Cardiac Rehabilitation in Older Adults: Benefits and Barriers
Cardiac rehabilitation is a multidisciplinary approach to chronic disease management that encompasses nutrition consultation, psychosocial services, lifestyle modification, and risk factor modification management, in addition to aerobic and resistance training. Cardiac rehabilitation referrals have traditionally included those patients who recently sustained a myocardial infarction or who underwent coronary artery bypass surgery; however, in recent years, cardiac rehabilitation has expanded to include those with stable congestive heart failure (CHF), symptomatic peripheral vascular disease, and coronary artery disease, as well as heart transplant candidates or recipients. As a result, more than half of patients eligible for cardiac rehabilitation are older than age 65. Despite its broadened applicability, cardiac rehabilitation remains severely underutilized, with only 10-20% of those eligible participating. In 2005, the American Heart Association published an update on cardiac rehabilitation and secondary prevention of coronary heart disease.1 Once again, older adults were identified as an appropriate yet underreferred patient population. This review examines the growing need for cardiac rehabilitation and the potential benefits of such programs in older adults with cardiovascular disease (CVD). An examination of obstacles to referral and participation as well as potential solutions to overcome these challenges are presented.
Cardiovascular Disease in Older Adults
Cardiovascular disease remains the leading cause of death in the United States, including those over the age of 85 years. An estimated 80.7 million Americans have one or more types of CVD. Of these, approximately 38.2 million are individuals older than age 60 years.2 The total direct and indirect costs of CVD and stroke were an estimated $448.5 billion in 2008.2 These numbers support the ongoing need for chronic disease management in the elderly and the potential role cardiac rehabilitation may play.
Description and Benefits of Cardiac Rehabilitation
In essence, a rehabilitation program offers medically monitored exercise along with a structured educational component. In order to individualize a patient’s risk reduction plan, programs will typically begin with body composition measurements, stress testing with oxygen consumption, and a lipid profile. At the start of a program, patients discuss personal goals and develop an action plan for achieving these goals. Based on this information, exercise physiologists design a personal exercise prescription for each patient with such activities as walking on a treadmill or using a stationary bicycle. The educational components can vary, but may include small group sessions designed to complement other aspects of cardiac rehabilitation (eg, a discussion of the benefits of smoking cessation or the importance of a low-salt diet). Most monitored programs are 6-8 weeks in duration; however, maintenance and follow-up phases will often continue for a minimum of 1 year.
Cardiac rehabilitation is effective in improving exercise tolerance, secondary cardiac risk factors, health-related quality of life (HRQoL), and psychological well-being in patients following myocardial infarction. Also, there is strong evidence that in addition to improved aerobic capacity, exercise training can, in fact, improve functional status and strength in older adults. Each of these issues is addressed in detail below.
Improved Aerobic and Functional Outcomes
During the past decade, multiple studies have demonstrated the benefits of cardiac rehabilitation on aerobic function. In 1995, Lavie and Milani3 demonstrated a greater improvement in exercise capacity in older adults as compared with younger adults following a cardiac event engaged in a 3-4 month cardiac rehabilitation program (43% vs 32%; P < 0.01). The next year, Balady and colleagues4 found similar increases in exercise tolerance in both men and women over the age of 75 years. More recently, Marchionni et al5 examined a group of older patients after myocardial infarction in both a hospital-based and home-based cardiac rehabilitation program, along with a control group who did not receive cardiac rehabilitation. The groups were stratified by age into three groups (45-65 yr, 66-75 yr, and > 75 yr). Total work capacity improved in all age groups who received either hospital- or home-based cardiac rehabilitation. Control group patients did not show an improvement in total work capacity. Those in the home-based group maintained the improvements in exercise tolerance at 12 months while those in the hospital-based arm reverted to baseline work capacity. Costs were also lower in the home-based group. The authors concluded that with lower costs and more prolonged benefit, home-based cardiac rehabilitation programs may be the treatment of choice among older patients with low cardiac risk.5
Similar aerobic benefits have been seen in older adults with CHF. The Exercise Rehabilitation Trial (EXERT) demonstrated an increase in the exercise group peak oxygen uptake as compared with the control group of 0.104 L/min from baseline (P = 0.026) at 3 months and continued to increase at 12 months (P = 0.081).6 In 2005, Austin et al7 demonstrated benefits in New York Heart Association classification and 6-minute walking distance at 24 weeks in a group of patients with CHF age 60-89 years who participated in an 8-week hospital-based program with a subsequent 16-week community-based program.
Aging-related muscle wasting, or sarcopenia, in older adults is a well-recognized phenomenon that is associated with frailty. A systematic literature review suggested that among adults with CHF, skeletal muscle abnormalities play a greater role in aerobic capacity than cardiac dysfunction.8 A number of investigations have demonstrated that strength training in addition to aerobic training provides additional benefits in muscle strength, mass, and endurance. In addition, some studies have found greater improvements in peak oxygen consumption when resistance training is combined with aerobic training versus aerobic training alone.9 Overall, data suggest that strength training is safe and can provide benefits beyond muscle strength; however, the duration of training, type of resistance training, and site of rehabilitation remain controversial. Ultimately, strength training is considered an essential component of cardiac rehabilitation.
Health-Related Quality-of-Life Outcomes
Some important outcome measures examined in many cardiac rehabilitation studies include measures of patients’ perceived disease burden and the impact on quality of life. One such measurement tool used is the Minnesota Living with Heart Failure (MLHF) questionnaire, which includes both physical and emotional domains. Austin and colleagues7 demonstrated improvements in MLHF scores in both domains at 8 and 24 weeks in the cardiac rehabilitation group. In the EXERT there was a slight improvement in the MLHF scores; however, it was not statistically significant.6
Marchionni et al5 examined HRQoL using the Sickness Impact Profile (SIP), which is a reflection of disease impact on quality of life. While the middle-aged and old groups in both cardiac rehabilitation and control showed similar improvements in HRQoL, in the very oldest group (> 75 yr), only those receiving cardiac rehabilitation (home- or hospital-based) demonstrated improvements in HRQoL.5
Lavie and Milani3 examined several quality-of-life parameters including mental health, energy, general health, pain, function, well-being, and total quality of life in older versus younger adults following a cardiac event. All parameters for both the younger and older cohorts improved similarly following cardiac rehabilitation (P < 0.01).3
In summary, the majority of studies examining the impact of cardiac rehabilitation on quality-of-life indicators suggest that older adults do incur benefits beyond those traditionally examined, such as aerobic capacity. These benefits in mental health, functional status, pain, and disease burden can translate to meaningful improvements in day-to-day functioning for older adults.
Hospital Admissions and Mortality
Cardiac rehabilitation has been associated with lower total and cardiac mortality rates in adults with coronary artery disease.10 Austin et al7 found that older adults with CHF had no mortality benefit; however, those who participated in cardiac rehabilitation had fewer readmissions (P < 0.01) and had shorter hospitalizations (P < 0.001). Belardinelli and colleagues11 found both reduced mortality and hospital admissions as compared with controls in older adults with CHF.
Barriers to Referral
There is significant underutilization of cardiac rehabilitation, particularly in older adults, women, and ethnic minorities. A variety of factors influence referral to cardiac rehabilitation (Table).
Barriers from the patient’s perspective include lack of motivation, limited knowledge regarding the benefits of cardiac rehabilitation, accessibility, and, in some instances, excessive financial burden due to inadequate insurance coverage.
From the physician standpoint, there is lack of recognition of the benefits of cardiac rehabilitation beyond those adults who have recently suffered a myocardial infarction. Older adults on stable medical regimens for their CVD, those with stable CHF, those with symptomatic peripheral vascular disease, or those with a history of coronary artery disease/myocardial infarction are appropriate candidates for referral to cardiac rehabilitation.
Many older adults who might benefit from cardiac rehabilitation have multiple medical problems that influence their mobility, including dementia, osteoarthritis, or peripheral neuropathy. Supervised exercise also allows for graded increases in exercise intensity to maximize aerobic and strength gains. While there may be concerns about safety, a review by Franklin et al12 demonstrated rare cardiac events or fatality during supervised exercise. The majority of studies examining older adults with CVD or CHF demonstrate no difference between the experimental and control groups with regard to cardiovascular events or mortality during the study period. Moreover, studies have demonstrated decreased emergency room visits, hospitalizations, and length of stay as a result of effective strategies focused on disease management through cardiac rehabilitation.7,13,14 There is also evidence for the potential cost-effectiveness of cardiac rehabilitation; however, larger randomized studies are needed.15
Cardiac rehabilitation is an effective and safe mode of chronic disease management in older adults with CVD. Beyond the individual benefits to patients, cardiac rehabilitation has been shown to reduce hospitalizations and length of stay in a population of patients who heavily utilize the healthcare system due to exacerbations of symptoms. There are few patients who will request a referral to cardiac rehabilitation, even if they note increased effort with performance of activities of daily living. Identifying patients who are appropriate candidates for cardiac rehabilitation is not only the role of cardiologists, but also that of primary care providers, geriatricians, and other practitioners treating this patient population.
Dr. Osevala reports no relevant financial relationships. Dr. Malani has received research grants from ViroPharma Inc. Dr. Osevala is a Junior Faculty Hartford Foundation Scholar, Division of Geriatric Medicine, Department of Internal Medicine, University of Michigan Health System; and Dr. Malani is from the Division of Geriatric Medicine, Department of Internal Medicine, Division of Infectious Diseases, Department of Internal Medicine, University of Michigan Health System, Veterans Affairs Ann Arbor Healthcare System, and Geriatric Research Education and Clinical Center (GRECC), Ann Arbor, MI.
1. Leon AS, Franklin BA, Costa F, et al; American Heart Association; Council on Clinical Cardiology (Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention); Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity); American association of Cardiovascular and Pulmonary Rehabilitation. Cardiac rehabilitation and secondary prevention of coronary heart disease: An American Heart Association scientific statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity), in collaboration with the American Association of Cardiovascular and Pulmonary Rehabilitation [published correction appears in Circulation 2005;111(13):1717]. Circulation 2005;111(3):369-376.
2. Rosamond W, Flegal K, Furie K, et al; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics—2008 update: A report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 2008;117:e25-e146. Published Online: December 17, 2007.
3. Lavie CJ, Milani RV. Effects of cardiac rehabilitation and exercise training on exercise capacity, coronary risk factors, behavioral characteristics, and quality of life in women. Am J Cardiol 1995;75:340-343.
4. Balady GJ, Jette D, Scheer J, Downing J. Changes in exercise capacity following cardiac rehabilitation in patients stratified according to age and gender. Results of the Massachusetts Association of Cardiovascular and Pulmonary Rehabilitation Multicenter Database. J Cardiopulm Rehabil 1996;16:38-46.
5. Marchionni N, Fattirolli F, Fumagalli S, et al. Improved exercise tolerance and quality of life with cardiac rehabilitation of older patients after myocardial infarction: Results of a randomized, controlled trial. Circulation 2003;107:2201-2206. Published Online: April 21, 2003.
6. McKelvie RS, Teo KK, Roberts R, et al. Effects of exercise training in patients with heart failure: The Exercise Rehabilitation Trial (EXERT). Am Heart J 2002;144:23-30.
7. Austin J, Williams R, Ross L, et al. Randomised controlled trial of cardiac rehabilitation in elderly patients with heart failure. Eur J Heart Fail 2005;7:411-417.
8. McKelvie RS, Teo KK, McCartney N, et al. Effects of exercise training in patients with congestive heart failure: A critical review. J Am Coll Cardiol 1995;25:789-796.
9. Ebben WP, Leigh DH. The effects of resistance training on cardiovascular patients. Streng Cond J 2006;28:54-58.
10. Taylor RS, Brown A, Ebrahim S, et al. Exercise-based rehabilitation for patients with coronary heart disease: Systematic review and meta-analysis of randomized controlled trials. Am J Med 2004;116:682-692.
11. Belardinelli R, Georgiou D, Cianci G, Purcaro A. Randomized, controlled trial of long-term moderate exercise training in chronic heart failure: Effects on functional capacity, quality of life, and clinical outcome. Circulation 1999;99:1173-1182.
12. Franklin BA, Bonzheim K, Gordon S, Timmis GC. Safety of medically supervised outpatient cardiac rehabilitation exercise therapy: A 16-year follow-up. Chest 1998;114:902-906.
13. Ades PA, Huang D, Weaver SO. Cardiac rehabilitation participation predicts lower rehospitalization costs. Am Heart J 1992;123(4 Pt 1):916-921.
14. Bondestam E, Breikss A, Hartford M. Effects of early rehabilitation on consumption of medical care during the first year after acute myocardial infarction in patients > or = 65 years of age. Am J Cardiol 1995;75:767-771.
15. Ades PA, Pashkow FJ, Nestor JR. Cost-effectiveness of cardiac rehabilitation after myocardial infarction. J Cardiopulm Rehabil 1997;17:222-231.