Question

Medical History

Mr. JW is a 76 yr old man with a history of obesity, hypertension, type 2 diabetes, heart failure with preserved ejection fraction (HFpEF), and obstructive sleep apnea (OSA). His medications include furosemide 40 mg, Lisinopril 20 mg, metformin 500 mg, and aspirin 81 mg daily. He has noticed progressive exercise intolerance and associated dyspnea, especially when walking uphill or climbing stairs. He complains that “I can’t keep up with my grandchildren like I could last year.” Although he can still perform all ADLs, he spends most of his time watching television or surfing the Internet. He sleeps well with his continuous positive airway pressure (CPAP) device. His hemoglobin A1c is well controlled at 7.6%, and morning home blood pressure averages in the low 140s/80s mmHg. He takes his medications regularly, eats a well-balanced diet, and sleeps well with CPAP.

Diagnosis

Mr. JW visits his internist about every 3 mo to monitor his hypertension, diabetes, HF, and OSA. An echocardiogram last year showed mild left atrial enlargement, normal LV size and function with moderate LV hypertrophy, and elevated Doppler E/e’, an index of LV-filling pressure, indicating diastolic dysfunction. On his most recent visit 1 mo ago, his physical examination was unremarkable except for a BMI of 33 kg · m–2 and blood pressure of 152/78 mmHg. A resting ECG showed left atrial abnormality and minor T wave flattening.

Objective and Laboratory Data

Exercise Test Results

To further investigate Mr. JW’s reported exercise intolerance, his internist administered a standard ECG treadmill exercise test using a modified Bruce protocol. The patient walked 5 min (4.5 METs), reaching a peak HR of 142 beats · min–1 and peak BP of 196/72 mmHg, stopping due to breathlessness and fatigue. Occasional premature ventricular beats were seen near peak effort, but there were no significant ST-segment changes.

Based on his examination and exercise test results, Mr. JW’s doctor increased lisinopril to 30 mg daily and began spironolactone 25 mg daily. He also referred him to a nutritionist for weight reduction counseling and suggested that he begin walking daily for 30 min, which can be divided into 10 or 15 min segments if needed.

Assessment and Plan

A weight loss goal of 40 lb from his current weight of 220 lb was set.

Exercise Prescription

This patient represents an all-too-common scenario in geriatric medicine. Mr. JW has exercise intolerance, most likely related to the combination of obesity, LV diastolic dysfunction, and inactivity-related deconditioning, superimposed on aging-associated physiologic changes that progressively reduce functional capacity. Unfortunately, this decrease in exercise tolerance often begets a vicious cycle of reduced physical activity that causes further deconditioning and exercise intolerance.

Mr. JW will likely benefit from an exercise program that emphasizes walking and other lower-level aerobic activities while incorporating resistance exercises and balance and flexibility training. Weight reduction via moderate caloric restriction is an important component of his treatment that will further increase exercise tolerance as well as improving BP and glycemia control and obstructive sleep apnea (OSA).

A clinical exercise physiologist will need to be cognizant of Mr. JW’s multiple medical disorders and medications superimposed on age-associated physiological changes. Exercise must begin at low levels and progress in small increments to ensure that the regimen is well tolerated and that it addresses the spectrum of needs underlying his functional limitations and health requirements.

Case Study Discussion Questions

1. What motivational strategies can be used to enhance his exercise adherence?
2. What are the major risks of Mr. JW’s participation in an exercise program?
3. What other tests might you perform on Mr. JW (diagnostic or functional)?
4. What might be appropriate recommendations for advancing Mr. JW to walking for 30 min on a daily basis?

Answer 1

●Some of the motivational strategies which can be applied for exercise adherence are

• Health educating the clients about the benefits of exercise and its major role in preventing complications
• Verbal rewards can be a better motivational strategy at this age which give them a self confidence and psychological support at this age
• Informing about the positive outcome to the client achieved out of exercise
• Self monitoring and goal setting can be used to motivate the client

●The major risk present die to exercise are

• Risk for cardiovascular issue like myocardial infarction in case of strenuous exercise
• Risk for respiratory complications when deprived of oxygen which is consumed in excercises

●The following functional or diagnostic test can be performed

• Leg or arm ergometry test to rule our any cardiovascular issues
• Resting heart rate to be assessed to rule out the aerobic exercise involvement.
• Lung function test to assess the respiratory function

●The appropriate recommendations for advancing walking for 30 minutes on daily base are

• The patient should have a normal blood 0ressure
• Should have gradual decrease in dyspnea and improve lung function to increase walking time .