Significant Sequelae Related to Common Chronic Conditions HESS 509 CHAPTER NINE Depression and Frailty are two common chronic comorbidities that develop as a consequence of chronic disease and that are often seen in persons who have the other chronic conditions Depression as a Comorbidity Up to half of all persons with a chronic disease or disability experience depression as a comorbid condition. Depression is a high-risk factor for noncompliance with prescribed treatments. People who are depressed are approximately three times more likely than others to not adhere to practitioner recommendations, which adversely affects outcomes. Depression is often accompanied by social isolation and withdrawal. Research suggests that support from family and friends facilitates a person’s attempts to comply with treatment. Any person who has a chronic condition or disability should be screened for depressive symptoms, for these reasons: Depression can be a barrier to engaging in and sustaining an exercise program. Depression reduces adherence to medical treatment for other conditions. Exercise therapy can directly benefit depressive symptoms

Significant Sequelae Related to Common Chronic Conditions HESS 509 CHAPTER NINE Basic Pathophysiology - Depression Biological causes of depression are likely multifaceted, an imbalance in the Neurotransmitter and hormonal pathways(or both) in the brain is believed to be a central cause of depression. These pathways are involved in the neural integration of several physiological systems, so depression has many physical, mental and cognitive symptoms. New research shows that depression is also strongly associated with inflammation. Notably, both inflammation and the brain pathways linked to depression can be modified by exercise.

Significant Sequelae Related to Common Chronic Conditions HESS 509 CHAPTER NINE Symptoms of depression include: profound sadness, fatigue, malaise, (general feel of discomfort) insomnia, anhedonia (inability to experience pleasure), suicidal ideation, self-degrading feelings, irritability, confused or confounded thinking, loss of appetite, and, involuntary weight change

Significant Sequelae Related to Common Chronic Conditions HESS 509 CHAPTER NINE Risk Factors of developing depression: Having a family history of depression Being female, especially in a postpartum period Early childhood trauma Substance abuse Having a chronic condition or disability Management and Medications - Depression First exclude a variety of other psychiatric or medical conditions that can mimic some or all of the symptoms of depression. A misdiagnosis may result in ineffective and potentially harmful treatment that may worsen the underlying causal disorder. A missed diagnosis of depression may slow the treatment of both the depression and underlying disease. Once a diagnosis of depression has been made, traditional treatment options include antidepressant medications and counseling (individual or group).

Significant Sequelae Related to Common Chronic Conditions HESS 509 Some people who are prescribed an antidepressant medication respond adequately, with no need for additional therapy. They typically remain on their medication for years. Others respond well with behavioral counseling or therapy or a combination of medication and therapy. (see Table 9.1 – FYI) CHAPTER NINE

Significant Sequelae Related to Common Chronic Conditions HESS 509 CHAPTER NINE Research suggests that the largest exercise-related antidepressant effects may stem from improvement in physical functioning, but more research is needed to determine the optimal dose of exercise training in these individuals Effects on the Exercise Response - Depression Patients with depression may have a blunted exercise response because of: early volitional exhaustion, possible increased perceived exertion relative to heart rate, peak exercise tolerance below maximal aerobic capacity related to an inability to motivate to push to maximal levels, and disorders in initiating or maintaining sleep and the occurrence of sleep apnea, which accelerate physical and cognitive fatigue and are associated with insulin resistance

Significant Sequelae Related to Common Chronic Conditions HESS 509 CHAPTER NINE Effects of Exercise Training - Depression Meta-analysis show therapeutic benefit for mild to moderate depression in both aerobic and strength training programs. Aerobic exercise may improve sleep integrity, and the circadian sleep cycle Exercise can increase several growth factors in the brain that modulate depression and improve cognitive functioning. Recommendations for Exercise Programming - Depression Use the major chronic condition for primary guidance. Otherwise the General Exercise Program Recommendation is a reasonable default program. Participating in group programs or having an exercise partner can be helpful More detailed information on Exercise Training and Programming in Chapter 32 (Dec 06 lecture)

Significant Sequelae Related to Common Chronic Conditions HESS 509 CHAPTER NINE Frailty Frailty is a complex and poorly understood phenomenon that is a complex interplay between aging, physical and cognitive functioning, chronic disease, and in many cases habitual physical inactivity. Exercise training is a mainstay of frailty prevention. Frailty is a syndrome characterized as a phenotype based on five criteria: Weight loss Exhaustion Low grip strength Slow walking speed Low physical activity Patients are classified based on scoring of these five criteria: 0 of 5 traits = robust 1 or 2 of 5 traits = pre-frail >2 of 5 traits = frail

Significant Sequelae Related to Common Chronic Conditions HESS 509 CHAPTER NINE A variety of physiological factors are involved in the pathogenesis of frailty

Significant Sequelae Related to Common Chronic Conditions HESS 509 CHAPTER NINE Deterioration of these physiological pathways in people who are physically inactive predisposes them to a downward spiral that includes these elements: Risk of falls Disability Cognitive decline Hospitalization Need for assistive living or nursing home admission Other conditions associated with physical inactivity and deconditioning

Significant Sequelae Related to Common Chronic Conditions HESS 509 CHAPTER NINE Management and Medications - Frailty Low walking speed and low physical activity are strong independent predictors of future disability . Additional traits, less strongly associated with future disability, include weight loss, poor balance, and poor lower-extremity functional tests. Patients who score poorly in these areas are at high likelihood for subsequent chronic illness, disability, and need for aid. Early detection is best achieved through assessment. Patients who are at risk should reasonably be screened as well as encouraged to participate in regular physical activity Medications are sometimes used to treat frailty, including growth and Growth hormone-releasing hormones, and Testosterone or testosterone analogs

Significant Sequelae Related to Common Chronic Conditions HESS 509 CHAPTER NINE Effects on the Exercise Response - Frailty Effects of frailty on the exercise response are: Muscular weakness Low endurance (easily fatigued) Slow gait speed and dynamic balance Lack of balance and higher risk of falling It is not known which comes first—loss of lower-extremity strength and function or slow gait speed; however, either results in sedentary lifestyle and a downward spiral of deconditioning that fosters further loss of muscle mass, strength, and function

Significant Sequelae Related to Common Chronic Conditions HESS 509 CHAPTER NINE Effects of Exercise Training - Frailty Both aerobic and strength training have proven useful in persons with frailty to improve gait speed, reduce risk of falling, and improve functional performance of various activities of daily living. Multimodal exercise programs that challenge multi-segmental motor control used in activities of daily living have been shown to improve several indices of balance and to modestly reduce fall rates. The inclusion of a combination of muscular endurance and functional balance training may prove useful for individuals with frailty, sarcopenia, and high fall risk. Because experience shows that frailty is hard to reverse, physical activity or an exercise program should be recommended before frailty becomes manifest.

Significant Sequelae Related to Common Chronic Conditions HESS 509 CHAPTER NINE Recommendations for Exercise Programming - Frailty It is advisable for clients to start under the supervision of a physical therapist, occupational therapist, or clinical exercise physiologist who has experience with frailty and in geriatrics. Otherwise, Follow the Basic Exercise Prescription Guidelines Emphasize strength and balance exercises (example below) End