absolute and relative exercise intensities.
To assist clinicians, Gill et al offer a set of recommendations regarding precautions to minimize risks of adverse cardiac events among older persons who do not have symptomatic cardiovascular disease and are interested in starting an exercise program.
Among the recommendations made for evaluating older persons are the following: a complete history and physical examination to identify potential cardiac contraindications such as a myocardial infarction in the past six months, a resting systolic blood pressure of 200 Hg or higher, and a diastolic blood pressure of 110 or higher. They recommend estimating cardiac reserve by simple office tests such as stair climbing or walking. If a person develops chest pain during the walking or stair climbing, he or she isn’t a candidate for an unsupervised program (this is a "no brainer"). They also recommend a resting EKG. Those with resting EKG abnormalities are beyond the scope of their discussion.
Comment by Ralph R. Hall, MD, FACP
One of the interesting tables in this article noted the prevalence of selected chronic conditions and physical limitations among community living older persons (see Table).
| Table-Prevalence of Selected Chronic Conditions and Physical Limitations |
|||
| Age, Years | |||
| 65-74 | 75-84 | ≥ 85 | |
| Peripheral artery disease | 8.3 | 14.5 | 23.3 |
| Parkinsonism | 14.9 | 29.5 | 52.4 |
| Knee osteoarthritis | 27.4 | 34.1 | 43.7 |
| Unable to walk 1 flight of stairs | 8.8 | 16.6 | 23 |
| Unable to walk 0.8 km | 15.7 | 29.4 | 50.1 |
| Functional vision loss | 7.2 | 13 | 31.7 |
The resting EKG is notoriously inadequate to identify severe coronary artery disease in the younger population, but Gill et al feel it is useful in this age group. I would prefer a stress test in selected individuals. This would be true in the few who wanted to do a more vigorous program. In any event, Gill et al’s advice to start slow and go slow is common sense. In my experience, the improvement in a person’s ability to gradually increase the intensity and amount of exercise has been surprising.
Gill et al’s plea for more research with regard to exercise in this group of individuals (who potentially have so much to gain) can only be seconded. What is the role of pharmacological stress testing? What is the risk of this approach? If we do more testing, do we discourage people from exercising? Is the risk of cardiovascular events attenuated over time with regular physical activity? How intense should weight training and endurance training be for maximum benefit?
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