Deconditioning

The adage "use it or lose it" is true at all ages, but it is a fundamental tenet of the care of older people. Given the difficulties of reversing deconditioning and its functional effects once established, prevention is the best option. This requires a variety of strategies.

Regular physical exercise in middle age protects against many conditions common in old age, including late-onset diabetes mellitus, osteoporosis, hypertension, and cardiac disease. The role of exercise in older life in combating these conditions is less clear. However, Roy Shephard has noted that physical training can lead to the equivalent of a twenty to thirty year reversal of the usual age-associated decline in aerobic power. Maintenance of physical fitness and avoidance of a sedentary lifestyle with increasing age must therefore be an important goal of community health programs, reinforced whenever possible by advice from doctors to individual patients. In particular, patients and caregivers must be educated about the importance of maintaining physical activity even in the face of significant chronic illness, as well as the importance of early intervention during acute decline or illness.

Prevention of deconditioning in hospitals during acute illness requires a multifaceted approach that includes physical therapy, maintenance of nutrition, medical management, and psychological support. Activity and independence should be promoted from the time of admission. Education of health care staff about the dangers of deconditioning is vital, since bed rest continues to be recommended during acute illness despite the lack of evidence showing benefits and the considerable evidence showing potential adverse effects from this advice. Sedative medications and restraints should be used sparingly, if at all.

Exercise programs can be beneficial for older people regardless of their disability. In randomized controlled trials of both healthy and frail elderly subjects, including people over eighty years of age, exercise has been shown to improve lower-limb muscle strength, exercise endurance, balance, speed of walking, and overall levels of physical activity. Practice of specific skills is required if improved muscle strength is to translate into functional benefits. Exercises including a balance component (e.g., tai chi) may be useful in preventing falls. Physical exertion has potential dangers, and exercise programs for older people should be tailored to the needs and capacity of the individual person.

Restoration of physical function and independence in a frail and deconditioned hospital patient is particularly difficult. Comprehensive clinical, functional, and psychosocial assessment is mandatory. It is important to set measurable, attainable goals and to monitor progress carefully. This is aided by the use of standardized tools to measure important areas such as cognitive function and the ability to perform daily activities. An active multidisciplinary rehabilitation program is essential, and should include nutritional and psychologic support.