Pathy's Principles and Practice of Geriatric Medicine. Группа авторов
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All consensus statements1,153 and position stands154 recommend aerobic exercise as part of the management plan in type 2 diabetes. Moderate‐ or high‐intensity aerobic exercise of 3–4 h per week results in improved insulin sensitivity and glucose homeostasis, assists in attaining or maintaining lower body weight, reduces visceral fat depots, modestly improves blood pressure and lipids, and lowers the risk of cardiovascular morbidity and mortality. However, the clinical management of the obese elderly patient with this disease is often complicated by increasing insulin resistance and resultant polypharmacy, in addition to multiple other comorbid health conditions that impede compliance with both diet and aerobic exercise and reduce quality of life.22 For example, it would not be unusual for an older adult with diabetes to present with obesity, osteoarthritis, ischaemic heart disease, hypertension, gout, hyperlipidaemia, peripheral vascular disease, sleep apnoea, peripheral neuropathy, a gait and balance disorder, functional impairment, renal disease, postural hypotension, bladder dysfunction, retinal disease, and depression. Such disease clustering makes the application of standard dietary and exercise recommendations in addition to intense pharmacological management a challenge to practitioner and patient alike. It is not surprising that aerobic exercise recommendations, endorsed by all international consensus statements,154 are often difficult or impossible to implement in such patients. In particular, obesity, osteoarthritis, amputations, visual impairment, foot problems, fall risk, orthostatic hypotension, peripheral vascular disease, and a low threshold for ischaemia may make aerobic exercise at the volumes and/or intensities shown to produce metabolic benefits in clinical trials unrealistic in practice.
Table 7.7 Exercise and disease treatment.
Disease state | Exercise modality of choice | Considerations for the prescription |
---|---|---|
Arthritis | Aerobic Resistance training | Low impact. Sufficient volume to achieve a healthy weight if obese. |
Chronic insomnia | Aerobic Resistance training | Time of day does not consistently influence efficacy. Effect is immediate. |
Chronic obstructive pulmonary disease | Aerobic Resistance training | Resistance training may be more tolerable in severe disease; combined effects complementary if feasible. |
Time exercise sessions to coincide with bronchodilator medication peak. Use oxygen during exercise as needed. | ||
Chronic renal failure | Aerobic Resistance training | Exercise reduces cardiovascular and metabolic risk factors, improves depression. |
Resistance training offsets myopathy of chronic renal failure. | ||
Congestive heart failure | Aerobic Resistance training | Resistance training may be more tolerable if dyspnoea severely limits aerobic activity. |
Cardiac cachexia is targeted by resistance training. | ||
Coronary artery disease | Aerobic Resistance training | Complementary effects on exercise capacity and metabolic profile from combined exercise modalities. |
Resistance training may be more tolerable if the ischaemic threshold is very low due to lower heart rate response to training. | ||
Depression | Aerobic Resistance training | High‐intensity resistance training and adequate volumes of aerobic exercise are more efficacious than low‐intensity/low‐volume exercise in major depression. |
Hypertension | Aerobic Resistance training | Small to moderate reduction in systolic and diastolic pressures is seen. |
Larger changes are seen if weight loss occurs. | ||
Obesity | Aerobic Resistance training | Sufficient energy expenditure to induce a deficit. |
Resistance training but not aerobic exercise maintains lean tissue (muscle and bone) during dietary weight loss. | ||
Osteoporosis | High‐impact exercise Resistance training Balance training | High‐impact, high‐velocity activity (e.g., jumping) is potent if tolerable; avoid if osteoarthritis is present. Resistance training effects are local to muscles contracted. Balance training should be added to prevent falls and must be challenging. |
Peripheral vascular disease | Aerobic Resistance training | Vascular effect is systemic; upper limb ergometry may be substituted for leg exercise if necessary. |
Resistance training has a similar effect on claudication as aerobic exercise. Low‐intensity resistance training is ineffective. Exercise only to the onset of claudication; rest and repeat. | ||
Venous stasis disease | Aerobic Resistance training | Local muscle contractions stimulate the return of fluid via the lymphatic system. |
Utilise lower body training; elevate legs when possible. |
An alternative approach to aerobic exercise recommendations for adults with diabetes is the use of progressive resistance training. Insulin resistance is worsened by loss of muscle mass, decreased glucose transport into skeletal muscle and subsequent glycogen storage, catabolic/inflammatory mediators, inactivity, visceral fat, and related inflammatory cytokines such as IL‐6 and C‐reactive protein. The specific indications for resistance training in older adults with diabetes include its ability to combat age and diabetes‐related sarcopenia155;