Exercise as it relates to Disease/Power of exercise throughout retirement

This page is a critique of the article: Impact of Exercise in Community-Dwelling Older Adults by Hubbard. R., Fallah, N., Searle, S.D., Mitnitski, A. & Rockwood, K.

What is the background to this research?
Multiple research papers demonstrate the benefits of increasing the physical activity levels in older adults. This study was completed to better understand health improvements for those living in retirement villages (or community dwellings), as the global population is ageing with other issues associated. While few research articles have suggested the use of this 'prehabilitation' to increase life-expectancy also increased frailty and decreased health, this study set out to investigate using exercise and observe the power it has on health improvements, deterioration and death.

Where is the research from?
This study was a part of the Canadian Study of Health and Aging (CSHA), a large scale study assessing over 10,000 adults 65 years and over. This particular study focused on those living in retirement villages. All five authors declared no competing interests during this study. The article was published in the open access journal of PLoS ONE, a peer-reviewed, online publisher.

Research was funded by the National Health Research and development Program (NHRDP) of Health Canada and the Canadian Institute of Health Research. Minor contributions were received from Alzheimer's Research at Dalhousie University, Peel Medical Research trust and Fountain Innovation fund of the Queen Elizabeth II Health Sciences Foundation.

What kind of research was this?
This study was a secondary analysis of the CSHA. This involves re-using previously gathered data to assess a new research question. They used the data to compare the differences between two existing groups design that occurred across a five year time period (ie a longitudinal study). Self-report was the main mode of data collection, as it is easy to collect by asking the participant to fill it out themselves. However, because it uses recall and its highly subjective to bias it needs to be considered when reviewing the results.

What did the research involve?
The study involved random sampling of 9008 community-dwelling participants. However, the CSHA-1 (a self-report risk factor questionnaire on frailty) could only be completed by 6297 participants. In the follow-up five years later, 742 of the eligible participants didn't or couldn't complete CSHA-2, 1064 died, while the remaining 4491 completed CSHA-2. Auxiliary information such as demographics, health, family and medical history, attitudes, ADL's (activities of daily living) and current health issues, were all assessed. The Frailty Index Phenotype comprised of a list of 40 deficits. The number of self-evaluated deficits present was then divided by 40 resulting in a decimal number score. The participants were also categorised into two groups; high exercise (3+/week, at least walking intensity) and low/no exercise (all other), of which they were already involved. The analyses used involved a multi-state model, consummating the four different outcomes with graded exercise exposure.

The lack of a coherent method makes it hard to replicate. The methodology used, in regard to how they implanted the CSHA reports, is not well documented which may be due to the nature of secondary analysis. While they started the questionnaires used were validated, they didn't state or link what it actually was. There was also a cognitive component of the study which was not alluded to in the methodology other than possibly coming under the auxiliary data. While they later stated they used the well know and validated 3MS cognitive test, this was not until well into the discussion.

What were the basic results?
While there were no results presented statistically, they used the mean and standard deviation of the collected information to make inferences. One of their main findings demonstrated age mortality could be reduced through the use of exercise. This was despite the initial frailty index reported in CSHA-1. However, those who exercised the most were somewhat demographically different, being younger, and comprised of more males, when compared to the low/no exercise group. For those in the low/no exercise group, two verdicts could be made. Participants in this group had a higher probability of death overall, regardless of the frailty scores and deficits. Once the higher frailty scores were added, the risk of mortality was substantially higher again. Another observed outcome, emphasised but the authors, was those reporting higher frailty on CSHA-1 had the greatest impact from exercise when comparing their results to CSHA-2. They reported that exercise should encouraged not limited with age and increased frailty.

The results observed by the researches have indicated the benefits of exercise on the frailty, but, there was no mention of exercise making ADL's easier or improving cognition. The background information alluded to exercise increasing survival not health, which has not been readdressed when looking for results.

What conclusions can we take from this research?
As a secondary analysis study, the results they were able to infer are reasonable. It compares well with other studies who ventured into the benefits of different types of exercise in community-dwelling adults. Tarazona-Santabalbina et al (2016), for example, developed a specialised exercise intervention for trial adults living in retirement villages and found unequivocal improvements in frailty, condition and sociability. Another study successfully demonstrated the use of computer game exercises as a means to improve frailty, balance and ADL's aligning with the outcomes found across this secondary analysis. These studies validate the argument of using exercise to improve ADL's through better balance, mobility and overall quality of life.

The researchers highlighted some limitations that exist in this study. The operational definition and measurement of frailty is still developing as it tends to over simplify and exclude the frailest. The authors agreed the follow up period of five years wasn't enough and should continue to investigate further health transitions. The method of self report was also a concern for the researchers, along with the exclusion of those unable to complete it due to their deficits.

Other limitations not mentioned by the authors comprise of the lack of CSHA-2 frailty results being published as a visual comparison for the reader. The random inclusion of the cognitive component at the end of the study was also of slight concern as it wasn't properly addressed apart from a brief statement of wanting a broad view across the whole health continuum.

Practical advice
The implications from this study can only encourage older adults, particularly those living in community be involved in exercise. While evaluating frailty scores isn't always required, having a qualified practitioner, such as an exercise physiologist (EP), around the local retirement villages to instruct classes or tailored exercise prescription, would be an ideal outcome to support healthy ageing.

It is important to note that when starting exercise, checking with medical professionals first is advised. Having the supervision from the EP should be top priority when initiating exercise as a prehabilitation to further ensure that heath is being improved and not hindered.

Further information/resources
Australian Ageing Agenda

Exercise Right A guide on getting involved and different types of activities