Physical Function Effects of Live Video Group Exercise Interventions for Older Adults: A Systematic Review and Veteran's Gerofit Group Case Study.

Background: Literature on telehealth interventions for older adults has been primarily on asynchronous interventions. During the COVID-19 pandemic, older adult exercise programs transitioned to an online format. This systematic review and case study examines the effectiveness of older adult live video exercise group interventions on physical health with insights from a Los Angeles VA program, Gerofit. Methods: PubMed was searched for live video older adult exercise groups from database inception to November 2021. All eligible studies included assessments of physical health and were limited to participants with an average age of 65 years or greater. Ten Veterans, who had participated in both in-person and virtual Gerofit sessions, were surveyed in the case study. Results: Nine studies met the inclusion criteria. Four studies included an equivalent in-person group as a comparator to the live video group and reported no significant between-group differences in outcomes, including energy expenditure and 6-minute walking distance test (6MWD). The other five studies reported statistically significant in-group improvement in outcomes including isokinetic knee strength. Case study participants reported similar attendance rates and perceived benefits, such as improved balance, when comparing virtual and in-person sessions. Discussion: Live video exercise groups in older adults demonstrated an improvement in physical function that was not statistically different from the comparison in-person sessions with the added benefit of averaging a higher attendance rate, providing initial support for the use of live video in older adult exercise programs. Insights from the case study supplement this by demonstrating older adults' positive attitude on these groups.

PTSD Improvement Associated with Social Connectedness in Gerofit Veterans Exercise Program.

OBJECTIVE: Post-traumatic stress disorder (PTSD) is common in Veterans. Symptoms can perpetuate into late life, negatively impacting physical and mental health. Exercise and social support are beneficial in treating anxiety disorders such as PTSD in the general population, although less is known about the impact on Veterans who have lived with PTSD for decades. This study assessed associations between social connectedness, physical function and self-reported change in PTSD symptoms among older Veterans specifically participating in Gerofit. DESIGN: Prospective clinical intervention. SETTING: Twelve sites of Veterans Affairs (VA) Gerofit exercise program across the United States. PARTICIPANTS: Three hundred and twenty one older Veteran Gerofit participants (mean age = 74) completed physical assessments and questionnaires regarding physical and emotional symptoms and their experience. MEASUREMENTS: Measures of physical function, including 30-second chair stands, 10-m and 6-min walk were assessed at baseline and 3 months; change in PTSD symptoms based on the Diagnostic Statistical Manual-5 (DSM-5) assessed by a self-report questionnaire; and social connection measured by the Relatedness Subscale of the Psychological Need Satisfaction in Exercise scale (PNSE) were evaluated after 3 months of participation in Gerofit. RESULTS: Ninety five (29.6%) Veterans reported PTSD. Significant improvement was noted in self-rated PTSD symptoms at 3 months (P < .05). Moderate correlation (r = .44) was found between social connectedness with other participants in Gerofit and PTSD symptom improvement for those Veterans who endorsed improvement (n = 59). All participants improved on measures of physical function. In Veterans who endorsed PTSD there were no significant associations between physical function improvement and PTSD symptoms. CONCLUSION: Veterans with PTSD that participated in Gerofit group exercise reported symptom improvement, and social connectedness was significantly associated with this improvement. In addition to physical health benefits, the social context of Gerofit may offer a potential resource for improving PTSD symptoms in older Veterans that warrants further study.

An innovative educational clinical experience promoting geriatric exercise.

Formal educational training in physical activity promotion is relatively sparse throughout the medical education system. The authors describe an innovative clinical experience in physical activity directed at medical clinicians on a geriatrics rotation. The experience consists of a single 2 1/2 hour session, in which learners are partnered with geriatric patients engaged in a formal supervised exercise program. The learners are guided through an evidence-based exercise regimen tailored to functional status. This experience provides learners with an opportunity to interact with geriatric patients outside the hospital environment to counterbalance the typical geriatric rotation in which geriatric patients are often seen in clinics or hospitals. In this experience, learners are exposed to fit and engaged geriatric patients successfully living in the community despite chronic or disabling conditions. A survey of 105 learners highlighted positive responses to the experience, with 96% of survey respondents indicating that the experience increased their confidence in their ability to serve as advocates for physical activity for older adults, and 89.5% of responders to a follow-up survey indicating that the experience changed their perception of geriatric patients. Modifications to the experience, implemented at partnering facilities are described. The positive feedback from this experience warrants consideration for implementation in other settings.

Despite Active Public Health Campaigns, Death from Falls Increased 30% in the Past Decade: Is Ageism Part of the Barrier to Self-Awareness?

Public health messaging campaigns stating that falls are bad and can be prevented are not effective, as evidenced by a 30% increase in death from falls over the past decade. A first approach is to use measures of balance to show the magnitude of the problem. Second, the role of ageism as a barrier to required behavioral change should be addressed. Third, explanations should be provided regarding why mobility and balance have changed. As a counter to ageism, pros and cons for specific interventions and how these maximize momentum and mobility should be discussed.

Gerofit Prehabilitation Pilot Program: Preparing Frail Older Veterans for Surgery.

Older Veterans are increasingly undergoing surgery and are at particularly high risk of postoperative morbidity and mortality. Prehabilitation has emerged as a method to improve postoperative outcomes by enhancing the patient's preoperative condition. We present data from our prehabilitation pilot project and plans for expansion and dissemination of a nationwide quality improvement effort. The infrastructure of the existing Veterans Affairs (VA) Gerofit health and exercise program was used to create our pilot. Pilot patients were screened for risk of postoperative functional decline, assessed for baseline physical function, enrolled in a personalized exercise program, and prepared to transition into the hospital for surgery. Patients (n = 9) completed an average of 17.7 prehabilitation sessions. After completing the program, 55.6% improved in ≥2 of the 5 fitness assessments completed. Postoperative outcomes including complications, 30-day mortality, and 30-day readmissions were better than predicted by the National Surgical Quality Improvement Program Surgical Risk Calculator. We have obtained institutional support for implementing similar prehabilitation programs at VA hospitals nationally through our designation as a VA Patient Safety Center for Inquiry. This is the first multi-institutional prehabilitation program for frail, older Veterans and represents an essential step toward optimizing surgical care for this vulnerable population.

Setting and Method of Measurement Affect Blood Pressure Readings in Older Veterans.

The present study demonstrated that standardized measurements of blood pressure were lower than the routine method used in most office settings.

Host resistance and immune responses in advanced age.

Immunosenescence results in populating immune tissues with less functional T cells, and perhaps B cells dendritic cells, that do not function well and produce more type 2 cytokines and fewer type 1 cytokines. Impaired immunity, distinct from immunosenescence, correlates more with disease burden than chronologic age. Older adults who have chronic diseases or chronic infections are more susceptible to common infections and have poor vaccine responses. Understanding specific mechanisms and targeting interventions are dependent on research to resolve the relationship between frailty-associated impaired immunity and the role of chronic infection versus immunosenescence in developing impaired immunity.

Outcomes of a consult fall prevention screening clinic.

OBJECTIVE: To report patient satisfaction and quality outcomes from a standardized, multicenter fall prevention screening clinic. DESIGN: Referrals were made to the fall prevention screening clinic, which was staffed by a physician, pharmacist, therapist, nurse, and the site coordinator. The fall prevention screening clinic staff utilized a team-meeting format with clearly delineated management options to determine the appropriate interventions based on various screening examinations. RESULTS: Primary care providers acknowledged pharmacy recommendations and >80% of the recommendations were followed. There was a reduction in reported falls (initial visit = 297 falls, follow-up visit = 141 falls, P = 0.0002) and in the number of recurrent fallers. There was a small (average difference = 1.8 secs) but significant (P = 0.025) decrease in the 8-foot Up-and-Go time, representing a functional improvement in walking speed. There was no significant change in the Fall Efficacy Scale, however. At least 80% of the patients reported that they were completely satisfied with their care. CONCLUSIONS: Patients who attended the fall prevention screening clinic demonstrated improved confidence during activities of daily living and reduced falls. They reported high satisfaction with the clinic format.

Immune dysfunction in the elderly and its reversal by antihistamines.

The decline in immunity seen in the elderly is a significant contributor to disease burden. This decline has largely been attributed to alterations in T cell immunity and contributes to an overall increased risk and severity of infection in the elderly. A key component of T cell immunity involves antigen presentation, an event where an antigen is processed and presented to specific immune cells for destruction. This event has been found to be crucial to immune function. Recent research has focused on a key antigen presenting cell (APC), the dendritic cell (DC), and changes within its function associated with aging. DCs are considered to be the most professional APCs, and are responsible for the initiation and outcome of effector T cells and their resultant immune response. DCs capture antigens and undergo a maturation process and polarize into either type 1 dendritic cells (DC1) or type 2 dendritic cells (DC2), based upon their ability to favor a T helper1 (Th1) or T helper 2 (Th2) T cell response, respectively. Evidence suggests that in normal healthy adults, a Th1 type response predominates, and in frail elders, a Th2 response predominates. It has been proposed that this change from a predominately Th1 type to a predominate Th2 type response is a possible mechanism for age-associated immune dysfunction. In addition, recent research has focused on how histamine, an inflammatory mediator, promotes a Th2 response. Histamine has also been shown to polarize human DCs into Th2 cell-promoting effector DCs or DC2s. This has been shown to occur via interaction with the H2 receptor. Therefore, we theorize that use of an H2 selective antihistamine will reverse this polarization back to a Th1 type response and therefore improve immune function of the frail elderly.

The frail elderly: role of dendritic cells in the susceptibility of infection.

The decline in immunity in the elderly has largely been attributed to impairment of T cell mechanisms. This seems reasonable since the thymus involutes with age, so that the number of naïve cells to respond to new foreign antigens also declines. However, little is known about how aging affects antigen-presenting cells (APC) that are responsible for the initiation and outcome of effector T cell immune responses. This review focuses on the age-related alterations of a key APC, the dendritic cell (DC). Recent findings suggest that interleukin-10, a key cytokine that can suppress cell mediated immunity and maturation of DC subsets, is elevated in the very healthy elderly. However, production of IL-12, required for the initiation of T cell immune responses, declines in frail elderly along with DC antigen presenting function. These findings suggest that shifts in IL-10 and IL-12 may not only directly influence immune response but may also alter the balance and maturation of DC subsets. Finally, study of immunologic differences between the very healthy and frail elderly may reveal important changes in DC function and regulation influenced by age and/or environment (disease, nutrition, medications, etc.).