Accepted Manuscript

Cardiac Rehabilitation in Older Adults

David W. Schopfer, MD, MAS, Daniel E. Forman, MD

PII: S0828-282X(16)00226-9
DOI: 10.1016/j.cjca.2016.03.003
Reference: CJCA 2069

To appear in: Canadian Journal of Cardiology

Received Date: 19 January 2016

Revised Date: 26 February 2016
Accepted Date: 5 March 2016

Please cite this article as: Schopfer DW, Forman DE, Cardiac Rehabilitation in Older Adults, Canadian
Journal of Cardiology (2016), doi: 10.1016/j.cjca.2016.03.003.

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TITLE:

Cardiac Rehabilitation in Older Adults

AUTHORS:

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David W Schopfer, MD, MAS1,2

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Daniel E Forman, MD3,4,5

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AFFILIATIONS:
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Department of Medicine, University of California San Francisco

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Department of Medicine, San Francisco VA Medical Center
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3
Geriatric Cardiology Section, University of Pittsburgh Medical Center
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Geriatric, Research, and Clinical Center, VA Pittsburgh Healthcare System
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Department of Medicine, University of Pittsburgh, Pittsburgh, PA
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Corresponding author:

Daniel Forman, MD
Section of Geriatric Cardiology
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3471 Fifth Avenue

Pittsburgh, PA 15213
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formand@pitt.edu

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Summary:

Cardiac rehabilitation (CR) is a comprehensive lifestyle program that reduces morbidity and mortality in

cardiovascular patients, and which also fosters adherence, physical function, and quality of life. It is an

especially beneficial therapy for older cardiovascular patients as it can moderate deconditioning and

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other management complexities influenced by age. Paradoxically, application of CR tends to diminish for

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older cardiovascular patients. New models of care may help better align CR to its conceptual potential.

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Abstract:

The biology of aging and the pathophysiology of cardiovascular disease (CVD) overlap with the

effect that CVD is endemic in the growing population of older adults. Moreover, CVD in older adults is

usually complicated by age-related complexities, including multimorbidity, polypharmacy, frailty and

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other intricacies that add to risks of ambiguous symptoms, deconditioning, iatrogenesis, falls, disability,

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and other challenges. Cardiac rehabilitation (CR) is comprehensive lifestyle program that can have

particular benefit for older cardiovascular patients. While CR was originally designed as primarily an

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exercise training program for younger adults after a myocardial infarction or coronary artery bypass

surgery, it has evolved as a comprehensive lifestyle program (promoting physical activity as well as

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education, diet, risk reduction, and adherence) for a broader range of CVD (coronary heart disease,
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heart failure, and valvular heart disease). It provides a valuable opportunity to address and moderate

many of the challenges pertinent for the large and growing population of older adults with CVD. Cardiac
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rehabilitation promotes physical function (cardiorespiratory fitness as well as strength and balance) that
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help overcome disease and deconditioning as well as related vulnerabilities to disability, frailty and falls.

Similarly, CR facilitates education, monitoring, and guidance to reduce iatrogenesis and promote
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adherence. Furthermore, CR fosters cognition, socialization, and independence in older patients. Yet
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despite all its conceptual benefits, CR is significantly under-utilized in older populations. This review

discusses benefits and the paradoxical underuse of CR, as well as evolving models of care that may
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achieve greater application and efficacy.

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Introduction

Cardiac rehabilitation (CR) is a comprehensive secondary prevention program that has evolved

as a standardized component of the cardiovascular armamentarium. Whereas CR originated as an

exercise program primarily for middle-aged male patients with coronary heart disease (CHD)[1], usually

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after a myocardial infarction (MI] and/or coronary artery bypass surgery (CABG), the range of eligible

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diagnoses and applications for CR has broadened over time. It is now a multidimensional treatment

designed to promote and facilitate physical activity and healthful lifestyle in the context of known

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cardiovascular disease (CVD), with tremendous relevance for older populations [2].

A number of reviews have been recently published reinforcing the efficacy of CR in patients [3,

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4] including specific focus on older adults [5]. The rationale to utilize CR for older men and women is
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particularly strong and demands additional review. More people are living longer, and the biology of

aging in this expanding senior population is intrinsically conducive to many types of CVD (CHD as well as
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heart failure [HF], valvular heart disease [VHD]) for which CR is now indicated [6, 7]. Moreover, older
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adults are more likely to experience unique consequences from CVD and CVD management for which CR

can be especially useful. Deconditioning, atypical symptoms, management conundrums, and poor
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adherence are all more likely in older age. Such vulnerabilities can arise when treatment goes smoothly
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(due to increased susceptibility to deconditioning and post-hospitalization syndrome with age) [8, 9] and

they are especially likely if/when common difficulties arise (e.g., through the compounding effects of
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concurrent diseases, delirium, and prolonged lengths of stay), all of which are everyday scenarios among
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older CVD patients. Similarly, CR provides opportunities to contend with predictable geriatrics intricacies

in these cardiac patients, including i. multimorbidity (multiple cardiac and non-cardiac diseases

occurring in combination), ii. polypharmacy (multiple new medications in the context of age-related

changes in pharmacokinetics and pharmacodynamics that predispose to side effects and iatrogenesis),

iii. detrimental processes of care (harmful effects of hospitalizations and transitions, including delirium,

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deconditioning, disability and to institutionalization thereafter), iv. sarcopenia (age-related atrophy and

weakening of skeletal muscle), and v. the challenge of education/decision making/and behavior changes

in the context of declining cognition (especially given the common changes in executive cognitive

function that are associated with CVD and age). Juxtaposed to all these challenges, CR stands out as one

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of the few standard therapeutic options routinely covered by insurers (including the Centers for

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Medicare and Medicaid Services [CMS]) that targets improved physical function as a primary outcome,

and which thereby has the potential to reduce age-related vulnerabilities to frailty and disability that are

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commonly exacerbated by CVD.

Contemporary CR in mainstream cardiology

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Cardiac rehabilitation is a comprehensive, long-term program involving exercise training as well

as medical evaluation, cardiac risk factor modification, education, and counseling, which is designed to
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limit the physiologic and psychological effects of cardiac illness, reduce the risk for sudden death or re-
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infarction, control cardiac symptoms, stabilize or reverse the atherosclerotic process, and enhance the

psychosocial and vocational status of patients [6]. Cardiac rehabilitation programs also provide
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opportunities to review medications and goals of care, to ensure management is well-directed, well-
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coordinated, and patient-centered. This can be particularly useful after a time of illness and related

upheavals. Finally, CR programs foster insight and healthful behaviors with the potential to instill
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prolonged living habits that sustain/prolong CR benefits.

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There are several types of CR program designs, including both inpatient and outpatient

variations. The majority of research and clinical emphasis has centered on outpatient CR [6] in part,

because foreshortened hospitalizations and rapid patient mobilizations have reduced time and priority

for inpatient programs. Outpatient programs offer preventive and rehabilitative services in the first 6

months but typically continue for up to one year after an incident hospitalization. Most programs aim

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for enrollment shortly after a cardiac event, and are situated in hospital-based facilities. The timing and

location are significant factors in terms of referral, access, and staffing. In general, hospital- or other

facility-based programs involve a standardized approach to care including, patient assessment and

evaluation, individualized exercise training, nutritional counseling, weight management, blood pressure

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management, lipid management, diabetes management, tobacco cessation counseling, psychosocial

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management, and physical activity counseling [2] based on criteria established by the American

Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) [2] in the United States and other

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equivalent medical organizations in other countries. A benefit of hospital and other facility-based

programs include direct medical supervision and assessments, which can be particularly advantageous

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to older adults who may be relatively frail or disconcerted after an illness. Other benefits also include
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the socialization and engagement associated with attending the program. Disadvantages include travel

logistics as well as costs related to travel and (when required) copayments.

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Recently, there has also been a proliferation of home-based outpatient CR programs which has
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great utility for many patients, including older patients, in respect to easier logistics. Nonetheless, home-

based programs are relatively less consistent in terms of standardization, safety, and quality, and
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provide less of the socialization benefits. A variety of home-based CR programs have been studied and
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were demonstrated to provide important clinical benefits [10]. However, the home-based programs had

more variability than facility-based programs in terms of frequency of contact (i.e. biweekly, weekly,
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monthly), type of contact (i.e. phone, nurse visits), whether any in-person sessions were conducted, and
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the method for providing education (i.e. book, verbal, computer modules).

A key limitation of home-based CR programs is that they are not currently reimbursed by most

insurers and therefore are rarely available. It seems self-evident that new models of financing must be

considered to advance the home-care model, particularly as a viable patient-centered option for the

growing number of older patients who cannot easily access hospital- or facility-based programs.

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Nonetheless, given the differences in direct supervision between home- and hospital-based programs,

candidates for home-based CR may benefit from more stringent screening prior to participating and

improved monitoring while exercising at home. The risks relate not only to cardiac concerns, but to

cognition, falling risks and other parameters that are relevant for many older patients. Monitoring for

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home-based CR may potentially be enhanced by newer technologies such as a videoconferencing and

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mobile applications that allow for frequent and direct contact between patients and providers; however,

their implementation among older patients requires substantiation.

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Unique relevance of CR for older adults

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From its inception, CR has enrolled relatively more middle aged white men than other
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populations. Older adults, and particularly older women and ethnic minorities have been under-

enrolled. This seems almost paradoxical as the conceptual utility of CR for issues pertinent to older
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adults with cardiovascular illness. Aging is associated with increased inflammation [11], increased
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oxidative stress and other biological changes that predispose to CVD as well as non-cardiac diseases.

Prevalence of CHD, HF, VHD, and peripheral arterial disease all increase with age, as does the prevalence
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of diabetes mellitus, chronic obstructive lung disease, chronic kidney disease, arthritis, anemia, mild
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cognitive impairment, dementia, and other diseases that often occur concurrently with CVD and

compound management complexity. Ironically, many of the effects of aging biology and associated
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disease are conducive to sedentary behaviors that escalate the progression of aggregate vulnerability
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[12]. The effects of acute disease and hospitalizations accelerate these risks, with progressive disability

associated each cardiac illness [13, 14], and then to even more downstream risks of recurrent disease,

institutionalization, and mortality.

Despite such inherent risks associated with aging, longevity is increasing, and the population of

older adults is growing. Cardiology providers are caring for increasing numbers of older patients who are

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also vulnerable to complexities related to their age. For older cardiovascular (CV) patients, almost every

aspect of standard CV care entails aspects of age-related trade-offs. Benefits of beta-blockers for CHD

are counterbalanced by greater age-related vulnerability to chronotropic incompetence. Benefits of

diuretics for HF are counterbalanced by incontinence. Benefits of anti-hypertensive medications are

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counter-balanced by increased risks of hypotension and falls. The list is almost endless. CR provides

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opportunity of longitudinal assessment to evaluate such issues and refine optimal management

strategies.

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Similarly, older CVD patients are the most prone to deconditioning, frailty and disability, such

that the implementation of exercise is often the most difficult. Issues of intrinsic muscle weakness, joint

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instability, and metabolic risks of advanced age, are compounded by the high prevalence of
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comorbidities, medications (sleeping pills, diuretics, etc.), sensory deficits (hearing, vision), and cognitive

limits (dementia, executive cognitive decline). Cardiac rehabilitation provides an important opportunity
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to address these intricacies and to achieve a realistic and safe routine.

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Evidence-based benefits of CR for an aging population

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Benefits – Mortality
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Multiple studies over decades have focused on aggregate mortality and morbidity benefits of

CR, as well as benefits regarding exercise capacity, obesity, lipids, inflammation, and psychosocial stress
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[15, 16]. A meta-analysis in 2011 of randomized controlled trials showed that CR for CHD significantly
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reduced the rate of reinfarction (odds ratio [OR] 0.75, 95% confidence interval [CI] 0.59-0.95), cardiac

mortality (OR 0.78, 95% CI 0.63-0.96), and all-cause mortality (OR 0.80, 95% CI 0.66-0.96) [16]. Another

more recent meta-analysis concluded that CR led to a reduction in cardiac mortality (relative risk [RR]

0.74, 95% CI 0.64-0.86) and hospital admissions (RR 0.82, 95% CI 0.70-0.96), but insignificant reductions

in mortality, MI, or revasulcarization [17]. Hammill et al studied 30,161 elderly Medicare patients

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(average age 74 years) who attended CR for CHD and found that participating in 36 sessions was

associated with a 47% lower risk of death over a 5 year follow-up period compared to those who only

attended one session (hazard ratio 0.53, 95% CI 0.48-0.59) [18]. Suaya et al. studied 601,099 Medicare

patients and showed that CR benefits to reduce mortality extended persisted across a range of age and

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disease severity [19]. Suaya’s study utilized three different statistical methods – propensity matching,

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regression modeling, and instrumental variables – to investigate differences in mortality among CR

participants and non-participants [19]. Regardless of the method used, mortality was significantly

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reduced at one year with progressively greater absolute difference in mortality at five years. Relative

reduction in mortality ranged from 43% to 58% at one year and 21% to 33% after 5 years. The benefits

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were seen across age groups including the very old, and irrespective of comorbidities (including HF) and
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gender.

The beneficial effects of CR have primarily been studied in patients with CHD, however, in the
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past decade a series of studies have also explored benefits of CR in patients with systolic HF. The major
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landmark randomized controlled HF trial to date is Heart Failure: A Controlled Trial Investigating

Outcomes of Exercise Training (HF-ACTION) which compared aerobic exercise training to usual care in
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2331 systolic HF patients, of whom approximately half were over age 60. The study showed significant
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reductions in the primary outcome of all-cause mortality or all-cause hospitalizations [20], but only after

accounting adjusting for baseline characteristics strongly predictive of these clinical outcomes (duration
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of the cardiopulmonary exercise test; left ventricular ejection fraction; Beck Depression Inventory II
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score; history of atrial fibrillation). Many attribute this equivocal success to limited enrollment and poor

adherence to the level of prescribed exercise [21]. Cochrane reviews of have also demonstrated that

exercise training may reduce mortality in HF patients, including those older and frailer than HF-ACTION,

with lower mortality demonstrated in studies with follow-up >1 year [22, 23]. Nonetheless, the long-

term benefits of CR for patients with HF with preserved ejection fraction (HFpEF) are not known.

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Evidence-Based CR Benefits – Exercise capacity

Exercise capacity is the maximum amount of physical exertion an individual can sustain [24].

Having greater exercise capacity allows one to be active at higher intensity or for a longer period of time

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and to also perform activities of daily living at a relatively lower percentage of overall fitness (which is

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conducive to increased physical activity throughout daily living and also to greater physical self-efficacy).

Exercise capacity becomes increasingly important in older adults because of the typical decline in

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exercise capacity as part of the aging process, vulnerabilities then exacerbated by acute deconditioning

and weakening from disease, medications, and hospitalizations, and associated predisposition to

increasing disability and dependency [14].

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Cardiac rehabilitation can help offset these risks [25]. A study of 1993 CHD patients who

enrolled in CR demonstrated that adults aged ≥65 years had lower baseline cardiorespiratory
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performance (as measured in peak metabolic equivalents [METs] achieved during baseline exercise
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testing), but had significant improvements after CR (i.e., similar to the improvements in the younger

patients [26]). McConnell et al also compared the changes in exercise capacity across different age
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groups and found that although peak exercise capacity was reduced relative to advancing age, the
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improvements achieved by CR were similar across all age groups [27]. Older patients >70 years old

achieved increased peak VO2 as well as improved anaerobic threshold after participating in CR [28], with
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higher anaerobic threshold being a particularly important indicator of capacity to complete more
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physical activity with less breathlessness and/or fatigue after CR.

Older CHD patients who participate in CR have also been demonstrated to benefit from

increased strength, a gain which is especially important for individuals who are frail or have limited

functional status due to the reduction in muscle mass and strength that typically accompanies aging and

hospitalizations. A recent study in 2013 showed that elderly patients had improved lower body muscle

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strength after CR [29]. Another study by Mandic et al found that exercise capacity in elderly individuals

after CR was similar to their age-matched healthy counterparts who were less active but healthy [30].

Participants in CR are able to maximize their exercise capacity giving them the ability to do daily tasks

which enrich their lives. Patient often increase capacities to carry groceries, navigate stairs, and

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maintain their self-care, i.e., critical capabilities for health and independence.

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Cardiac rehabilitation has also been demonstrated to increase exercise capacity in older adults

with HF. In HF-ACTION, three months of aerobic training resulted in significant increases in 6-minute

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walk test distance, time tolerated on a standardized cardiopulmonary exercise test, and peak oxygen

consumption [31]. These benefits were seen across all age groups; older subjects derived as much

benefit as those who were younger.

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Evidence-Based CR Benefits – Quality of life & symptoms
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Cardiac rehabilitation has been demonstrated to improve quality of life and symptoms. A study
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of CHD patients who participated in CR reported higher scores on the Medical Outcomes Study Short

Form-36 in total quality of life, as well as pain, energy level, physical functional, well-being, general
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health, and mental health [32]. These improvements were as significant in older (≥65 years) as well as in
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younger subjects. Even when subjects aged ≥75 years were compared to younger patients the

improvements in quality of life and functional status persisted [33]. Another study studied the benefits
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of CR to reduce symptoms of dyspnea and palpitations in older patients aged 65-84 years. Symptoms
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significantly decreased and overall fitness improved as assessed by the Goteborg quality of life index

[34]. A study by Lavie and Milani compared older CHD patients aged >70 years to younger patients aged

<55 years after participating in CR. They found that older patients had significant improvements in

quality of life scores and these improvements were even greater than those in the younger patients

(20% vs. 14%; p=0.03) [28].

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Studies of CR for HF have demonstrated similar quality of life and symptoms benefits. HF-

ACTION trial reported significant benefits in quality of life using the Kansas City Cardiomyopathy

Questionnaire (KCCQ). The KCCQ score improved by 3.3 points in the control group and 5.2 points in the

exercise group which was a significant difference of 1.9 points (p<0.001). Although this improvement

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stabilized after 3 months, it did not attenuate over time. This finding was consistent regardless of age

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and gender as well [31]. Subsequent Cochrane reviews which included older and older and sicker

patients than HF-ACTION, also demonstrated improvements in patient-reported quality of life [22, 23].

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Evidence-Based CR Benefits - Psychological

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The bearing of psychological diseases on CVD is increasingly recognized. In particular, depression
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has been independently associated with greater CVD morbidity and mortality [35, 36]. The association

with depression and CHD is complex, but lower physical activity [36] is considered a key mediator. A
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study of CR in patients aged ≥65 years showed that depressed patients had lower levels of exercise
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capacity and quality of life at baseline compared to non-depressed patients, but improved their exercise

capacity similarly and increased their quality of life more than non-depressed patients [37]. Patients
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were also significantly less likely to be depressed after CR [37]. More recently, a meta-analysis studied
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18 randomized controlled trials to assess the impact of CR on depression in elderly patients using studies

with a mean age ≥64 years and demonstrated that exercise therapy combined with psychosocial
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interventions are more effective in decreasing depression than usual care [38].
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Evidence-Based CR Benefits – Cardiac risk factors

Cardiac rehabilitation patients receive tailored education and counseling to address individual

needs. Programs have demonstrated improvements in lipid levels [39], blood pressure [40], weight loss

[41], and reduction in smoking [42]. Although weight loss can be a sign of worsening frailty in patients

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when there is concomitant decline in exercise tolerance, weight loss when accompanied by increased

physical activity is a valuable benefit for older adults who are dealing with the additional challenges of

being overweight [43]. Similarly, personalized education and management help achieve achievable

strategies of medication adherence, diet, and self-care (sleep, stress reduction) that can impact

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significantly on favorable outcomes.

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Evidence-Based CR Benefits – Cognition & Socialization

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Cardiac rehabilitation can also help improve cognitive function in older adults. Observational

studies have demonstrated that physical activity is associated with a slowing in age-related decline of

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cognition and reduction in cognitive impairment [44, 45]. The optimal intensity and duration of exercise
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necessary for the benefits is uncertain, however, it generally appears that higher exercise levels is

associated with better cognitive health [46]. A cross-sectional study of older adults reported better
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performance on executive function testing in those individuals who had higher levels of physical activity
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[47]. Although not all interventions of aerobic and resistance exercise have shown improvement in

cognitive performance, multicomponent exercise interventions, which are more representative of CR

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programs combining aerobic and resistance training together, may be more beneficial to cognitive
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function than aerobic exercise alone [48]. Similarly, CR goals to improve medication regimens, sleep

hygiene, diet, and mood likely contribute to improved cognition.

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Socialization is also a critical component of CR that may especially benefit older patients. For
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many, CR serves as a means to counterbalance vulnerabilities to isolation that often arise amidst aging

and disease. A study of adults age ≥65 years were surveyed and reported that the socialization aspect of

CR was very important and they would even prefer more socialization as part of any CR program [49].

Women in particular highlighted the importance of emotional support from attending CR [49].

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Age-specific benefits – CR for frailty

Definition of frailty remains controversial, but it generally involves a state of overall weakening

and fatigability, and translates into increased vulnerability to disease and decreased tolerance of

therapies [50]. Older adults with CVD are particularly prone to frailty [51, 52] and to its detrimental

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prognostic implications. Patients with CVD who are frail have more than twice the morbidity and

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mortality than similarly aged patients without frailty [52]. A recent review of interventions for frail

elderly patients evaluated 20 studies with exercise interventions including 13 studies of exercise alone

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[53]. All of the studies were of patients aged ≥65 years and used various exercise prescriptions including

both aerobic and resistance training for 3 months up to 2.6 years in one study. Outcomes included

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different measures of function including the short physical performance battery, activities of daily living,
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gait speed, strength, and exercise capacity. Exercise training consistently resulted in improved physical

performance tests in frail individuals. Patients with CVD were specifically addressed in two studies and
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observed benefits of exercise [54, 55]. In fact, frail patients with CVD are ideally suited for exercise
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training because of common pathophysiologic links between the two entities such as increased

inflammation and insulin resistance.

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Older adults with HF are especially susceptible to frailty, and HF hospitalizations often
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exacerbate these tendencies [56]. CR programs can be a valuable therapy for patients to regain mobility,

strength, and balance. This potential is usually complemented by efforts to optimize medications,
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nutrition, and other pertinent parameters of care.

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Risks associated with Cardiac Rehabilitation

Cardiovascular Events

Although there are no large studies which have specifically evaluated the safety of CR in older

adults, the incidence of cardiovascular events during and following sessions of CR has been studied and

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shown to be exceedingly rare. Many studies of safety were done prior to current optimal medical

therapy and coronary revascularization, thus safety is likely to be even greater today. A study in 2003 of

patients at 65 CR programs identified one cardiovascular event for every 50,000 patient hours of

exercise and one cardiac arrest for every 77,000 patient hours of exercise [57]. A statement in 2007 by

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the American Heart Association regarding the risk of acute cardiovascular events during exercise

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estimated the risk of death, cardiac arrest, or myocardial infarction to be between one event for every

60,000 to 80,000 hours of exercise [58].

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Injury Potential

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One of the most common concerns among physicians and patients is that CR is not safe for older
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adults due to greater risks of sustaining a fall or exercise-related injury. This is inconsistent with studies

which consistently show that exercise training is actually useful at reducing the risk of falls and fall-
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related injuries. A systematic review of 17 trials of exercise interventions in older adults found that all
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falls, including falls which produced major injuries, were reduced [59]. Although the etiologies of falls in

older adults vary, they are frequently due to imbalance that results from weakness [60]. CR programs
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have been demonstrated to increase strength, and to thereby improve balance and reduce falling risks
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[61]. The multifaceted nature of CR adds to this benefit as effects of arrhythmias, medication

interactions, sleep impairments, and/or dietary limits (e.g., dehydration) are also considered, with the
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impact that falling risks are reduced even further.

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In consideration of falls and other safety parameters, it is important clarify that older patients’

response to exercise is different than those who are younger, and added precautions to minimize risks

in older patients are warranted [62]. Longer warm-up periods are necessary to ensure adequate

flexibility and blood flow to large muscle groups. Cool-down time allows for the vasodilation present

during exercise to recover and return to normal which can put the patient at risk of hypotension if

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regular activity is restarted too quickly. Monitoring for proper breathing, exercise techniques,

hemodynamics, and capacity to control the equipment are all important, particularly amidst frailty,

cognitive deficiencies, and comorbidity that can complicate care.

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Underutilization of Cardiac Rehabilitation

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Despite the compelling benefits of CR and the widespread endorsement of its use, CR is vastly

underutilized [63]. A study of claims data from more than 250,000 US Medicare beneficiaries found that

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CR was used in only 14% of post-myocardial infarction patients and 31% of patients who underwent

coronary artery bypass graft surgery [64]. While 36 sessions of CR is associated with lower risks of death

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and myocardial infarction at 4 years compared with attending fewer than 36 sessions [18], many
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patients are simply not able to attend CR in this ideal schedule. Therefore, it is notable that patients

attending any number of CR sessions do better than patients not attending CR at all [16]. It is evident
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that CR has wide-ranging benefits and all eligible patients should be encouraged to attend a CR program
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to the extent they are able.

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Barriers to cardiac rehabilitation

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The reasons for inadequate use of CR have been well studied and can broadly be categorized

into system, physical, and personal barriers [65]. Chronologically, these barriers to CR can occur at the
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time of referral or during potential participation. Barriers that have been identified across all age groups
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include transportation issues [66-68], lack of understanding of the disease process [69], lack of

understanding of the rationale for CR [65], and poor rates of referral by physicians [65, 67].

Lack of referral

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A single center study of elderly patients who were hospitalized were most likely (66% vs. 2%) to

participate in CR after hospitalization for MI or CABG if the physician made a “strong” recommendation

to participate [70, 71]. Unfortunately, many physicians and allied providers do not recommend CR for

their older patient, or explain its potential value [72-74]. Consequently, older adults are less likely to be

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aware of CR programs and to pursue options for CR which they do not understand [75].

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Lack of participation

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Not only are older adults are less like to be referred to CR compared to younger patients, but

they are less likely to participate even if referred. Many older CR candidates suffer from many

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comorbidities such as arthritis, chronic obstructive pulmonary disease, and diabetes which results in
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mobility issues, dyspnea, or other symptoms that make participation difficult and therefore they opt out

[76]. Moreover, many older adults cannot drive or arrange alternative transportation [66-68].
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Strategies to improve utilization

Novel strategies to overcome barriers to CR are now being considered and investigated. Efforts
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to minimize barriers to participation, set attainable goals, promote spouse or family members’
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involvement/support, and to continually monitor goals of care may all be beneficial.

Whereas most programs in the United States are hospital- or other facility-based, and last 36
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weeks, efforts to implement longer program duration are being studied, with greater emphasis on
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home-training in combination with intermittent home visits and/or telephone

conferencing/assessments to reinforce education, safety and compliance. Similarly, hybrid models of

care integrate intermittent site-based CR sessions with predominant home-based care. A Cochrane

review concluded that both home-based and facility-based programs have similar benefits on lowering

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risk factors, increasing quality of life, and reducing clinical events [10], but despite such compelling ideas

and substantiation, home-based programs will likely lag until finances are considered.

The safety of older adults in home-based CR is also an important consideration. Whereas home-

based CR for older adults raise relevant safety concerns regarding compliance, falls, and other elements

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of safety, stringent screening and novel monitoring capacities (especially those facilitated by new

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telehealth technologies) may help surmount these challenges.

Notable, the American Heart Association published a Presidential Advisory in 2011 which

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outlines several recommendations to increase referral and participation in CR. These include automated

referrals in the hospital discharge plan (in which patients are aware of and agree to the referral),

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bedside visits by a CR liaison, establishing an appointment at the time of referral, providing
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transportation or parking assistance if necessary, and re-contacting those patients referred but not yet

enrolled [77]. The true value and impact of CR will likely grow if and when such novel strategies are
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implemented, especially if coupled with novel models of care.

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Conclusions
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Benefits of CR include reduced mortality and morbidity, but also improved exercise capacity,
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quality of life, symptoms, and mood, parameters that may be particularly important to older CV

patients. Cardiac rehabilitation is also particularly useful in addressing idiosyncrasies of advance age,
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including atypical symptoms, multimorbidity, polypharmacy, falling risks, learning impairments and
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other intricacies of care. Nonetheless, underuse of CR in all ages remains entrenched, particularly

among older adults. Future research needs to address these challenges and continue pursuing optimal

methods to increase CR enrollment and implementation for older candidates.

Funding:

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Dr. Schopfer is supported by the National Center for Advancing Translational Sciences of the NIH

under Award Number KL2TR000143. Dr. Forman is supported in part by NIA grant P30 AG024827 and VA

Office of Rehabilitation Research and Development grant F0834-R.

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Table. Summary of Benefits of Cardiac Rehabilitation in Older Adults

Cardiac Rehabilitation Benefits Implications

Cardiovascular effects

Reduction in symptom burden (chest Improved quality of life

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pain, shortness of breath, palpitations,
claudication) but also greater insight Improved confidence to exercise or stay physically active
regarding one’s own safety and stability

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even if some symptoms persist and are Reduced anxiety and depression
part of a new sense of normal in old age
(e.g., understanding that in some people,

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increased dyspnea may be persistent, but
without physiological risks, and therefore
it should not become a reason to avoid
exercise).

Increased exercise capacity

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Increased capacity to perform ADLs
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Greater physical self-efficacy

Reduced risk of deconditioning and disability

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Improved quality of life

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Reduced CV events and CV mortality

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Reduced BMI and body fat Reduced obesity and associated health risks

Improved metabolism and decreased inflammation

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Relatively increased proportions of lean body mass which

provides additive health benefits relative to changes in
body fat.
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Lipids Reduced CV events and CV mortality

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Reduced claudication with statin therapy

Non-Cardiovascular effects

Reduced stress and depression Improved quality of life

Improved diet, medication adherence, Moderate some of the risks associated with
and self-care polypharmacy, frailty, multimorbidity

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Improved cognition Reduced and potentially even reversed age-and

cardiovascular disease-related cognitive declines that
resulted from sedentary lifestyle or inadvertent effects of
medications (that may be adjusted)

Greater socialization Reduced risks associated with isolation

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Greater emotional support

Improved strength Reduced sarcopenia and frailty

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Reduced falls

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Improved balance Reduce risks of falls

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